Ohio Admin. Code 5123-9-30 - Home and community-based services waivers - homemaker/personal care under the individual options and level one waivers
(A) Purpose
This rule defines homemaker/personal care and sets forth provider qualifications, requirements for service delivery and documentation of services, and payment standards for the service.
(B) Definitions
For the purposes of this rule, the following definitions shall apply:
(1) "Adult day support" has the
same meaning as in rule 5123-9-17 of the Administrative Code.
(2) "Agency provider" has the same meaning as
in rule 5123-2-08 of the Administrative Code.
(3) "County board" means a county board of
developmental disabilities.
(4)
"Department" means the Ohio department of developmental disabilities.
(5) "Developmental center" means a
state-operated intermediate care facility for individuals with intellectual
disabilities.
(6) "Fifteen-minute
billing unit" means a billing unit that equals fifteen minutes of service
delivery time or is greater or equal to eight minutes and less than or equal to
twenty-two minutes of service delivery time. Minutes of service delivery time
accrued throughout a day shall be added together for the purpose of calculating
the number of fifteen-minute billing units for the day.
(7) "Funding range" means one of the dollar
ranges contained in appendix A to rule
5123-9-06
of the Administrative Code to which individuals enrolled in the individual
options waiver have been assigned for the purpose of funding services. The
funding range applicable to an individual is determined by the score derived
from the Ohio developmental disabilities profile that has been completed by a
county board employee qualified to administer the tool.
(8) "Group employment support" has the same
meaning as in rule 5123:2-9-16
5123-9-16 of the Administrative Code.
(9) "Group size" means the number of
individuals who are sharing services, regardless of the funding source for
those services.
(10)
"Homemaker/personal care" means the coordinated provision of a variety of
services, supports, and supervision necessary to ensure the health and welfare
of an individual who lives in the community. Homemaker/personal care advances
the individual's independence within his or her home and community and helps
the individual meet daily living needs. Examples of supports that may be
provided as homemaker/personal care include:
(a) Self-advocacy training to assist in the
expression of personal preferences, self-representation, self-protection from
and reporting of abuse, neglect, and exploitation, asserting individual rights,
and making increasingly responsible choices.
(b) Self-direction, including the
identification of and response to dangerous or threatening situations, making
decisions and choices affecting the individual's life, and initiating changes
in living arrangements and life activities.
(c) Daily living skills including training in
and providing assistance with routine household tasks, meal preparation,
personal care, self-administration of medication, and other areas of day-to-day
living including proper use of adaptive and assistive devices, appliances, home
safety, first aid, and communication skills such as using the
telephone.
(d) Implementation of
recommended therapeutic interventions under the direction of a professional or
extension of therapeutic services, which consist of reinforcing physical,
occupational, speech, and other therapeutic programs for the purpose of
increasing the overall effective functioning of the individual.
(e) Behavioral support strategies including
training and assistance in appropriate expressions of emotions or desires,
assertiveness, acquisition of socially-appropriate behaviors, or extension of
therapeutic services for the purpose of increasing the overall effective
functioning of the individual.
(f)
Medical and health care services that are integral to meeting the daily needs
of the individual such as routine administration of medication or tending to
the needs of individuals who are ill or require attention to their medical
needs on an ongoing basis.
(g)
Emergency response training including development of responses in case of
emergencies, prevention planning, and training in the use of equipment or
technologies used to access emergency response systems.
(h) Community access services that explore
community services available to all people, natural supports available to the
individual, and develop methods to access additional services, supports, and
activities needed by the individual to be integrated in and have full access to
the community.
(i) When provided in
conjunction with other components of homemaker/ personal care, assistance with
personal finances which may include training, planning, and decision-making
regarding the individual's personal finances.
(11) "Independent provider" has the same
meaning as in rule 5123-2-09 of the Administrative Code.
(12) "Individual" means a person with a
developmental disability or for purposes of giving, refusing to give, or
withdrawing consent for services, his or her guardian in accordance with
section
5126.043
of the Revised Code or other person authorized to give consent.
(13) "Individual employment support" has the
same meaning as in rule 5123:2-9-15
5123-9-15 of the Administrative Code.
(14) "Individual service plan" means the
written description of services, supports, and activities to be provided to an
individual.
(15) "Intermediate care
facility for individuals with intellectual disabilities" has the same meaning
as in section
5124.01 of the
Revised Code.
