Or. Admin. Code § 410-172-0830 - Personal Care Attendant Service Assessment, Authorization and Monitoring
(1) The Division
administers the personal care services program and may use a designee also
known as the Independent and Qualified Agent (IQA). The IQA is responsible for:
(a) Receiving and processing requests for
personal care attendant services from any source;
(b) Conducting a BH PCA assessments of
eligible individuals using Agency-provided assessment tools, prior to
initiating services through the BH PCA program and at least every 12 months
following initial authorization to determine program eligibility and level of
service need, and when the individual's circumstances or needs change. The IQA
shall comply with the following:
(A)
Assessment must be performed on all individuals by a PCA Service Coordinator
prior to receiving personal care services to determine their level of need.
Personal Care Services are available to all eligible individuals, including
children who are not in a foster care setting;
(B) In all following reassessments, the PCA
Service Coordinator shall review the individuals service eligibility, the cost
effectiveness of the individual's service plan, and whether the services
provided are medically appropriate and meeting the individual's identified
service needs;
(C) The PCA Service
Coordinator may adjust the number of hours authorized or the types of BH PCA
services included in the individual's service plan and shall authorize a new or
revised service plan based on the individual's current service needs. All
adjustments must be documented in individual's medical record and be authorized
in EVV system.
(c)
Facilitating the PCA enrollment process;
(d) Providing ongoing Service Coordination;
and
(e) Provide notice of action,
including:
(A) Notice of adverse benefit
determination (NOABD) with Medicaid contested case hearing rights to
individuals denied services through the BH PCA program in whole or in part;
or
(B) Notice of determination
describing increases in services hours based on assessed needs; and
(C) The NOABD must be provided to the
individual within the timeframes required by OAR
410-120-1865; and
(D) Notify the requesting provider in
accordance with OAR 410-120-1860 to 1865.
(2) The PCA Service
Coordinator shall meet in person with an individual to perform a personal care
assessment to document the individual's ability to perform the ADL, IADL, and
personal care tasks listed in Oregon Administrative Rule (OAR)
410-172-0780:
(a) An individual's natural supports may
participate in the assessment if requested by the individual or their
representative, if applicable;
(b)
The PCA Service Coordinator shall assess an individual's service needs,
identify the resources required to meet the individual's needs and determine if
the individual is eligible for the BH PCA program or other services;
(c) The PCA Service Coordinator shall meet
with an individual in person at least once every 365 days to reassess the
individual's service needs; or
(d)
When the individual or their legal representative, requests reassessment;
or
(e) When there is documented
evidence indicating the individual's needs or circumstances have
changed.
(3) The PCA
Service Coordinator shall prepare a person-centered service plan identifying
the tasks for which an individual requires assistance and the number of monthly
authorized service hours. The PCA Service Coordinator shall document an
individual's natural supports that currently meet some or all the individual's
service needs:
(a) The service plan shall
describe the tasks to be performed by a qualified provider and shall authorize
the maximum hours that may be reimbursed for those services during a 14-day pay
period;
(b) The PCA Service
Coordinator shall consider the cost effectiveness of services that adequately
meet the individual's service needs when developing person-centered service
plans;
(c) Payment for services
authorized through the BH PCA program shall be prior authorized as described in
OAR 410-172-0650 PCA Service
Coordinator and based on the service needs of an individual as documented in
the individual's written person centered service plan.
(4) The PCA Service Coordinator shall provide
ongoing coordination of services through the BH PCA program, including
authorizing changes in providers and service hours, addressing risks and
monitoring and providing information and referral to an individual when
indicated.
(5) Monitoring is
necessary to ensure the service plan is effectively implemented and adequately
addresses the needs of the individual and includes documentation of:
(a) Quarterly, or more frequent, in-person,
face-to-face asynchronous audio/video telehealth, or telephone interviews with
the individual or their legal representative were completed by the PCA Service
Coordinator, as directed by the individual;
(A) Monitoring preferences shall be
determined by the individual or their legal representative and identified in
the person-centered service plan; and
(B) An in-person monitoring visit shall be
completed annually, or more often, as determined by the individual or their
legal representative.
(b) Services delivered in accordance with the
individual's service plan and applicable Oregon Administrative Rules;
(c) How the person-centered service plan
adequately meets the individual's assessed needs and identified
goals;
(d) Changes in the needs or
status of the individual;
(e)
Follow-up activities identified to ensure the service plan is adjusted to meet
the individual's need.
(6) The Authority may not authorize services
within an eligible individual's home when:
(a) The individual's home has dangerous
conditions that jeopardize the health or safety of the individual or the
provider and necessary safeguards cannot be taken to improve the
setting;
(b) The services cannot be
provided safely by the PCA, in the individual's home;
(c) The individual does not have the ability
to make an informed decision, does not have a designated representative to make
decisions on their behalf, and necessary safeguards cannot be provided to
protect the individual's safety, health, and welfare.
(7) The PCA Service Coordinator shall give an
individual or the individual's representative information on service
alternatives and provide assistance to assess other choices when a provider or
service setting selected by the individual or the individual's representative
is not authorized. Eligible individuals have free choice of
providers.
Notes
Statutory/Other Authority: ORS 413.042 & 430.640
Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715
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