Oklahoma Department of Human Services
Sequoyah Memorial Office Building, 2400 N. Lincoln Blvd. • Oklahoma City, OK 73105
(405) 521-3646 • Fax (405) 521-6684 • Internet: www.okdhs.org
 
317:35-15-13.2. Individual Personal Care contractor; billing, training, and problem resolution
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Revised 7-1-13

 

     While OHCA is the contractor authorized under federal law, the Oklahoma Department of Human Services (OKDHS) initiates initial contracts with qualified individuals for provision of Personal Care services as defined in OAC 317:35-15-2.  • 1 The contract renewal for the PCA is the responsibility of the Oklahoma Health Care Authority (OHCA).

  • (1) Payment for Personal Care.  Payment for Personal Care is generally made for care in the member's own home.  A rented apartment, room or shelter shared with others is considered "own home".  A facility that meets the definition of a nursing facility, room and board, licensed residential care facility, licensed assisted living facility, group home, rest home or a specialized home as set forth in O.S. Title 63, Section 1-819 et seq., Section 1-890.1 et seq., and Section 1-1902 et seq., does not constitute a suitable substitute home.  Personal Care may not be approved if the member lives in the PCA's home except with the interdisciplinary team's written approval.  • 2  The potential individual PCA must meet the minimum requirements under (2) of this subsection.  With OKDHS area nurse approval, or for ADvantage waiver members, with service plan authorization and ADvantage Program Manager approval, Personal Care services may be provided in an educational or employment setting to assist the member in achieving vocational goals identified on the service plan.  • 3
    • (A) Reimbursement.  Personal Care payment for a member is made according to the number of units of service identified in the service plan.
      • (i) The unit amounts paid to individual contractors is according to the established rates.  A service plan will be developed for each eligible individual in the home and units of service assigned to meet the needs of each member. The service plans will combine units in the most efficient manner to meet the needs of all eligible persons in the household.
      • (ii) From the total amounts billed by the individual PCA in (i) of this subparagraph, the OHCA (acting as agent for the member-employer) withholds the appropriate percentage of FICA tax and sends it to the Internal Revenue Service as the individual contractor's contribution toward Social Security coverage.  To assure that the individual contractor's social security account may be properly credited, it is vital that the individual contractor's social security number be entered correctly on each claim. In order for the OHCA to withhold FICA tax, the LTC nurse must obtain a signed OHCA Form HCA-66, Authorization for Withholding of FICA Tax in Personal Care, from the member as soon as the area nurse, or designee, has approved Personal Care.  A copy of the signed HCA-66 must be in the case record.  A signed OHCA-0026, Personal Care Program Individual Contract, must be on file with the OHCA before the individual contractor's first claim can be submitted.
      • (iii) The contractor payment fee covers all Personal Care services included on the service and care plans developed by the LTC nurse or ADvantage case manager.  Payment is made for direct services and care of the eligible member(s) only.  The area nurse, or designee, authorizes the number of units of service the member receives each month.
      • (iv) A member may select more than one individual  contractor.  This may be necessary as indicated by the service and care plans.
      • (v) The individual contractor may provide SoonerCare Personal Care services for several households during one week, as long as the daily number of paid service units do not exceed eight per day.  The total number of hours per week cannot exceed 40.
    • (B) Release of wage and/or employment information for individual contractors.  Any inquiry received by the local office requesting wage and/or employment information for an individual Personal Care contractor will be forwarded to the OHCA, Claims Resolution.
  • (2) Member selection of individual PCA.  Members and/or family members recruit, interview, conduct reference checks, and select the individual to be considered as an individual contractor.  Prior to placing a Personal Care service provider in the member's home, an OSBI background check and registry check must be completed in accordance with Section 1-1944 through 1-1948 of Title 63 of the Oklahoma Statutes. The OKDHS LTC nurse must also check the Certified Nurse Aid Registry.  The OKDHS LTC nurse must affirm that the applicant's name is not contained on any of the registries.  The LTC nurse will notify the OHCA if the applicant is on the registry.
    • (A) Persons eligible to serve as individual Personal Care Assistants.  Payment is made for Personal Care Services to an individual who:
      • (i) is at least 18 years of age,
      • (ii) has no pending notation related to abuse, neglect or exploitation as reported by the Oklahoma State Department of Health Nurse Aide Registry,
      • (iii) has no criminal background history or registry listings that prohibit employment,
      • (iv) demonstrates the ability to understand and carry out assigned tasks,   • 4
      • (v) is not a legally responsible family member (spouse, legal guardian, or parent of a minor child) of the member being served,
      • (vi) has a verifiable work history and/or personal references, verifiable identification, and
      • (vii) meets any additional requirements as outlined in the contract and certification requirements with the Oklahoma Health Care Authority.  •
    • (B) Persons ineligible to serve as Personal Care Assistants. Payment from SoonerCare funds for Personal Care services may not be made to an individual who is a legally responsible family member (spouse, legal guardian, or parent of a minor child) of the member to whom he/she is providing personal care services.
      • (i) Payment cannot be made to a OKDHS or OHCA employee.  Payment cannot be made to an immediate family member of an OKDHS employee who works in the same county without OKDHS/Aging Services Division approval.  When a family member relationship exists between an OKDHS LTC nurse and a PCA in the same county, the LTC nurse cannot manage services for a member whose individual provider is a family member of the LTC nurse.
      • (ii) If it is determined that an employee is interfering in the process of providing Personal Care Services for personal or family benefit, he/she will be subject to disciplinary action.
  • (3) Orientation of the Personal Care Assistant.  When a member selects an individual PCA, the LTC nurse contacts the individual to report to the county office to complete the ODH form 805, Uniform Employment Application for Nurse Aide Staff, and the OKDHS form 06PE039E, Employment Application Supplement, and for a determination of qualifications and orientation.  This process is the responsibility of the LTC nurse.  • 6  The PCA can begin work when:
    • (A) he/she has been interviewed by the member,
    • (B) he/she has been oriented by the LTC nurse,
    • (C) he/she has executed a contract (OHCA-0026) with the OHCA,
    • (D) the effective service date has been established,
    • (E) all registries have been checked and the PCA's name is not listed,
    • (F) the Oklahoma State Department of Health Nurse Aide Registry has been checked and no notations found, and
    • (G) the OSBI background check has been completed.
  • (4) Training of Personal Care Assistants.  It is the responsibility of the LTC nurse to make sure for each client, that the PCA has the training needed to carry out the plan of care prior to service initiation.
  • (5) Problem resolution related to the performance of the Personal Care Assistant.  When it comes to the attention of the LTC nurse or worker that there is a problem related to the performance of the PCA, a counseling conference is held between the member, LTC nurse and worker.  The LTC nurse will counsel the PCA regarding problems with his/her performance.  Counseling is considered when the staff believe that counseling will result in improved performance.  • 7
  • (6) Termination of the PCA Provider Agreement.
    • (A) A recommendation for the termination of a PCA's contract is submitted to the OHCA and the services of the PCA are suspended immediately when:
      • (i) a PCA's performance is such that his/her continued participation in the program could pose a threat to the health and safety of the member or others; or
      • (ii) the PCA failed to comply with the expectations outlined in the PCA Provider Agreement and counseling is not appropriate or has not been effective; or
      • (iii) a PCA's name appears on the OKDHS Community Services Worker Registry, any of the registries listed in Section 1-1947 of Title 63 of the Oklahoma Statutes, even though his/her name may not have appeared on the Registry at the time of application or hiring.
    • (B) The LTC nurse makes the recommendation for the termination of the PCA to the OKDHS State Office Aging Services Division who then notifies the OHCA Legal Division of the recommendation. When the problem is related to allegations of abuse, neglect, or exploitation, OKDHS Adult Protective Services, State Attorney General's Medicaid Unit, the OHCA, and the Oklahoma State Department of Health are notified by the LTC nurse.
    • (C) When the problem is related to allegations of abuse, neglect or exploitation, the LTC nurse follows the process as outlined in OAC 340:100-3-39.

 

INSTRUCTIONS TO STAFF

 

1.    LTC nurse responsibilities in the provision of Medicaid Personal Care Services.

Determines and documents an individual's competency to meet the needs of each client prior to the initiation of Personal Care Services.

