6 CCR 1011-1 Chapter 26, pt. 7 - NON-MEDICAL/PERSONAL CARE

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7.1 Governing Body

(A) An HCA may choose to convene a governing body that shall have legal authority and responsibility for the conduct of the HCA. If an HCA does not convene a governing body, the HCA shall designate an individual who shall have responsibility for all tasks as set forth in this Part 7.1.

(B) At least one (1) member of the governing body or designee shall have knowledge of HCA operations.

(1) Have bylaws or a governing document that shall specify the programs and services offered by the HCA and be reviewed and revised as needed;

(2) Designate and employ an HCA manager;

(3) Develop and adopt policies and procedures for the operation and administration of the HCA, to be reviewed annually and revised as needed;

(4) Ensure any program or service offered by the HCA, directly or under arrangement, shall be provided in accordance with the service plan and HCA policy and procedure;

(5) Review the operations of the HCA at least annually;

(6) Keep minutes of all meetings;

(7) Provide and maintain a fixed office location that provides for consumer confidentiality and a safe working environment; and

(8) Organize services furnished, administrative control, and lines of authority for the delegation of responsibility down to the consumer care level that are clearly set forth in writing and are readily identifiable.

(D) Agency Evaluation

(1) The HCA's governing body or designee shall conduct a comprehensive evaluation of the HCA's total operation at least annually.

(2) The evaluation shall assure the appropriateness and quality of the HCA's services with findings used to verify policy implementation, to identify problems, and to establish problem resolution and policy revision as necessary, and shall include any findings or improvement strategies identified by the HCA's Quality Management Program required in Part 5.12.

(3) The HCA shall implement a method for ongoing process improvement and policy and administrative review, which includes a review of the scope of services offered, arrangements for services with other agencies or individuals, admission and discharge policies, supervision and service plan, urgent consumer care, service records, and personnel qualifications.

(a) The HCA shall implement an on-going mechanism for consumer involvement to provide input and comment regarding services provided by the HCA in accordance with HCA policy.

(b) All findings from the policy and administrative review and consumer input and commentary shall be provided to the governing body at least annually to identify trends or issues requiring consideration.

(4) In evaluating each aspect of its total program, the HCA shall consider four (4) main criteria:

(a) Appropriateness - assurance that the area being evaluated addresses existing and/or potential problems.

(b) Adequacy - a determination as to whether the HCA has the capacity to overcome or minimize existing or potential problems.

(d) Efficiency - whether there is a minimal expenditure of resources by the HCA to achieve desired goals and anticipated consumer outcomes.

(5) Documentation of the annual evaluation shall include the names and titles of the persons carrying out the evaluation, the criteria and methods used to accomplish it, and any action taken by the HCA as a result of its findings.

(6) Appropriate qualified individuals representing the programs and services offered by the HCA shall evaluate the HCA's consumer records on an ongoing basis, but no less than quarterly.

(a) The evaluation shall include a review of sample active and closed consumer records to ensure that HCA policies are followed in providing services, both directly and under arrangement, and to assure that the quality of service is satisfactory and appropriate. The review shall consist of a representative sample of all home care services provided by the HCA.

7.2 HCA Manager

(A) The HCA's governing body or designee shall appoint an HCA manager to supervise the provision of the HCA's services.

(B) The HCA manager shall meet the following qualifications:

(1) Be at least twenty-one (21) years of age, possess a high school diploma or GED, and have at least one (1) year documented supervisory experience in the provision of personal care services;

(a) If the HCA manager does not have the required one (1) year of experience supervising the delivery of personal care services, they shall demonstrate they have the following:

(i) A college degree in healthcare services plus at least one (1) year of work experience in health care during the previous ten (10)-year period; or

(ii) A college degree in any field plus two (2) years of work experience in health care during the previous ten (10)-year period.

