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
(2)(3) "Agency provider"
has the same meaning as in
means an entity that directly employs at least one
person in addition to a director of operations for the purpose of providing
services for which the entity is certified in accordance with rule
5123-2-08 of the Administrative
Code.
(3)(4) "County board"
means a county board of developmental disabilities.
(4)(5) "Department" means
the Ohio department of developmental disabilities.
(5)(6) "Developmental
center" means a state-operated
department-operated intermediate care facility
for individuals with intellectual disabilities.
(6)(7) "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
will be added together for the purpose of
calculating the number of fifteen-minute billing units for the day.
(7)(8)
"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)(9) "Group employment
support" has the same meaning as in rule
5123-9-16 of the Administrative
Code.
(9)(10) "Group size" means
the number of individuals who are sharing services, regardless of the funding
source for those services.
(10)(11)
"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
the individual's home and community
and helps the individual meet daily living needs. Examples of supports that may
be provided as homemaker/personal care include:
(11)(12)
"Independent provider" has the same meaning as
in
means a self-employed person who provides
services for which the person is certified in accordance with rule
5123-2-09 of the Administrative
Code and does not employ, either directly or through
contract, anyone else to provide the services.
(12)(13) "Individual"
means a person with a developmental disability or for purposes of giving,
refusing to give, or withdrawing consent for services,
his or her
the
person's guardian in accordance with section
5126.043 of the Revised Code or
other person authorized to give consent.
(13)(14)
"Individual employment support" has the same meaning as in rule
5123-9-15 of the Administrative
Code.
(14)(15) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual.
(15)(16) "Intermediate
care facility for individuals with intellectual disabilities" has the same
meaning as in section
5124.01 of the Revised
Code.
(17)(18) "Non-medical
transportation" has the same meaning as in rule
5123-9-18 of the Administrative
Code.
(18)(19) "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)(20) "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. This rate and service may
only be authorized in the residence of the individual or at another location in
the community selected by the individual other than the residence of the
provider of the service.
(20)(21) "Residential
respite" has the same meaning as in rule
5123-9-34 of the Administrative
Code.
(21)(22) "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
includes the items delineated in paragraph (E) of
this rule to validate payment for medicaid services.
(23)(24) "Team"
has the same meaning as in rule 5123-4-02 of the
Administrative Code
means the group of persons
chosen by an individual with the core responsibility to support the individual
in directing development of the individual service plan. The team includes the
individual's guardian or adult whom the individual has identified, as
applicable, the service and support administrator, direct support
professionals, providers, licensed or certified professionals, and any other
persons chosen by the individual to help the individual consider possibilities
and make decisions.
(24)(25) "Vocational
habilitation" has the same meaning as in rule
5123-9-14 of the Administrative
Code.
(25)(26) "Waiver
eligibility span" means the twelve-month period following either an
individual's initial waiver enrollment date or a subsequent eligibility
re-determination date.
For the purposes of this rule, the following definitions
shall apply:
(1)
"Acute care
hospital" means a hospital that provides inpatient medical care and other
related services for surgery, acute medical conditions, or injuries (usually
for a short-term illness or condition).
(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
Implementation of
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.
(C) Provider qualifications
(1) Homemaker/personal care
shall
will 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
will 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
will
complete and submit an application through the
department's website (http://dodd.ohio.gov)
and adhere to the requirements of as applicable, rule
5123-2-08 or
5123-2-09 of the Administrative
Code.
(4) Providers licensed
under section 5123.19 of the Revised Code
seeking to provide homemaker/personal care shall
will:
(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 Chapter 5123-3 of the
Administrative Code may result in denial, suspension, or revocation of the
provider's license.
(D)
Requirements for service delivery(7)(8) A
provider of homemaker/personal care shall
will 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)(9) A provider
delivering homemaker/personal care in fifteen-minute billing units in
accordance with this rule, excluding on-site/on-call,
shall
will
utilize electronic visit verification in accordance with rule
5160-1-40 of the Administrative
Code.