(16) "Money
management" has the same meaning as in rule
5123-9-20
of the Administrative Code.
(17)
"Non-medical transportation" has the same meaning as in rule
5123-9-18
of the Administrative Code.
(18)
"Ohio developmental disabilities profile" means the standardized instrument
utilized by the department to assess the relative needs and circumstances of an
individual compared to others. The individual's responses are scored and the
individual is linked to a funding range, which enables similarly situated
individuals to access comparable waiver services paid in accordance with rules
adopted by the department.
(19)
"On-site/on-call" means a rate authorized when no need for supervision or
supports is anticipated because the individual is expected to be asleep for a
continuous period of no less than five hours, and a provider must be present
and readily available to provide homemaker/personal care if an unanticipated
need arises but is not required to remain awake.
(20) "Residential respite" has the same
meaning as in rule
5123-9-34
of the Administrative Code.
(21)
"Service documentation" means all records and information on one or more
documents, including documents that may be created or maintained in electronic
software programs, created and maintained contemporaneously with the delivery
of services, and kept in a manner as to fully disclose the nature and extent of
services delivered that shall include the items delineated in paragraph (E) of
this rule to validate payment for medicaid services.
(22) "Shared living" has the same meaning as
in rule 5123-9-33 of the Administrative Code.
(23) "Team" has the same meaning as in rule
5123-4-02 of the Administrative Code.
(24) "Vocational habilitation" has the same
meaning as in rule 5123-9-14 of the Administrative Code.
(25) "Waiver eligibility span" means the
twelve-month period following either an individual's initial waiver enrollment
date or a subsequent eligibility redetermination date.
(C) Provider qualifications
(1) Homemaker/personal care shall be provided
by an independent provider or an agency provider that meets the requirements of
this rule and that has a medicaid provider agreement with the Ohio department
of medicaid.
(2) Homemaker/personal
care shall not be provided by a county board or a regional council of
governments formed under section
5126.13 of the
Revised Code by two or more county boards.
(3) An applicant seeking approval to provide
homemaker/personal care shall complete and submit an application through the
department's website (http://dodd.ohio.gov).
(4) Providers licensed under section
5123.19
of the Revised Code seeking to provide homemaker/personal care shall:
(a) Meet all of the requirements set forth in
and maintain a license issued under section
5123.19
of the Revised Code.
(b) Maintain a
current medicaid provider agreement with the Ohio department of
medicaid.
(5) Failure of
a certified provider to comply with this rule and as applicable, rule 5123-2-08
or 5123-2-09 of the Administrative Code, may result in denial, suspension, or
revocation of the provider's certification.
(6) Failure of a licensed provider to comply
with this rule and Chapters 5123-3 and 5123:2-3 of the Administrative Code may
result in denial, suspension, or revocation of the provider's
license.
(D) Requirements
for service delivery
(1) Homemaker/personal
care shall be provided pursuant to an individual service plan that conforms to
the requirements of rule 5123-4-02 of the Administrative Code. Providers shall
participate in individual service plan development meetings when a request for
their participation is made by the individual.
(2) A provider of homemaker/personal care
shall not also provide money management or shared living to the same
individual.
(3) Homemaker/personal
care shall not be provided to an individual at the same time as residential
respite.
(4) Homemaker/personal
care services may extend to those times when the individual is not physically
present and the provider is performing homemaker activities on behalf of the
individual.
(5) Homemaker/personal
care services involving direct contact with an individual receiving the
services shall not be provided at the same time the individual is receiving
adult day support, group employment support, individual employment support, or
vocational habilitation.
(6) A
provider shall not bill for homemaker/personal care provided by the driver
during the same time non-medical transportation at the per-trip rate is
provided.
(7) A provider of
homemaker/personal care shall arrange for substitute coverage, when necessary,
only from a provider certified or approved by the department and as identified
in the individual service plan; notify as
applicable, the individual or legally responsible person in the event
that substitute coverage is necessary; and notify the person identified in the
individual service plan when substitute coverage is not available to allow such
person to make other arrangements.
(8) A provider delivering homemaker/personal
care in fifteen-minute billing units in accordance with this rule, excluding
on-site/on-call, shall utilize electronic visit verification in accordance with
rule
5160-1-40
of the Administrative Code.