(2) Be able to communicate and understand return communication effectively in exchanges between the consumer, family representatives, and other providers, including the use of appropriate translator services as needed;

(3) Have successfully completed an eight (8) hour agency manager training course. Additional related annual training that equals twelve (12) hours shall be required in the first year and annually thereafter;

(a) Any person commencing service as an HCA manager shall meet the minimum training requirements approved by the Department pursuant to Part 7.2(D) of this chapter or provide documented and confirmed previous job related experience or related education equivalent to successful completion of such program. The Department may require additional training to ensure that all the required components of the training curriculum are met.

(b) A copy of the certificate of completion shall be retained in the HCA manager's personnel file.

(4) Be familiar with all applicable local, state, and federal laws and regulations concerning the operation and provision of home care services.

(1) The HCA is in compliance with all applicable federal, state, and local laws;

(2) The completion, maintenance, and submission of reports and records as required by the Department;

(3) Ongoing liaison with the governing body or designee, staff members, and the community;

(4) Maintenance of a current organizational chart to show lines of authority down to the consumer level;

(5) Maintenance of appropriate personnel, bookkeeping, and administrative records and policies and procedures of the HCA;

(6) Orientation of new personnel, and regularly scheduled in-service education programs and opportunities for continuing education are provided for personnel;

(7) Designating in writing the qualified staff member to act in the absence of the manager;

(8) Availability of the manager or designee for all hours that personnel are providing services;

(9) Marketing, advertising, and promotional information accurately represent the HCA and address the care, treatment, and services that the HCA can provide directly or through contractual arrangement;

(10) Maintenance of a coordinated HCA-wide program for appropriate infection prevention and control that is an integral part of the HCA's quality management program; and

(11) The implementation and monitoring of the HCA's training program for all homemakers and personal care workers, including managing or delegating employee training and development activities for the HCA.

(D) An HCA manager training program shall be approved by the Department if:

(1) The program or its components are conducted by an accredited college, university, or vocational school or by an organization, association, corporation, group, or agency with specific expertise in that area and the curriculum includes at least eight (8) actual hours of training.

(2) Instruction includes, at a minimum, discussion of each of the following topics:

(a) Home care overview including other agency types providing services and how to interact and coordinate, including limitations of personal care versus health care services;

(b) Regulatory responsibilities and compliance, including:

(i) Consumer rights,

(ii) Governing body or designee responsibilities,

(iii) Quality management plans,

(iv) Occurrence reporting, and

(v) Complaint investigation and resolution process;

(d) Needs of the fragile, ill, and physically, cognitively, and/or developmentally disabled in the community setting regarding special training and staffing considerations; and

(e) Behavior management techniques.

7.3 Homemaker

(A) A homemaker shall complete training, in accordance with the following requirements, prior to providing services independently.

(B) A homemaker must complete training as specified in Part 7.3(C) and pass a competency evaluation that includes a visual observation and evaluation of relevant skills, prior to providing care to a consumer.

(1) If the HCA utilizes another entity to provide the training, the HCA must validate that the training program meets the requirements in Part 7.3(C) below and retain evidence of the individual's successful completion of the training program in the personnel record.

(1) All homemaker staff shall complete HCA training before independently providing services to consumers. Initial training must be interactive in nature and may be completed through the following modes: in-person, online/virtual, or a hybrid, with demonstration of learned concepts. Initial training shall include:

(a) Personnel duties and responsibilities, including but not limited to incident reporting and mandatory reporting;

(b) Rules for non-medical care and services as described in this chapter;

(d) Consumer rights, including freedom from abuse or neglect and confidentiality of personal, financial, and health information;

(e) Basic health and safety, including but not limited to: home safety, fall prevention, hand washing, and infection control;

(f) Assignment and supervision of services;

(g) Communication skills;

(h) The physical, emotional, and developmental needs of and methods to work with the populations served and assignment of consumers by the HCA, including the need for respect of the consumer, their privacy, and property; and

(i) Training and core competency evaluation of homemaking and housekeeping skills shall be conducted before completion of initial training, including the evaluation of maintenance of a clean, safe, and healthy environment and the appropriate and safe techniques for each assigned task.

(2) The HCA shall provide orientation for all personnel upon hire that includes, but is not limited to HCA policies and procedures and emergency response policies and emergency contact numbers for the HCA and for the individual consumer(s) assigned.

