PURPOSE: This rule sets forth standards to be met by any agency which contracts with the Missouri Department of Social Services, Division of Aging for provision of in-home services.

1. (1) The Department of Health and Senior Services (also referred to as the department), Division of Senior Services’ (also referred to as the division) payment to the provider is made on behalf of an eligible client as an act of indirect or third-party reimbursement and is not made as a payment for the purchase of a service. Only those services authorized by the division shall be reimbursable to the provider.
2. (2) The in-home service provider shall deliver services in compliance with the standards set forth in this rule and 13 CSR 70-91.010 Personal Care Program, 13 CSR 70-3.020 Title XIX Provider Enrollment, and 13 CSR 70-3.030 Sanctions for False and Fraudulent Claims for Title XIX Services.
3. (3) Failure of the in-home service provider to comply with the terms of the contract and these standards may constitute a breach of contract.

4. (4) In accordance with the protective service mandate (Chapter 660, RSMo), the division may take immediate action to protect clients from providers who are found to be out of compliance with the requirements of this rule and of any other rule applicable to the inhome services program, when such noncompliance is determined by the division to create a risk of injury or harm to clients.

   1. (A) Evidence of such risk may include:

      1. 1. Unreliable, inadequate, falsified, or

fraudulent documentation of service delivery or training;

1. 2. Failure to deliver services in a reli-

able and dependable manner;

1. 3. Use of in-home service workers who

do not meet the minimum employment requirements or training standards of this rule;

1. 4. Failure to comply with the require-

ments for background screening of employees (sections 660.315, RSMo and 660.317, RSMo); or

1. 5. Discontinuing services outside the

provisions specified in section (16) of this rule without the knowledge and consent of the client for a period of one (1) week or three (3) consecutive scheduled service delivery dates, whichever is shorter.

1. (B) Immediate action may include, but is not limited to:

   1. 1. Removing the provider from any

list of providers, and for clients who request the unsafe and noncomplaint provider, informing the clients of the determination of noncompliance after which any informed choice will be honored by the division; or

1. 2. Informing current clients served by

the provider of the provider’s noncompliance and that the division has determined the provider unable to deliver safe care. Such clients will be allowed to choose a different provider from the list maintained by the division which will then be immediately authorized to provide service to them.

1. (5) The division will not consider any proposal for an in-home services contract and subsequent enrollment as a Medicaid personal care provider under 13 CSR 70-91.010(3) unless the proposal is fully completed, properly attested to or affirmed by a person with the expressed authority to sign the proposal, and contains all required attachments.

   1. (A) The proposal shall be made in the exact legal name of the applicant for a contract. The attachments to the proposal shall include, but are not limited to the following information/copies:

      1. 1. Federal tax identification number;
      2. 2. Most recent corporate annual regis-

tration report filed with the Missouri secretary of state (if applicable);

1. 3. Certificate of Good Standing issued

by the Missouri secretary of state (if applicable);

1. 4. Fictitious name registration filed with

the Missouri secretary of state (if applicable);

1. 5. Corporation by-laws, if the applicant

is a corporation;

1. 6. Operating agreement and manage-

ment agreement, if applicable, if the provider is a limited liability company; and

1. 7. Certificate of Insurance evidencing

the coverage described in subsection (18)(F) of this rule, naming the division as a certificate holder.

1. (B) Upon receipt of a proposal, the division will conduct whatever investigation which, in the division’s discretion, is necessary to determine the applicant’s eligibility for a contract. The decision determining eligibility for a contract may include, but is not limited to, the conduct of the provider and principals of the provider during any prior contractual periods.
2. (C) Prior to the issuance of an initial contract, a site visit will be conducted for inhome service providers entering the program after July 1, 2001.

1. (6) Respite care services are maintenance and supervisory services provided to a client in the individual’s residence to provide temporary relief to the caregiver(s) that normally provides the care.

   1. (A) Respite care services shall include, at a minimum, the following activities:

      1. 1. Supervision—The respite care worker

will provide personal oversight of the client for the duration of the service period. Personal oversight includes making a reasonable effort to assure the safety of the client and to assist the client in meeting his/her own essential human needs. Sleeping is permitted when the client is asleep, provided there is no indication that the condition of the client would pose a risk if the client awoke while the respite care worker was sleeping. The worker must be in close proximity to the client during a sleeping period;

1. 2. Companionship—The worker will

provide companionship during the client’s waking hours and attempt to make the client as comfortable as possible; and 3.Direct client assistance—The worker will provide direct client assistance as needed to meet needs usually provided by the regular caregiver.

1. (B) Basic respite care services are provided to clients with nonskilled needs.