(9) An
agency provider shall develop and implement a documented process by which it
reviews and manages overtime of staff members who provide homemaker/ personal
care in a manner that ensures the health and safety of individuals served and
staff members and considers the specific needs of individuals served, the
abilities of staff members, and patterns of overtime with the goal of reducing
overtime.
(E)
Documentation of services
Service documentation for homemaker/personal care shall include each of the following to validate payment for medicaid services:
(1) Type of service.
(2) Date of service.
(3) Place of service.
(4) Name of individual receiving
service.
(5) Medicaid
identification number of individual receiving service.
(6) Name of provider.
(7) Provider identifier/contract
number.
(8) Written or electronic
signature of the person delivering the service or initials of the person
delivering the service if a signature and corresponding initials are on file
with the provider.
(9) Group size
in which the service was provided.
(10) Description and details of the services
delivered that directly relate to the services specified in the approved
individual service plan as the services to be provided.
(11) Number of units of the delivered service
or continuous amount of uninterrupted time during which the service was
provided.
(12) Times the delivered
service started and stopped.
(F) Payment standards
(1) The billing units, service codes, and
payment rates for homemaker/personal care are contained in appendix A to this
rule. Payment rates are based on the county cost-of-doing-business category.
The cost-of-doing-business category for an individual is the category assigned
to the county in which the service is actually provided for the preponderance
of time. The cost-of-doing-business categories are contained in appendix B to
this rule. The department may cause independent providers to be paid a rate
that exceeds the payment rates contained in appendix A to this rule as
necessary to comply with increases to minimum wage pursuant to Section 34a of
Article II, Ohio Constitution.
(2)
Payment rates for homemaker/personal care are established separately for
services provided by independent providers and services provided by agency
providers.
(3) Payment rates for
homemaker/personal care shall be adjusted to reflect the number of individuals
being served and the number of people providing services.
(a) When two individuals are being served by
one person, the base rate shall be one hundred seven per cent of the base rate
for one-to-one service. When three individuals are being served by one person,
the base rate shall be one hundred seventeen per cent of the base rate for
one-to-one service. When four or more individuals are being served by one
person, the base rate shall be one hundred thirty per cent of the base rate for
one-to-one service.
(b) The base
rate is divided by the number of individuals being served to determine the rate
apportioned to each individual.
(c)
When multiple staff members of an agency provider simultaneously provide
services to more than one individual, the payment rate is adjusted to reflect
the average staff-to-individual ratio at which services are provided. The
calculation of rates apportioned to each individual when multiple staff members
simultaneously provide services to more than one individual are contained in
the "Application of Appendix A to Rule 5123-9-30" (January 1,
2021
2022 ),
which is available at the department's website (http://dodd.ohio.gov).
(4) Payment rates for routine
homemaker/personal care shall be adjusted by the behavioral support rate
modification to reflect the needs of an individual requiring behavioral support
upon determination by the department that the individual meets the criteria set
forth in paragraph (F)(4)(a) of this rule. The amount of the behavioral support
rate modification applied to each fifteen-minute billing unit of service is
contained in appendix A to this rule.
(a) The
department shall determine that an individual meets the criteria for the
behavioral support rate modification when:
(i)
The individual has been assessed within the last twelve months to present a
danger to self or others or have the potential to present a danger to self or
others; and
(ii) A behavioral
support strategy that is a component of the individual service plan has been
developed in accordance with the requirements in rules established by the
department; and
(iii) The
individual either:
(a) Has a response of "yes"
to at least four items in question thirty-two of the behavioral domain of the
Ohio developmental disabilities profile; or
(b) Requires a structured environment that,
if removed, will result in the individual's engagement in behavior destructive
to self or others.
(b) The duration of the behavioral support
rate modification shall be limited to the individual's waiver eligibility span,
may be determined needed or no longer needed within that waiver eligibility
span, and may be renewed annually.
(c) The purpose of the behavioral support
rate modification is to provide funding for the implementation of behavioral
support strategies by staff who have the level of training necessary to
implement the strategies; the department retains the right to verify that staff
who implement behavioral support strategies have received training (e.g.,
specialized training recommended by clinicians or the team or training
regarding an individual's behavioral support strategy) that is adequate to meet
the needs of the individuals served.
