Ohio Admin. Code 5123-9-32 - Home and community-based services waivers - participantdirected homemaker/personal care under the individual options, level one, and self-empowered life funding waivers
(A) Purpose
This rule defines participant-directed 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) "Agency with
choice" means an arrangement available to an individual enrolled in the
self-empowered life-funding waiver whereby an agency provider acts as a
co-employer with the individual for purposes of provision of
participant-directed homemaker/personal care. Under this arrangement, the
individual is responsible for recruiting, selecting, training, and supervising
the persons providing participant-directed homemaker/personal care. Agency with
choice enables the individual to exercise choice and control over services
without the burden of carrying out financial matters and other legal
responsibilities associated with the employment of workers. The agency provider
is considered the employer of staff and assumes responsibility for:
(4)(5) "Co-employer" means
an arrangement available to an individual enrolled in the self-empowered life
funding waiver whereby either an agency with choice or a financial management
services entity under contract with the state functions as the employer of
staff recruited by the individual. The individual directs the staff and is
considered their co-employer. The agency with choice or financial management
services entity conducts all necessary payroll functions and is legally
responsible for the employment-related functions and duties for
individual-selected staff based on the roles and responsibilities identified in
the individual service plan for the two co-employers.
(5)(6)
"Common law employee" means a natural person certified by the department to
provide participant-directed homemaker/personal care to an individual who is
exercising employer authority. A common law employee shall
will not
employ, either directly or through contract, anyone else to provide
participant-directed homemaker/personal care.
(6)(7) "Common law
employer" means an arrangement available to an individual enrolled in the
individual options, level one, or self-empowered life funding waiver whereby
the individual is the legally responsible employer of persons selected by the
individual to furnish supports. The individual hires, supervises, and
discharges those persons. The individual is liable for the performance of
necessary employment-related tasks and uses a financial management services
entity under contract with the state to perform necessary payroll and other
employment-related functions as the individual's agent in order to ensure that
the employer-related legal obligations are fulfilled.
(7)(8)
"County board" means a county board of developmental disabilities.
(8)(9)
"Department" means the Ohio department of developmental disabilities.
(9)(10)
"Employer authority" means the individual has the authority to recruit, hire,
supervise, and direct the persons who furnish participant-directed
homemaker/personal care and functions as either the co-employer or the common
law employer of those persons.
(10)(11) "Family" means a
person who is related to the individual by blood, marriage, or
adoption.
(11)(12) "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.
(12)(13)
"Financial management services" means services provided to an individual who
directs some or all of his or her
the individual's waiver services. When used in
conjunction with employer authority, financial management services includes,
but is not limited to, operating a payroll service for individual-employed
staff and making required payroll withholdings.
(13)(14) "Group employment
support" has the same meaning as in rule
5123-9-16 of the Administrative
Code.
(14)(15) "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.
(15)(16)
"Individual employment support" has the same meaning as in rule
5123-9-15 of the Administrative
Code.
(16)(17) "Individual
service plan" means the written description of services, supports, and
activities to be provided to an individual.
(18)(19) "Non-medical
transportation" has the same meaning as in rule
5123-9-18 of the Administrative
Code.
(19)(20) "Ohio
developmental disabilities profile" means the standardized instrument utilized
by the department to assess the relative needs and circumstances of an
individual compared to other individuals.
(20)(21) "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 participant-directed 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.
(21)(22)
"Participant-directed 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 and chooses to
exercise employer authority. Participant-directed 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 participant-directed homemaker/personal care include:
(22)(23) "Provider" means
an agency with choice or a common law employee.
(23)(24) "Residential
respite" has the same meaning as in rule
5123-9-34 of the Administrative
Code.
(24)(25) "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.
(26)(27) "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.
(27)(28) "Vocational
habilitation" has the same meaning as in rule
5123-9-14 of the Administrative
Code.
(28)(29) "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) Employing and paying staff who have been
selected by the individual;
(b)
Reimbursing allowable services;
(c)
Withholding, filing, and paying federal, state, and local income and employment
taxes; and
(d) Providing other
supports to the individual as described in the individual service
plan.
(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 participant-directed 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) Participant-directed homemaker/personal
care provided to an individual enrolled in the individual options waiver or the
level one waiver shall
will be provided by a common law
employee.
(2) Participant-directed
homemaker/personal care provided to an individual enrolled in the
self-empowered life funding waiver shall
will be provided by a common law employee or an
agency with choice.
(3) A provider
of participant-directed homemaker/personal care shall
will meet the
requirements of this rule and have a medicaid provider agreement with the Ohio
department of medicaid.
(4) Neither
a county board nor a regional council of governments formed under section
5126.13 of the Revised Code by
two or more county boards shall
will provide participant-directed
homemaker/personal care.
(5) A
provider of participant-directed homemaker/personal care is subject to the
requirements of rule
5123-2-08 or
5123-2-09 of the Administrative
Code, as applicable, except that:
(a) A common
law employee need not hold a high school diploma or certificate of high school
equivalence, "American Red Cross" or equivalent certification in first aid, or
"American Red Cross" or equivalent certification in cardiopulmonary
resuscitation unless specifically required to do so by the individual receiving
services; and
(b) A common law
employee need not complete the eight hours of annual training described
on page two of
in appendix A to rule
5123-2-09 of the Administrative
Code unless specifically required to do so by the individual receiving
services, but in any case shall
will annually complete training in accordance
with standards established by the department in:
(i) The rights of individuals set forth in
section 5123.62 of the Revised Code;
and
(ii) Rule
5123-17-02 of the Administrative
Code including a review of health and welfare alerts issued by the department
since the previous year's training.
