Or. Admin. Code § 410-172-0830

Current through Register Vol. 63, No. 12, December 1, 2024

Section 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.

Or. Admin. Code § 410-172-0830

DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 32-2015, f. 6-24-15, cert. ef. 6/26/2015; DMAP 36-2021, temporary amend filed 09/14/2021, effective 9/14/2021 through 3/12/2022; DMAP 38-2022, amend filed 03/23/2022, effective 3/23/2022

Statutory/Other Authority: ORS 413.042 & 430.640

Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715