(5) Payment rates for routine
homemaker/personal care provided to individuals enrolled in the individual
options waiver shall be adjusted by the complex care rate modification to
reflect the needs of an individual requiring total support from others upon
determination by the county board that the individual meets the criteria set
forth in paragraph (F)(5)(a) of this rule. The amount of the complex care rate
modification applied to each fifteen-minute billing unit of service is
contained in appendix A to this rule.
(a) The
county board shall determine that an individual meets the criteria for the
complex care rate modification based on the individual's responses to specific
questions on the Ohio developmental disabilities profile that indicate that the
individual:
(i) Must be transferred and
moved; and
(ii) Cannot walk, roll
from back to stomach, or pull himself or herself to a standing position;
and
(iii) Requires total support in
toileting, taking a shower or bath, dressing/ undressing, and eating.
(b) The duration of the complex
care rate modification shall be limited to the individual's waiver eligibility
span, may be determined needed or no longer needed within that waiver
eligibility span, and may be renewed annually.
(6) Payment rates for routine
homemaker/personal care shall be adjusted by the medical assistance rate
modification to reflect the needs of an individual requiring medical assistance
upon determination by the county board that the individual meets the criteria
set forth in paragraph (F)(6)(a) of this rule. The amount of the medical
assistance rate modification applied to each fifteen-minute billing unit of
service is contained in appendix A to this rule.
(a) The county board shall determine that an
individual meets the criteria for the medical assistance rate modification
when:
(iii)(ii) The individual
requires a nursing procedure or nursing task that a licensed nurse agrees to
delegate in accordance with rules in Chapter 4723-13 of the Administrative
Code, which is provided in accordance with section
5123.42
of the Revised Code, and when such nursing procedure or nursing task is not the
administration of oral prescribed medication,
or topical prescribed medication, oxygen, or metered dose inhaled medication, or a
health-related activity as defined in rule
5123:2-6-01
of the Administrative Code.
(i) The individual requires routine
feeding and/or the administration of prescribed medication through gastrostomy
or jejunostomy tube, and/or requires the administration of routine doses of
insulin through subcutaneous injection or insulin pump; or
(ii) The individual requires oxygen
administration that a licensed nurse agrees to delegate in accordance with
rules in Chapter 4723-13 of the Administrative Code; or
(b) The duration of the medical assistance
rate modification shall be limited to the individual's waiver eligibility span,
may be determined needed or no longer needed within that waiver eligibility
span, and may be renewed annually.
(7) Payment rates for routine
homemaker/personal care shall be adjusted by the staff competency rate
modification when homemaker/personal care is provided by independent providers
or staff of agency providers who meet the criteria set forth in paragraph
(F)(7)(a) of this rule and as determined in accordance with, as applicable,
paragraph (F)(7)(b) or (F)(7)(c) of this rule. The amount of the staff
competency rate modification applied to each fifteen-minute billing unit of
service is contained in appendix A to this rule.
(a) An independent provider or a staff member
of an agency provider shall be determined eligible for the staff competency
rate modification when he or she:
(i) Has
successfully completed at least two years of full-time (or equivalent
part-time) paid work experience providing direct services to individuals;
and
(ii) Either:
(a) Holds a "Professional Advancement Through
Training and Education in Human Services" or "DSPaths" certificate of initial
proficiency or certificate of advanced proficiency; or
(b) Within the past five years has
successfully completed at least sixty hours of competency-based training with
proof of successful completion that is available for print, download, or issued
to the learner that includes the name of the learner, the course title, the
completion date, and the number of hours of training completed. For purposes of
this paragraph, "competency-based training" means online or in-person training
in topics not otherwise required by rule 5123-2-08, rule 5123-2-09, rule
5123-17-02,
Chapter 5123:2-3, Chapter 5123-3, Chapter 5123:2-9, or Chapter 5123-9 of the
Administrative Code that:
(i) Is accredited by
the "National Alliance for Direct Support Professionals"; or
(ii) Is approved by the department for
purposes of the staff competency rate modification.
(b)
Eligibility for the staff competency rate modification for an independent
provider shall be determined by the department when documentation submitted by
the independent provider through the department's website (http://dodd.ohio.gov) demonstrates that the
independent provider meets the criteria set forth in paragraph (F)(7)(a) of
this rule.
