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317:35-15-4. Determination of medical eligibility for Personal Care
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Revised 2-1-09
(a) Eligibility. The OKDHS area nurse, or designee, utilizes the UCAT criteria and professional judgment in determining medical eligibility and level of care. To be eligible for Personal Care services, the individual must:
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(1) have adequate informal supports that contribute to care, or decision making ability as documented on the UCAT, to remain in his/her home without risk to his/her health, safety, and well-being:
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(A) the individual must have the decision making ability to respond appropriately to situations that jeopardize his/her health and safety or available supports that compensate for his/her lack of ability as documented on the UCAT, or
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(B) the individual who has his/her decision making ability, but lacks the physical capacity to respond appropriately to situations that jeopardize health and safety and has been informed by the OKDHS nurse of potential risks and consequences may be eligible;
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(2) require a plan of care involving the planning and administration of services delivered under the supervision of professional personnel;
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(3) have a physical impairment or combination of physical and mental impairments. An individual who poses a threat to self or others as supported by professional documentation may not be approved for Personal Care services;
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(4) not have members of the household or persons who routinely visit the household who, as supported by professional documentation, pose a threat of harm or injury to the individual or other household visitors;
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(5) lack the ability to meet personal care needs without additional supervision or assistance, or to communicate needs to others; and
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(6) require assistance, not of a technical nature, to prevent or minimize physical health regression and deterioration.
(b) Definitions. The following words and terms when used in this subsection, have the following meaning, unless the context clearly indicates otherwise:
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(1) "ADL" means the activities of daily living. Activities of daily living are activities that reflect the member's ability to perform self-care tasks essential for sustaining health and safety such as:
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(A) bathing,
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(B) eating,
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(C) dressing,
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(D) grooming,
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(E) transferring (includes getting in and out of a tub, bed to chair, etc.),
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(F) mobility,
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(G) toileting, and
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(H) bowel/bladder control.
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(2) "ADLs score of three or greater" means the member cannot do one ADL at all or needs some help with two ADLs.
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(3) "ADLs score is two" means the member needs some help with one ADL.
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(4) "Client support very low need" means the member's UCAT Client Support score is zero which indicates in the UCAT assessor's clinical judgment, formal and informal sources are sufficient for present level of member need in most functional areas.
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(5) "Client support low need" means the member's UCAT Client Support score is 5 which indicates in the UCAT assessor's clinical judgment, support from formal and informal sources are nearly sufficient for present level of member need in most functional areas.
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(6) "Client support moderate need" means the UCAT Client Support score is 15, which indicates in the UCAT assessor's clinical judgment formal and informal support is available, but overall, it is inadequate, changing, fragile or otherwise problematic.
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(7) "Client support high need" means the member's UCAT Client Support score is 25 which indicates in the UCAT assessor's clinical judgment, formal and informal supports are not sufficient as there is very little or no support available to meet a high degree of member need.
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(8) "Community Services Worker" means any person employed by or under contract with a community services provider who provides, for compensation or as a volunteer, health-related services, training, or supportive assistance to frail elderly, disabled person(s), or person(s) with developmental disabilities, and who is not a licensed health professional.
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(9) "Community Services Worker Registry" means a registry established by the Oklahoma Department of Human Services, as required by Section 1025.1 et seq. of Title 56 of the Oklahoma Statutes, to list community services workers against whom a final investigative finding of abuse, neglect, or exploitation, as defined in Section 10-103 of Title 43A of the Oklahoma Statutes, involving a frail elderly, disabled person(s) or person(s) with developmental disabilities has been made by OKDHS or an administrative law judge, amended in 2002 to include the listing of SoonerCare personal care assistants providing personal care services.
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(10) "Instrumental activities of daily living" means those activities that reflect the member's ability to perform household chores and tasks within the community essential for sustaining health and safety such as:
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(11) "IADL" means the instrumental activities of daily living.
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(12) "IADLs score is at least six" means the member needs some help with at least three IADLs or cannot do two IADLs at all.
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(13) "IADLs score of eight or greater" means the member needs some help with four IADLs or the member cannot do two IADLs at all and needs some help with one other IADLs.
(14) SoonerCare personal care services provider" means a program, corporation, or individual who provides services under the state's SoonerCare personal care program or ADvantage Waiver to individuals who are elderly or who have a physical disability.
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(15) "MSQ" means the mental status questionnaire.
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(16) "MSQ moderate risk range" means a total weighted score of seven or more which indicates an orientation-memory-concentration impairment or a memory impairment.
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(17) "Nutrition moderate risk" means the total weighted UCAT Nutrition score is 8 or more which indicates poor appetite or weight loss combined with special diet requirements, medications or difficulties in eating.
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(18) "Social resources score is eight or more" means the member lives alone or has no informal support when sick or needs assistance, or has little or no contact with others.
(c) Medical eligibility minimum criteria for Personal Care. The medical eligibility minimum criteria for Personal Care is the minimum UCAT score criteria which a member must meet for medical eligibility for personal care and are:
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(1) functional ADLs score is a five or greater; or IADLs score of eight or greater; or Nutrition score is eight or greater; or the MSQ score is seven or greater; or the ADLs score is three and IADLs score is at least six, and
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(2) Client Support is moderate risk; or Client Support score is five and the Social Resources score is eight or more.
(d) Medical eligibility determination. Medical eligibility for Personal Care is determined by the Oklahoma Department of Human Services. The medical decision for Personal Care is made by the OKDHS area nurse, or designee, utilizing the Uniform Comprehensive Assessment Tool (UCAT).