Provides and documents ongoing training to the PCA based upon the needs of the PCA and/or the needs of the client.

Utilizes the plan of care to determine the training needs of the PCA for each client assigned and implements the plan of care that meets the needs of each client.

Reports any PCA suspected of abuse, neglect or exploitation to the DHS Adult Protective Services staff, the Attorney General's Medicaid Unit and the Oklahoma Department of Health Nurse Aide Registry.

Prior to service delivery assignment of the PCA, contacts the Oklahoma State Department of Health Nurse Aide Registry for any pending notation related to the abuse, neglect and/or exploitation of a client by a PCA.

Prior to service delivery assignment of the PCA, contacts the Department of Human Services Community Services Worker Registry created pursuant to Section 1025.3 of Title 56 of the Oklahoma Statutes.

An Oklahoma State Bureau of Investigation (OSBI) background check will be initiated prior to the PCA beginning work.

2.    The LTC nurse, with input from the DHS social worker, submits a written request for an exception to the rule for the client receiving Personal Care while living in the PCA's home.  Documentation included with the exception request shall include the name and case number of the client, the name and address of the potential PCA, the client's diagnosis, physical condition and care needs and the reason for the request.

3.    The LTC nurse or Administrative Agent (AA) nurse submits a written request to the area nurse for an exception to the rule restricting provision of Personal Care to the home setting.  Documentation included with the exception request shall include the name and case number of the client, the client's vocational goal(s) and goal justification, the name of the potential PCA, the client's diagnosis and care needs in the vocational setting, the number of hours of care requested per week in the vocational setting and the vocational setting name and address.

4.    An Oklahoma State Bureau of Investigation (OSBI) background check will be initiated prior to the PCA beginning work.  The LTC nurse must complete the DHS form ADM-130, Request for Background Check, and submit it to the DHS-DCFS Fingerprint Processing Section.  The original copy will be returned to the LTC nurse who will file it in the Personal Care Assistant's file.  If the results indicate that the individual PCA may have had a felony charge filed against them, the LTC nurse checks with the county court house indicated for the deposition of the case and notes it on the original copy.  If the PCA was convicted, pled guilty, or pled no contest, he/she cannot serve as a PCA.

5.    When the client selects the individual to be considered as the Personal Care Assistant, the client notifies the county or the LTC nurse.  The LTC nurse makes an appointment for the individual to come to the DHS county office for orientation and determination that the individual meets the minimum qualifications to be a Personal Care Assistant.  The PCA may begin work after a contract is executed by the OHCA and a determination of competency to carry out the plan of care is made by the LTC nurse.  The LTC nurse notifies the social worker of the service effective date and documents it in the client's case record.  The county forwards the original contract to the OHCA, who will be responsible for annual renewal.  Once the client selects the PCA, the social worker updates the authorization file.

6.    Initial interaction between the LTC nurse and the PCA includes, at a minimum:

(A) a determination that the PCA has met the qualifying criteria for Personal Care Service provision and has the knowledge and skill to carry out the assigned task on the plan of care as documented on DHS form AG-24, Documentation of Qualifications to Provide Personal Care Service;

(B) discussion of the role and responsibilities of the PCA;

(C) discussion of the needs of the client and the tasks included on the plan of care, DHS form AG-4, Personal Care Plan;

(D) discussion of the employer/employee relationship between the client and PCA;

(E) assistance in completing OHCA form OHCA-0026, Personal Care Program Individual Contract;

(F) discussion of the method of filing claim for payment and record maintenance;

(G) discussion of the date service is to begin, the number of hours, and the days per week;

(H) discussion of the use of DHS form AG-5, Personal Care Planning Schedule, and DHS form AG-6, Personal Care Service Plan;

(I) FICA information;

(J) when and how to contact the LTC nurse and DHS social worker; and

(K) how to complete the Individual Personal Care Provider Services Record, DHS form AG-PC-8).

7.    A follow-up letter is sent to the PCA stating the reason for counseling and the expected change in performance.  Notice is also given that continued problems will result in a recommendation for termination.  The LTC nurse sends a copy of the PCA letter to the client and files a copy in the county's PCA file and the client's case record maintained by the nurse.

 

Last Updated:  11/6/2013