(c) Eligibility for the
staff competency rate modification for a staff member of an agency provider
shall be determined by the employing agency provider. The employing agency
provider shall review, verify, and maintain documentation that demonstrates
that the staff member meets the criteria set forth in paragraph (F)(7)(a) of
this rule.
(d) The cost of a staff
competency rate modification is excluded from an individual's waiver budget
limitation.
(8) Payment
rates for routine homemaker/personal care may be modified to reflect the needs
of individuals enrolled in the individual options waiver who formerly resided
at developmental centers when the following conditions are met:
(a) The individual was a resident of a
developmental center immediately prior to enrollment in the individual options
waiver;
(b) Homemaker/personal care
is identified in the individual service plan as a service to be delivered and
the individual begins receiving the service on or after July 1, 2011;
and
(c) The director of the
department determines that the rate modification is warranted due to
time-limited cost increases experienced when individuals move from
institutional settings to community-based settings.
(9) Payment rates for routine
homemaker/personal care may be modified to reflect the needs of individuals
enrolled in the individual options waiver who formerly resided at intermediate
care facilities for individuals with intellectual disabilities when the
following conditions are met:
(a) The
individual was a resident of an intermediate care facility for individuals with
intellectual disabilities immediately prior to enrollment in the individual
options waiver;
(b) As a result of
the individual enrolling in the individual options waiver, the intermediate
care facility for individuals with developmental disabilities has reduced its
medicaid-certified capacity;
(c)
Homemaker/personal care is identified in the individual service plan as a
service to be delivered and the individual begins receiving the service on or
after April 1, 2013; and
(d) The
director of the department determines that the rate modification is warranted
due to time-limited cost increases experienced when individuals move from
institutional settings to community-based settings.
(10) The amount of the payment rate
modifications set forth in paragraphs (F)(8) and (F)(9) of this rule shall be
limited to fifty-two cents for each fifteen-minute billing unit of routine
homemaker/personal care provided to the individual during the first year of the
individual's enrollment in the individual options waiver.
(11) The team shall use a department-approved
tool to assess and document in the individual service plan when on-site/on-call
may be appropriate.
(a) In making the
assessment, the team shall consider:
(i)
Medical or psychiatric condition which requires supervision or supports
throughout the night;
(ii)
Behavioral needs which require supervision or supports throughout the
night;
(iii) Sensory or motor
function limitations during sleep hours which require supervision or supports
throughout the night;
(iv) Special
dietary needs, restrictions, or interventions which require supervision or
supports throughout the night;
(v)
Other safety considerations which require supervision or supports throughout
the night; and
(vi) Emergency
action needed to keep the individual safe.
(b) A provider shall be paid at the
on-site/on-call rate for homemaker/personal care contained in appendix A to
this rule when:
(i) Based upon assessed and
documented need, the individual service plan indicates the days of the week and
the beginning and ending times each day when it is anticipated that an
individual will require on-site/on-call; and
(ii) On-site/on-call does not exceed eight
hours for the individual in any twenty-four-hour period.
(c) During an authorized on-site/on-call
period, a provider shall be paid the routine homemaker/personal care rate
instead of the on-site/on-call rate for a period of time when an individual
receives supervision or supports. In these instances, the provider shall
document the date and beginning and ending times during which supervision or
supports were provided to the individual.
(d) The payment rate modifications set forth
in paragraphs (F)(4), (F)(5), (F) (6), (F)(7), (F)(8), and (F)(9) of this rule
are not applicable to the on-site/ on-call payment rates for homemaker/personal
care.
(12) Payment for
homemaker/personal care shall not include room and board, items of comfort and
convenience, or costs for the maintenance, upkeep, and improvement of the home.
Notes
Promulgated Under: 119.03
Statutory Authority: 5123.04, 5123.049, 5123.1611
Rule Amplifies: 5123.04, 5123.045, 5123.049, 5123.16, 5123.161, 5123.1611, 5166.21
Prior Effective Dates: 07/24/1995, 04/28/2003, 07/01/2005, 04/20/2006, 07/01/2006, 07/01/2007, 12/21/2007 (Emer.), 03/20/2008, 07/01/2010, 04/19/2012, 09/01/2013, 01/01/2014, 07/01/2014, 01/01/2016, 04/01/2017, 09/01/2017, 02/15/2018, 07/05/2018, 01/01/2019, 01/01/2020, 01/01/2021, 10/01/2021
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.