(3) The HCA shall ensure that ongoing training of homemakers occurs and shall consist of at least four (4) training topics outlined in Part 7.3(C)(1) above every twelve (12) months after the starting date of employment or calendar year as designated by HCA policy. The training requirement shall be prorated in accordance with the number of months the employee was actively working for the HCA.

(D) Homemakers shall provide services in accordance with the policies and requirements of the HCA as well as the service arrangements spelled out in the service plan.

(E) The duties of a homemaker shall include the following:

(1) Reporting any observed environmental concerns or changes in the consumer's status that may impact the safety and security of the consumer to the HCA.

(2) Completion of appropriate service notes regarding service provision of each visit, to include confirmation of services provided and the date and time in and out. Such confirmation shall also be according to HCA policy.

(F) The duties of a homemaker may include the following:

(1) Routine light house cleaning, meal preparation, dishwashing, and bed making. Homemakers may also assist in teaching these tasks to the consumer.

(a) Where meal preparation is provided in accordance with the service contract, the homemaker should receive instruction regarding any special diets required to be prepared.

(2) Assistance in completing activities outside the home, such as shopping or laundry.

(3) Companionship, including but not limited to: social interaction, conversation, emotional reassurance, encouragement of reading, writing, and activities that stimulate the mind.

7.4 Personal Care Worker

(A) A personal care worker must meet all requirements in Part 7.3, Homemaker, in addition to the specific requirements for personal care workers outlined below, prior to providing services independently.

(B) A personal care worker must complete training as specified in Part 7.4(C), personal care worker training, and pass a competency evaluation and skills validation, including visual observation, prior to providing care to a consumer.

(1) Initial training shall include the topics identified in homemaker training at Part 7.3(C)(1), in addition to the following:

(a) The differences in personal care, nurse aide care, and health care in the home including limiting factors for the provision of personal care as specified in Part 7.4(E) below;

(b) Observation, reporting, and documentation of consumer status and the service(s) furnished;

(c) Non-medical assistance with activities of daily living, including bathing, skin care, hair care, nail care, mouth care, shaving, dressing, feeding, assistance with ambulation, exercises and transfers, positioning, bladder care, bowel care, and protective oversight;

(d) Medication reminders; and

(e) Performance of the ability to assist in the use of specific adaptive equipment if the worker will be assisting consumers who use the device.

(2) The HCA shall provide orientation for all personnel upon hire that includes, but is not limited to, topics identified in homemaker orientation at 7.3(C)(2) and a description of the services provided by the HCA.

(3) The HCA is responsible for ensuring that the individuals who furnish personal care services on its behalf are competent to carry out all assigned tasks in the consumer's place of residence.

(a) Prior to assignment, the HCA manager or supervisor shall conduct a proof of competency evaluation involving the tasks listed in Part 7.4(C)(1)(c), (d), and (e), along with any other tasks that require specific hands-on application.

(4) The HCA shall ensure that ongoing supervisory and direct care staff training occurs and shall consist of at least six (6) topics every twelve (12) months after the starting date of employment or calendar year as designated by HCA policy. The training requirement shall be prorated in accordance with the number of months the employee was actively working for the HCA. Training shall include, but is not limited to, the following items:

(a) Behavior management techniques and the promotion of consumer dignity, independence, self-determination, privacy, choice, and rights, including abuse and neglect prevention and reporting requirements.

(b) Disaster and emergency procedures.

(d) Basic first aid and home safety.

(D) The duties of a personal care worker shall include all duties outlined in homemaker duties at Part 7.3(E), in addition to the following:

(1) Observation and maintenance of the home environment in accordance with the service plan that ensures the safety and security of the consumer.

(2) Reporting any observed or stated changes in the consumer's physical, cognitive, and/or developmental status.

(E) The duties of personal care worker may include all duties outlined in homemaker duties at Part 7.3(F), in addition to the following:

(1) Assistance with non-medical activities of daily living, personal care, and any other assignments as included in the service plan.