2. (C) Advanced respite care services are maintenance and supervisory services provided to a client with nonskilled needs that require specialized training.

   1. 1. Clients appropriate for this service

include persons with special needs, requiring a higher level of personal oversight as determined by the division.

1. 2. An initial on-site evaluation of the

client’s condition and identification of special training needs for the advanced respite care worker shall be made by the provider RN prior to initiation of service.

1. 3. A monthly nurse visit will be autho-

rized for each advanced respite care client for each month advanced respite care is authorized. During the visit the nurse will evaluate and document the client’s condition and adequacy of the care plan.

1. 4. Although monthly visits may be per-

formed by a licensed nurse, for clients receiving ongoing advanced respite care services, it is required that the on-site visit be conducted by an RN at six (6) month intervals.

1. (D) Nurse respite care services are maintenance and supervisory services provided to a client with special skilled needs. Nurse respite care services are provided to relieve a caregiver who lives with the client.

   1. 1. Clients appropriate for this service

include persons with special needs as determined by the division.

1. 2. An initial on-site evaluation of the

client’s condition and identification of special training needs for the nurse respite care worker shall be made by the provider RN prior to initiation of service.

1. 3. For clients receiving ongoing nurse

respite care services, it is required that an onsite evaluation be conducted by an RN at six (6) month intervals. The RN evaluation shall document the client’s condition and the adequacy of the care plan.

1. (7) Homemaker services are general household activities provided by a trained homemaker when the client is unable to manage the home and care for him/herself or others in the home or when the individual (other than the client) who is regularly responsible for these activities is temporarily absent. Homemaker services shall include, at a minimum, the following activities:

   1. (A) Plan and prepare meals, including special diet menus; cleanup after meals;
   2. (B) Wash dishes, pots, pans and utensils; 19 CSR 15-7
   3. (C) Clean kitchen counters, cupboards and appliances, including oven, surface burners and inside refrigerator;
   4. (D) Clean bathroom fixtures;
   5. (E) Make beds and change sheets;
   6. (F) Sweep, vacuum and scrub floors;
   7. (G) Tidy and dust the home;
   8. (H) Launder clothes and linens;
   9. (I) Iron and mend clothes;
   10. (J) Wash inside windows and clean blinds that are within reach without climbing;
   11. (K) Bag trash inside the home and put it out for pick up;
   12. (L) Shop for essential items (for example, groceries, cleaning supplies, etc.);
   13. (M) Perform essential errands (for example, pick up medication, post mail, etc.);
   14. (N) Read and write essential correspondence for blind, illiterate or physically impaired clients; and
   15. (O) Instruct the client in ways to become self-sufficient in performing household tasks.

2. (8) Optional homemaker services are household tasks necessary to maintain a safe and habitable home environment provided intermittently as needed by a trained homemaker. Optional homemaker services include the following activities:

   1. (A) Wash walls and woodwork;
   2. (B) Clean closets, basements and attics;
   3. (C) Shampoo rugs;
   4. (D) Air mattresses and bedding;
   5. (E) Spray for insects within the home with over-the-counter supplies;
   6. (F) Provide rodent control within the home (for example, setting traps and putting out over-the-counter supplies);
   7. (G) Wash or change curtains, drapes, or both;
   8. (H) Wash inside windows, clean blinds, or both, which require climbing;
   9. (I) Bag outside trash; and
   10. (J) Outside maintenance including lawn mowing, raking or snow removal.
3. (9) The range of homemaker and respite activities the in-home worker provides is mutually determined by the provider agency and the client.
4. (10) Basic personal care services are maintenance services provided to a client in the individual’s residence to assist with the activities of daily living. Regulations for personal care are filed at 13 CSR 70-91.010.
5. (11) Advanced personal care services are maintenance services provided to a recipient in the individual’s home to assist with activities of daily living when this assistance requires devices and procedures related to altered body functions. Regulations for advanced personal care are filed at 13 CSR 70-91.010.
6. (12) Authorized nurse visits are skilled nursing services of a maintenance or preventive nature provided to clients with stable chronic conditions. They are provided at the client’s residence and prior-authorized by the division case manager. These services are not intended primarily as treatment for an acute health condition. Authorized nurse visit services may be provided by a licensed practical nurse (LPN) under the direction of a registered nurse (RN). Regulations for authorized nurse visits are filed at 13 CSR 70-91.010.