(9)(10) An agency provider
shall
will
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.
(1)
Homemaker/personal care shall
will be provided pursuant to an individual
service plan that conforms to the requirements of rule
5123-4-02 of the Administrative
Code. Providers shall
will 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
will not also provide money management or shared
living to the same individual.
(3)
Homemaker/personal care shall
will 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
will 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
will 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)
Homemaker/personal care may be provided to an individual in an acute care
hospital to address the individual's intensive personal care, behavioral
support/stabilization, or communication needs when the following conditions are
met:
(a)
Homemaker/personal care is necessary to ensure smooth
transition between the acute care hospital and the individual's home and to
preserve the individual's functional abilities;
(b)
Homemaker/personal care is not a substitute for services the
acute care hospital provides or is obligated to provide (e.g., attendant care)
through its conditions of participation, federal law, state law, or other
applicable requirement;
(c)
The person providing homemaker/personal care is
awake;
(d)
A maximum of sixteen hours of homemaker/personal care
per day may be provided to an individual in an acute care
hospital;
(e)
An individual may receive homemaker/personal care in an
acute care hospital on no more than thirty calendar days per waiver eligibility
span; and
(f)
The cost of homemaker/personal care provided to an
individual in an acute care hospital can be accommodated by the individual's
budget authorized in the medicaid services system.
(E) Documentation of services
Service documentation for homemaker/personal care
shall
will
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 provided
January 1, 2024 through June 30, 2024 are contained in appendix A to this
rule. The billing units, service codes, and payment
rates for homemaker/personal care provided on or after July 1, 2024 are
contained in appendix B 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
C to this rule. The department may cause
independent providers to be paid a rate that exceeds the payment rates
contained in appendix A or appendix B 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
will 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
is
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
is
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
is
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, as applicable, the "Application of Appendix A to
Rule 5123-9-30"
(January 1, 2022), which is available at the
department's website (http://dodd.ohio.gov)
or
the "Application of Appendix B to Rule
5123-9-30" available at
https://dodd.ohio.gov.
(4) Payment rates for routine
homemaker/personal care shall
will 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 as applicable, appendix A
or appendix B to this rule.
(a) The department shall
will 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
is 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
will 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 as applicable, appendix A
or appendix B to this rule.
(a) The county board
shall
will
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
self 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
is 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
will 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 as applicable, appendix A
or appendix B to this rule.
(a) The county board
shall
will
determine that an individual meets the criteria for the medical assistance rate
modification when:
(i) The individual
requires routine feeding and/or the
administration of fluid, nutrition, and/or
prescribed medication through gastrostomy or jejunostomy tube,
; and/or requires
the administration of routine doses of
insulin through subcutaneous injection,
inhalation, or insulin pump; and/or requires the
administration of medication for the treatment of metabolic glycemic disorder
by subcutaneous injection; or
(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, topical prescribed medication, oxygen, or metered dose
inhaled medication, or a health-related activity as defined in rule
5123:2-6-01
5123-6-01 of the Administrative Code.
(b) The duration of the medical
assistance rate modification shall be
is 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
will 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 as applicable, appendix A
or appendix B to this rule.
(a) An independent provider or a staff member
of an agency provider shall
will be determined eligible for the staff
competency rate modification when he or she
the independent provider or staff member:
(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
will 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
will be
determined by the employing agency provider. The employing agency provider
shall
will
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
is
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
will 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
will 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.
;
and
(vii)
On-site/on-call will be delivered in the residence of
the individual or at another location in the community selected by the
individual other than the residence of the provider of the
service.
(b) A
provider shall
will be paid at the on-site/on-call rate for
homemaker/personal care contained in as
applicable, appendix A or appendix B 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
will 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
will
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
does not include room and board, items of comfort
and convenience, or costs for the maintenance, upkeep, and improvement of the
home in which homemaker/personal care is
provided.
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, 01/01/2022
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