(F) Personal care worker tasks. The purpose of this part is to delineate the types of services that can be provided by a personal care worker. The following are examples of limitations where skilled home health care would be needed to meet higher needs of the consumer.

(1) Skin care

(a) A personal care worker may perform general skin care assistance.

(b) A personal care worker may perform skin care only when skin is unbroken, and when any chronic skin problems are not active.

(c) The skin care provided by a personal care worker shall be preventative rather than therapeutic in nature and may include the application of non-medicated lotions and solutions or of lotions and solutions not requiring a physician's prescription.

(d) Skilled skin care includes wound care other than basic first aid, dressing changes, application of prescription medications, skilled observation, and reporting. Skilled skin care should be provided by an HCA licensed to provide skilled home health services.

(2) Ambulation

(a) A personal care worker may generally assist consumers with ambulation if they have the ability to balance and bear weight.

(b) If the health professional has determined that the consumer is independent with an assistive device, a personal services worker may be assigned to assist with ambulation.

(3) Bathing

(a) A personal care worker may assist consumers with bathing only if they have the ability to balance and bear weight, except when a transfer involves a lift device as described in Part 7.4(F)(13)(d).

(b) When a consumer has skilled skin care needs or skilled dressings that will need attention before, during, or after bathing, the consumer should be in the care of an HCA licensed to provide skilled home health services for those needs.

(4) Dressing

(a) A personal care worker may assist a consumer with dressing. This may include assistance with ordinary clothing and application of support stockings, including ace bandages and anti-embolic or pressure stockings that can be purchased without a physician's prescription.

(b) A personal care worker that assists a consumer with application of any support stocking must receive training from a qualified individual in the stocking's proper application. Prior to application and on an annual basis, the qualified individual shall conduct a proof of competency evaluation in the correct application of support stockings.

(5) Exercise

(a) A personal care worker may assist a consumer with exercise. However, this does not include assistance with a plan of exercise prescribed by a licensed health care professional.

(b) A personal care worker may remind the consumer to perform ordered exercise. Assistance with exercise that can be performed by a personal care worker is limited to the encouragement of normal bodily movement, as tolerated, on the part of the consumer and encouragement with a prescribed exercise program.

(6) Feeding

(a) Assistance with feeding may generally be performed by a personal service worker.

(b) Personal care workers can assist consumers with feeding when the consumer can independently chew and swallow without difficulty and be positioned upright.

(c) Unless otherwise allowed by statute, assistance by a personal care worker does not include syringe, tube feedings, and intravenous nutrition. Whenever there is a high risk that the consumer may choke as a result of the feeding, the consumer should be in the care of an HCA licensed to provide skilled home health services.

(7) Hair care

(a) As a part of the broader set of services provided to consumers who are receiving personal services, personal care workers may assist consumers with the maintenance and appearance of their hair.

(b) Hair care may include shampooing, drying, combing, and styling of hair. Medicated shampoo or shampoo that requires a physician's prescription may not be used.

(c) Over-the-counter medicated shampoos may be used as part of the broader set of services provided to the consumer, if the personal care worker has been trained by the agency in the proper use of the product. Prior to application and on an annual basis, a qualified individual shall conduct a proof of competency evaluation in the correct use of these products.

(8) Mouth care

(a) A personal care worker may assist and perform mouth care. This may include denture care and basic oral hygiene.

(b) Mouth care for consumers who are unconscious, have difficulty swallowing, or are at risk for choking and aspiration shall be performed by an HCA licensed to provide skilled home health services.

(9) Nail care

(a) A personal care worker may assist generally with nail care. This assistance may include soaking of nails, pushing back cuticles without utensils, and filing of nails.

(b) Assistance by a personal care worker shall not include nail trimming.

(c) Consumers with a medical condition that might involve peripheral circulatory problems or loss of sensation shall be under the care of an HCA licensed to provide skilled home health services.

(10) Positioning

(a) A personal care worker may assist a consumer with positioning when the consumer is able to identify to the personal care staff, verbally, non-verbally, or through others, when the positions needs to be changed.

(b) Positioning shall not exceed simple alignment in a bed, wheelchair, or other furniture.