7. (13) The in-home service provider shall not perform and shall not be reimbursed for the following activities:

   1. (A) Providing therapeutic/health-related activities that should be performed by a registered nurse, licensed practical nurse or home health aide under Titles XVIII or XIX home health programs;
   2. (B) Providing transportation services;
   3. (C) Administering over-the-counter or prescribed medications;
   4. (D) Performing household services not essential to the client’s needs; and
   5. (E) Providing friendly visiting.

8. (14) Prior to approval by the division for an in-home services contract and subsequent enrollment as a Medicaid personal care provider under 13 CSR 70-91.010(3), in addition to the contract, after August 1, 1998, all providers must—

   1. (A) Designate to the division the manager who will be responsible for the provider’s day-to-day operation. This manager shall be a policy maker and direct the provider’s record keeping, service delivery verification, hiring and firing practices and staff training;
   2. (B) Ensure that the designated manager successfully completes (or has completed) a division provider certification course offered (quarterly or as needed) at no charge. Attendees shall be responsible for their own expenses, including but not limited to travel, meal and lodging costs they may incur in attending this course;
   3. (C) Be responsible for maintaining documentation of attendance and requiring attendance by new managers within six (6) months of hire; and
   4. (D) Ensure the designated managers annually attend division sponsored training designed to update certified managers.

9. (15) Clients shall be accepted for care on the basis of a reasonable expectation that the client’s maintenance care needs can be met adequately by the agency in the client’s place of residence. Services shall follow a written state-approved care plan developed in collaboration with and signed by the client.

   1. (A) The care plan shall consist of an identification of the services and tasks to be provided, frequency of services, the maximum number of units of service per month, functional limitations of the client, nutritional requirements if a special diet is necessary, medications and treatments as appropriate, any safety measures necessary to protect against injury and any other appropriate items.
   2. (B) A new in-home assessment and care plan may be completed by the division as needed to redetermine the need for in-home services or to adjust the monthly amount of authorized units. In collaboration with the client, the provider agency may develop a new or revised set of service tasks, and weekly schedule for service delivery which shall be forwarded to the division. The service provider must always have, and provide services in accordance with, a current care plan. Only the division, not the service provider, may increase the maximum number of units for which the individual is eligible per month.
   3. (C) The client will be informed of the option of services available to him/her in accordance with the level-of-care determination and assessment findings.

10. (16) To ensure safety and welfare of clients, the following policies and procedures shall be followed when discontinuing in-home services:

    1. (A) Services for a client shall be immediately discontinued by a provider upon receipt of information that the client’s case is closed by the division;
    2. (B) When the provider learns of circumstances that may require closing the case: (for example, death, entry into a nursing home, client no longer needs services, etc.), the provider shall immediately notify the division case manager in writing and request that the client’s service be discontinued;
    3. (C) When the client, family member, or other person living in the household, threatens or abuses provider personnel, the provider shall immediately notify the division case manager by telephone and in writing including information regarding the threat(s) or abusive acts. The division and provider shall mutually determine appropriate intervention and the feasibility of continuing services; or
    4. (D) When a client is noncompliant with the agreed upon care plan or the provider is unable to continue to meet the needs of a client still in need of assistance, the provider shall contact the division case manager and client (Including the caregiver or family when appropriate). The provider shall give written notice of discharge to the client or client’s family and the division case manager at least twenty-one (21) days prior to the date of discharge. During this twenty-one (21)-day period, the division case manager shall make appropriate arrangements with the client for transfer to another agency, or arrange for care in another care setting. The provider must continue to provide care in accordance with the care plan for these twenty-one (21) days or until alternate arrangements can be made by the case manager, whichever comes first.

11. (17) A unit of in-home service is one (1) hour of direct service provided to the client in the client’s home by a trained in-home service worker, including time spent on completing documentation of service units provided and obtaining the client’s signature. No units are reimbursed except as authorized by the division.

    1. (A) Time spent for travel, lunch, breaks or administrative activities, such as completing other reports or paperwork, shall not be included.
    2. (B) For monthly invoicing purposes, partial units of a particular service provided in the course of the month may be accumulated over the billing cycle; partial units shall not be accumulated or carried over to the next month’s billing cycle.
    3. (C) Advanced respite care is authorized in one (1)-hour units, six to eight (6–8)-hour blocks and twenty-four (24)-hour blocks.
    4. (D) Nurse respite care is authorized as a four (4)-hour block of service, per unit.
    5. (E) The monthly invoice submitted to the Division of Aging for in-home service shall not exceed actual delivered units of services.