(6) A provider of participant-directed
homemaker/personal care shall
will not administer medication or perform
health-related activities unless the provider meets the applicable requirements
of Chapters 4723., 5123., and 5126. of the Revised Code and rules adopted under
those chapters.
(7) An applicant
seeking certification to provide participant-directed 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.
(8) The individual
receiving participant-directed homemaker/personal care
shall
will
determine training to be completed by the common law employee or staff of the
agency with choice as necessary to meet the individual's unique
needs.
(D)
Requirements for service delivery(8)(9) A provider
shall
will
not bill for participant-directed homemaker/personal care provided by the
driver during the same time non-medical transportation at the per-trip rate is
provided.
(9)(10) The ratio of
persons providing participant-directed homemaker/personal care to the
individuals being served shall
will not exceed one to three.
(10)(11)
A provider of participant-directed 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.
(11)(12) A provider
delivering participant-directed homemaker/personal care 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.
(1) The
individual receiving participant-directed homemaker/personal care or the
individual's guardian or the individual's designee must be willing and able to
perform the duties associated with participant direction.
(2) Participant-directed 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.
(3) An individual enrolled in
the individual options waiver or the level one waiver may receive
participant-directed homemaker/personal care only when living alone or with
family.
(4) A provider of
participant-directed homemaker/personal care shall
will not also
provide money management or shared living to the same individual.
(5) Participant-directed homemaker/personal
care shall
will not be provided to an individual at the same time
as residential respite.
(6)
Participant-directed 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.
(7)
Participant-directed homemaker/personal care services may extend to those times
when the individual is not physically present and the common law employee is
performing homemaker activities on behalf of the individual.
(8)
Participant-directed 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)
Participant-directed 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)
Participant-directed 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 participant-directed homemaker/personal care is
awake;
(d)
A maximum of sixteen hours of participant-directed
homemaker/personal care per day may be provided to an individual in an acute
care hospital;
(e)
An individual may receive participant-directed
homemaker/personal care in an acute care hospital on no more than thirty
calendar days per waiver eligibility span; and
(f)
The cost of
participant-directed 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
(1) Service documentation for
participant-directed homemaker/personal care shall
will include each of the following to
validate payment for medicaid services:
(a)
Type of service.
(b) Date of
service.
(c) Place of
service.
(d) Name of individual
receiving service.
(e) Medicaid
identification number of individual receiving service.
(f) Name of provider.
(g) Provider identifier/contract
number.
(h) Written or electronic
signature of the person delivering the service.
(i) Group size in which the service was
provided.
(j) 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.
(k) Number of units of
the delivered service or continuous amount of uninterrupted time during which
the service was provided.
(l) Times
the delivered service started and stopped.
(2) A common law employee
shall
will
prepare an accurate time sheet to be verified by the individual receiving
participant-directed homemaker/personal care prior to submission to the
financial management services entity.
(F) Payment standards
(1) The billing unit, service codes, and
payment rates for participant-directed homemaker/personal care
provided January 1, 2024 through June 30, 2024
are contained in the appendix
A to this rule. The
billing unit, service codes, and payment rates for participant-directed
homemaker/personal care provided on or after July 1, 2024 are contained in
appendix B to this rule.
(2)
The payment rates for participant-directed homemaker/personal care provided by
a common law employee shall be
are negotiated by the individual and the common
law employee subject to the minimum and maximum payment rates contained in
the
as
applicable, appendix A or appendix B to
this rule and shall
will be recorded in the individual service plan. An
individual who meets the criteria for a rate modification described in
paragraph (F)(4), (F)(5), or (F)(6) of this rule may choose to add the
applicable rate modification to the negotiated base payment rate.
(3) The payment rates for
participant-directed homemaker/personal care shall
be
are adjusted to reflect the number of
individuals being served and the number of persons providing
services.
(4) Payment rates for
routine participant-directed homemaker/personal care may 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
the
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
participant-directed homemaker/personal care may 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)(5)(a) of this rule. The amount of
the medical assistance rate modification applied to each fifteen-minute billing
unit of service is contained in the
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.
(6) Payment rates for routine
participant-directed homemaker/personal care provided to individuals enrolled
in the individual options waiver may 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)(6)(a) of this rule. The amount of the
complex care rate modification applied to each fifteen-minute billing unit of
service is contained in the
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.
(7) 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
participant-directed homemaker/personal care contained in
the
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 participant-directed
homemaker/personal care rate instead of the on-site/on-call rate for a period
of time when an individual receives supports. In these instances, the provider
shall
will
document the date and beginning and ending times during which supports were
provided to the individual.
(d) The
payment rate modifications described in paragraphs (F)(4), (F)(5), and (F)(6)
of this rule are not applicable to the on-site/on-call payment rates for
participant-directed homemaker/personal care.
(8) Payment for participant-directed
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 participant-directed 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: 02/01/2018, 01/01/2019, 01/01/2020, 01/01/2021, 10/01/2021, 01/01/2022
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