(c) A personal care worker may assist a skilled home health worker with a consumer's positioning when any position change addresses skilled skin care concerns, as defined at Part 7.4(F)(1)(d). A personal care worker may not be assigned to or independently perform this function.

(11) Shaving

(a) A personal care worker may assist a consumer with shaving only with an electric or a safety razor.

(12) Toileting

(a) A personal care worker may assist a consumer to and from the bathroom; provide assistance with bedpans, urinals, and commodes; provide pericare; or change clothing and pads of any kind used for the care of incontinence.

(b) A personal care worker may empty urinary collection devices, such as catheter bags. In all cases, the insertion and removal of catheters and care of external catheters is considered skilled care and shall not be performed by a personal care worker.

(c) A personal care worker may empty ostomy bags and provide assistance with other consumer-directed ostomy care only when there is no need for skilled skin care or for observation or reporting to a nurse. A personal care worker shall not perform digital stimulation, insert suppositories, or give an enema.

(13) Transfers

(a) A personal care worker may assist with transfers only when the consumer has sufficient balance and strength to reliably stand and pivot and assist with the transfer to some extent.

(b) Adaptive and safety equipment may be used in transfers, provided that the consumer and personal care worker are fully trained in the use of the equipment, and the consumer, consumer's family member, or guardian can direct the transfer step by step. Adaptive equipment may include, but is not limited to wheel chairs, tub seats, and grab bars.

(c) Gait belts may be used in a transfer as a safety device for the personal care worker as long as the worker has been properly trained in its use and as long as the consumer is able to assist with the transfer.

(d) A personal care worker shall not perform assistance with transfers when the consumer is unable to assist with the transfer. Personal care workers, with training and demonstrated competency, may assist a consumer in a transfer involving a lift device.

(e) A personal care worker may assist the informal caregiver with transferring the consumer provided the consumer is able to direct and assist with the transfer.

(14) Medication Assistance. The following requirements apply to all prescription and all over-the-counter medications:

(a) Unless otherwise allowed by statute, a personal care worker may assist a consumer with medication only when the medications have been preselected by the consumer, a family member, a nurse, or a pharmacist, and are stored in containers other than the prescription bottles, such as medication minders.

(b) Medication minder containers shall be clearly marked as to day and time of dosage and reminding includes: inquiries as to whether medications were taken; verbal prompting to take medications; handing the appropriately marked medication minder container to the consumer; and, opening the appropriately marked medication minder container for the consumer if the consumer is physically unable to open the container.

(c) Any irregularities noted in the pre-selected medications such as medications taken too often, not often enough, or not at the correct time as marked in the medication minder container, shall be reported immediately by the personal care worker to the supervisor.

(15) Respiratory Care

(a) Respiratory care is considered skilled care and shall not be performed by a personal care worker. Respiratory care includes postural drainage, cupping, adjusting oxygen flow within established parameters, nasal, endotracheal, and tracheal suctioning.

(b) Personal care workers may temporarily remove and replace a cannula or mask from the consumer's face for the purposes of shaving and/or washing a consumer's face.

(c) Personal care workers may set a consumer's oxygen flow according to written instruction when changing tanks, provided the personal care worker has been specifically trained and demonstrated competency for this task.

(16) Accompaniment

(a) Accompanying the consumer to medical appointments, banking errands, basic household errands, clothes shopping, grocery shopping, or other excursions to the extent necessary and as specified on the service plan may be performed by the personal care worker when all the care that is provided by the personal care staff in relation to the trip is unskilled personal care, as described in these regulations.

(17) Protective oversight

(a) A personal care worker may provide protective oversight including standby assistance with any personal care task described in these regulations.

(b) When the consumer requires protective oversight to prevent wandering, the personal care worker shall have been trained in appropriate intervention and redirection techniques.

(18) Respite care

(a) A personal care worker may provide respite care in the consumer's home according to the service plan as long as the necessary provision of services during this time does not include skilled home health services as defined in Part 2.29 of this chapter.