12. (18) The in-home service provider shall meet, at a minimum, the following administrative requirements:

    1. (A) Employ and train the staff necessary to provide the required services and make staff available to serve in all sections of the provider’s designated service area;
    2. (B) Successfully contact at least two (2) credible references for each employee within thirty (30) calendar days of the date of employment. The term “credible” references shall mean former employers or other knowledgeable persons, excluding relatives of the employee. The documentation shall include the name of the employer and the individual giving the reference, the date, the response given when the reference was obtained by telephone and the signature of the person receiving the reference;
    3. (C) Monitor a current copy of the department’s Employee Disqualification List to ensure that no current or prospective employee’s name appears on the list and discharge and such employee once it is discovered by the provider that the employee is on the Employee Disqualification List;
    4. (D) Have the capability to provide service outside of regular business hours, on weekends and on holidays as authorized by the division;
    5. (E) Protect the department and its employees, agents or representatives from any and all liability, loss, damage, cost and expense which may accrue or be sustained by the department, its officers, agents or employees as a result of claims, demands, costs, suits or judgments against it arising from the loss, injury, destruction or damage, either to person or property, sustained in connection with the performance of the in-home service;
    6. (F) Maintain a commercial general liability insurance policy in full force and effect that covers all places of business and any and all clients, customers, employees and volunteers. Such policy shall be an occurrence policy and shall provide coverage for no less than one (1) million dollars per event and three (3) million dollars aggregate and shall include coverage for negligent acts and omissions of the provider’s employees and volunteers in the provision of services to clients in such clients’ homes. Such policy shall name the division as a certificate holder. Providers shall also maintain a professional liability insurance policy in full force and effect that covers all places of business and any and all clients, customers, employees and volunteers. Such policy shall provide coverage for no less than one (1) million dollars per event and three (3) million dollars aggregate and shall include coverage for negligent acts and omissions of the provider’s employees and/or volunteers in the provision of professional services to clients in such clients’ homes. Such policy shall name the division as a certificate holder. The policies shall be coordinated to ensure coverage for all negligent acts and omissions in the provision of the in-home services described in this rule and in 13 CSR 70- 91.010, by the provider’s employees and volunteers. Additionally, providers shall maintain an employee dishonesty bond covering employees and volunteers who are connected with the delivery and performance of in-home services in the client’s home;
    7. (G) Furnish adequate identification (ID) to employees of the provider. This ID shall be carried by the employee in a way that the client can see the name of the agency with whom the aide is employed. A permanent ID including the provider’s name, employee’s name and title shall be considered adequate

13. ID. At the time of employment, an ID shall be issued which will meet the ID requirement. The provider shall require the return of the ID from each employee upon termination of employment;

    1. (H) Ensure that no in-home services worker is a member of the immediate family of the client being served by that worker. An immediate family member is defined as a parent; sibling; child by blood, adoption, or marriage; spouse; grandparent or grandchild;
    2. (I) Notify the division’s central office and regional manager of any changes in location, telephone number, administrative or corporate status;

    3. (J) Have and enforce a written code of ethics which is distributed to all employees and clients. The code of ethics shall allow use of the bathroom facilities, and, with the client’s consent, eat the lunch provided by the worker, in the client’s home. The code of ethics shall be reviewed with the client, caregiver or family when appropriate, and include, at a minimum, the following prohibitions:

       1. 1. Use of client’s car;
       2. 2. Consumption of client’s food or drink

(except water);

1. 3. Use of client’s telephone for personal

calls;

1. 4. Discussion of own or other’s person-

al problems, religious or political beliefs with the client;

1. 5. Acceptance of gifts or tips;
2. 6. Bringing other persons to the client’s

home;

1. 7. Consumption of alcoholic beverages,

or use of medicine or drugs for any purpose, other than medical, in the client’s home or prior to service delivery;

1. 8. Smoking in client’s home;
2. 9. Solicitation or acceptance of money

or goods for personal gain from the client;

1. 10. Breach of the client’s privacy and

confidentiality of information and records;

1. 11. Purchase of any item from the client

even at fair market value;

1. 12. Assuming control of the financial or

personal affairs, or both, of the client or of his/her estate including power of attorney, conservatorship or guardianship;

1. 13. Taking anything from the client’s

home; and

1. 14. Committing any act of abuse,

neglect or exploitation;

1. (K) Ensure prompt initation of authorized services to new clients. The provider shall deliver the in-home service within seven (7) calendar days of receipt of the service autho- 19 CSR 15-7

rization from the division case manager or on the beginning date specified by the authorization, whichever is later, and on a regular basis after that in accordance with the care plan. The date of receipt must be recorded on each service authorization by the provider. Verbal authorization shall be effective upon acceptance by the provider and services must begin as agreed. If service is not initiated within the required time period, detailed written justification must be sent to the division case manager with a copy maintained in the client’s file;