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(1) When Personal Care services are requested, the local office is responsible for completing the UCAT, Part III.
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(2) Categorical relationship must be established for determination of eligibility for Personal Care. If categorical relationship to Aid to the Disabled has not already been established but there is an extremely emergent need for Personal Care and current medical information is not available, the local office authorizes a medical examination. When authorization is necessary, the county director issues the Authorization for Examination, OKDHS form 08MA016E, and the Report of Physician's Examination, OKDHS form 08MA02E, to a licensed medical or osteopathic physician (refer to OAC 317:30-5-1). The physician cannot be in a medical facility intern, residency, or fellowship program or in the full time employment of the Veterans Administration, Public Health Service or other agency. The OKDHS county worker submits the information to the Level of Care Evaluation Unit (LOCEU) to request a determination of eligibility for categorical relationship. LOCEU renders a decision on categorical relationship using the same definition used by SSA. A follow-up is required by the OKDHS county worker with the Social Security Administration (SSA) to be sure that SSA's disability decision agrees with the decision of LOCEU.
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(3) Approved contract agencies may complete the UCAT Part I for intake and screening and forward the form to the county office.
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(4) When the OKDHS county office does not receive a UCAT from the AA, a UCAT I is initiated by the DHS county staff upon receipt of the referral.
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(5) The OKDHS nurse completes the assessment visit within 10 working days of receipt of the referral for Personal Care from the OKDHS county worker or receipt of the UCAT I(Intake and Screening) request for Personal Care for the member who is SoonerCare eligible at the time of the request. The OKDHS nurse completes the assessment visit within 20 working days of SoonerCare application for the applicant who has not been determined financially SoonerCare eligible at the time of the request. The OKDHS county worker is responsible for contacting the applicant within three working days from the date of the receipt of the request for services to initiate the financial eligibility process. If the UCAT Part I indicates the request is from an individual who resides at home and an immediate response is required to ensure the health and safety of the person (emergency situation) or to avoid institutional placement, the UCAT Part III assessment visit has top priority for scheduling.
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(6) During the assessment visit, the OKDHS nurse completes the UCAT III and reviews with the member rights to privacy, fair hearing and provider choice. The OKDHS nurse informs the member of medical eligibility criteria and provides information about the different OKDHS long-term care service options. The OKDHS nurse documents on the UCAT III whether the member wants to be considered for nursing facility level of care services or if the member is applying for a specific service program. If based upon the information obtained during the assessment, the OKDHS nurse determines the member may be at risk for health and safety, an immediate referral is made to Adult Protective Services (APS). The referral is documented on the UCAT.
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(A) If the member's needs cannot be met by Personal Care services alone, the OKDHS nurse informs the member of the other community long term care service options. The OKDHS nurse assists the member in accessing service options selected by the member in addition to, or in place of, Personal Care services.
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(B) If multiple household members are applying for SoonerCare Personal Care services, the UCAT assessment is done for all the household members at the same time.
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(C) The OKDHS nurse informs the member of the qualified agencies in their local area available to provide services and obtains the member's primary and secondary choice of agencies. If the member or family declines to choose a primary personal care service agency, the OKDHS nurse selects an agency from a list of all available agencies, using a round-robin system. The OKDHS nurse documents the name of the selected personal care service agency.
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(7) The OKDHS nurse completes the UCAT III within three working days of the assessment visit and sends it to the OKDHS area nurse, or designee, for medical eligibility determination. Personal care service eligibility is established as of the date that both medical eligibility is approved and financial eligibility is established.
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(A) If the length of time from the date the initial assessment to the date of service eligibility determination exceeds 60 days, the assessment must be updated as necessary including a new signature and date. A new UCAT and assessment visit is required if the length of time exceeds 90 days.
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(B) Upon establishment of Personal Care service eligibility, the OKDHS nurse contacts the member's preferred personal care service agency, or if necessary, the secondary agency or the agency selected by the rotation system.
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(C) Within one working day of agency acceptance, the OKDHS nurse forwards the referral to the personal care service agency for Service Authorization Model (SAM) packet development. [Refer to OAC 317:35-15-8(a)]. The date the referral is forwarded is the certification effective date.
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(8) Following the development of the Service Authorization Model (SAM) packet by the personal care service agency, and within three working days of receipt of the packet from the agency, the OKDHS nurse reviews the packet to ensure agreement with the plan. Once agreement is established, the packet is forwarded to the OKDHS area nurse or designees for review.
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(9) Within 10 working days of receiving the Service Authorization Model (SAM) packet from the OKDHS nurse, the OKDHS area nurse, or designee, certifies or denies the Service Authorization Model (SAM) packet. If there is certification, the OKDHS area nurse enters into the system the units authorized. Service Authorization Model (SAM) packets that fail to meet authorization are returned to the OKDHS nurse for revision or further justification by the personal care service agency.
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(10) The OKDHS area nurse, or designee, assigns a medical certification period of not more than 36 months. The service plan certification period under the Service Authorization Model (SAM) is for a period of 12 month.
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(11) Once the OKDHS nurse is notified of the service plan authorization, and within one working day, forwards copies of the certified Personal Care Service Plan [OKDHS form 02AG031E (AG-6)] to the agency.
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(12) The OKDHS nurse notifies the OKDHS county worker in writing of the service and the number of authorized personal care service units including the start and end dates. The OKDHS county worker opens the service authorization. These steps are automated via ELDERS. Once the authorization is opened, five Service Authorization Model (SAM) visits by a skilled nurse are automatically authorized.
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