(G) In addition to the exclusions prescribed in the preceding section, the HCA shall not allow personal care workers to:

(1) Perform skilled home health services as defined in Part 2.29 of this chapter;

(2) Perform or provide medication set-up for a consumer; or

(3) Perform other actions specifically prohibited by HCA policy, regulations, or law.

7.5 Training Exemptions

(A) Initial orientation or training shall not be required under the following circumstances:

(1) A returning employee is exempt from initial training if they are returning to the same HCA within one (1) year of leaving, and meet all of the following conditions:

(a) The employee completed the HCA's required training and competency assessment at the time of initial employment;

(b) The employee successfully completed the HCA's required competency assessment at the time of rehire or reactivation;

(c) The employee did not have performance issues directly related to consumer care and services in the prior active period of employment; and

(d) All orientation, training, and personnel action documentation from the prior active period of employment is retained in the personnel files.

(2) An employee moving from one office to another in the same HCA if previous training is documented and the offices have the same orientation and training procedures.

(a) Evidence of completed initial orientation and training and competency evaluation must be maintained by each separately licensed HCA.

(3) A personal care worker with proof of current healthcare related licensure or certification is exempt from initial training in the provision of personal care tasks if such training is recognized as included in the training for that health discipline. The HCA shall provide orientation and perform a competency evaluation to ensure the personal care worker is able to differentiate and appropriately perform all personal care worker tasks.

7.6 Training, Competency, and Skills Validation Documentation

(A) All training, competency, and skills validation shall be documented by the HCA.

(1) Documented evidence of trainings, competency testing, and skills validation shall be documented with the date of training; length of training; entity or instructor(s) that offered or produced the training; a short description of the content; and staff member's written or electronic signature or proof of attendance.

(2) The HCA shall maintain evidence of training, competency testing, skills validation, and related certificates along with proof of completion in each individual's personnel file.

7.7 Supervisor of Homemakers and Personal Care Workers (A) The supervisor shall:

(1) Be at least eighteen (18) years of age;

(2) Have appropriate experience or training in the home care industry or closely related personal care services in accordance with HCA policy; and

(3) Have completed training in the provision of personal care services.

7.8 Supervision of Homemakers and Personal Care Workers

(A) Supervision of a homemaker or personal care worker shall:

(1) Be performed by an employee of the HCA qualified as a supervisor under Part 7.7, who is in a designated supervisory capacity and available to the worker at all times care and services are being provided;

(2) Occur at a minimum of every three (3) months and must include an assessment of consumer satisfaction with services and the worker's competence and adherence to the service plan.

(a) Supervision shall be conducted either in person or via telehealth, in accordance with Telehealth Supervisory Visits at Part 7.9(A)(1); and

(3) Occur, in person, annually for evaluation of each worker providing services in a consumer's home and shall include observation of tasks performed and relationship with the consumer.

(B) Evidence of all supervisory activities must be documented and retained in the consumer's record. Documentation shall include:

(1) The date, time, method of delivery, and location of the supervisory activity along with documentation of persons present;

(2) Specific tasks evaluated and/or observed along with outcome; and

(3) Information on any re-training, instruction, or other support provided during the supervisory activity.

(C) An in-person supervisory visit is required to evaluate consumer complaints related to the delivery of care by staff when such concerns cannot be successfully addressed remotely through an interactive audiovisual connection.

7.9 Telehealth Supervisory Visits

(A) With the exception of the annual supervision requirement in Part 7.8(A)(3) and responding to consumer complaints in Part 7.8(C), The HCA may conduct supervisory visits using telehealth, so long as the HCA continues to ensure consumer care and treatment are delivered in accordance with the service plan that addresses the consumer's status and needs.

(1) The designated supervisor may evaluate the delivery of care and services required every three (3) months at Part 7.8(A)(2) through an interactive audiovisual connection with the homemaker or personal care worker and consumer. The results of the supervisory visit must be documented by the qualified employee.

(B) All other general requirements for supervisory visits, such as documentation and meeting the same standard of care, must be met.

Notes

6 CCR 1011-1 Chapter 26, pt. 7

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