1. (L) Recommend, verbally or in writing, changes to the authorized care plan any time the client has an ongoing need for service activities which may require more or fewer units than the amount specified in the care plan;
2. (M) Keep documentation of undelivered services, including the reason for this failure to deliver authorized units;
3. (N) Be aware that in-home services provided shall not be reimbursed unless authorized in writing by the division;
4. (O) Ensure that all subcontractors comply with all standards required by section (2) of this rule;

5. (P) Shall give a written statement of the client’s rights and review the statement with each client and primary caregiver, when appropriate at the time service is initiated. The statement of client rights must contain at a minimum, the right to:

   1. 1. Be treated with respect and dignity;
   2. 2. Have all personal and medical infor-

mation kept confidential;

1. 3. Have direction over the services pro-

vided, to the degree possible, within the care plan authorized;

1. 4. Know the provider’s established

grievance procedure and how to make a complaint about the service and receive cooperation to reach a resolution, without fear of retribution;

1. 5. Receive service without regard to

race, creed, color, age, sex or national origin; and

1. 6. Receive a copy of the provider’s code

of ethics under which services are provided;

1. (Q) Have a system through which clients may present grievances concerning the operation of the in-home service program and/or delivery of care;
2. (R) Report all instances of potential abuse, neglect, exploitation of a client, or any combination of these, to the division’s Elder Abuse Hotline (1-800-392-0210), including all instances which may involve an employee of the provider agency;
3. (S) Copayment, as determined by the division’s case manager, shall be collected monthly from non-Medicaid clients. Liability levels for copayment are based on a sliding fee schedule as determined by the division. The money collected as copayment replaces the amount withheld from reimbursement by the automated payment system. Prompt and reasonable attempts to collect from the client, the client’s guardian or estate shall be made by the provider. Failure of clients to submit the required copayment, when determined to be a condition of participation, shall be reported to the division. Failure of clients to comply with copayment requirements may result in termination of services. Unsuccessful attempts to collect from the estate of a deceased client are to be referred to the home and community services deputy director of the division;
4. (T) Implement a contribution system which accounts for contributions received from clients for in-home services. Non-Medicaid clients shall be informed of their right to voluntarily contribute when they are admitted for services. Services shall not be denied to any client based on failure to make a contribution. Reports of contributions by county shall be made to each home and community services regional manager including the balance on hand, contributions received, contributions used for division authorized services, and ending balance. The provider shall submit to the regional manager, a contributor report at the end of any month in which contributions are received and/or expended;

5. (U) Understand that both program and fiscal monitoring of the in-home service program shall be conducted by the division or its designee.

   1. 1. Monitoring visits may be announced

or unannounced.

1. 2. The division shall disclose the find-

ings of the visit to the provider.

1. 3. Upon request by the division, the

provider shall submit a written plan for correcting areas found to be out of compliance;

1. (V) Designate trainer(s) to perform the sessions required as part of the basic training. The designated trainer(s) may be the RN, LPN, supervisor, or an experienced aide who has been employed by the provider agency at least six (6) months. A list of designated trainers must be available for monitoring; and
2. (W) Providers must establish, enforce and implement a policy whereby all contents of the personnel files of its employees are made available to department employees or representatives when requested as part of an official investigation of abuse, neglect, financial exploitation, misappropriation of client’s funds or property, or falsification of documentation which verifies service delivery.

1. (19) In-home service providers shall meet, at a minimum, the following personnel requirements:

   1. (A) The in-home provider shall employ an RN or designate an RN as a consultant, who meets each of the following qualifications:

      1. 1. Currently licensed in Missouri;
      2. 2. Have at least one (1)-year verifiable

experience with direct care of the elderly, disabled, or infirm;

1. 3. Meet the RN supervisory require-

ments for personal care and advanced personal care in accordance with 13 CSR 70- 91.010;

1. (B) A supervisor shall be designated by the provider to supervise the day-to-day delivery of in-home service who shall be at least twenty-one (21) years of age and meet at least one

1. (1) of the following requirements:

   1. 1. Be a registered nurse who is current-

ly licensed in Missouri; or

1. 2. Possess a baccalaureate degree; or
2. 3. Be a licensed practical nurse who is

currently licensed in Missouri with at least one (1) year of experience with the direct care to the elderly, disabled or infirm; or

1. 4. Have at least three (3) years experi-

ence with the direct care to the elderly disabled or infirm.

1. (C) All in-home service workers employed by the provider shall meet the following requirements:

   1. 1. Be at least eighteen (18) years of age;
   2. 2. Be able to read, write and follow

directions; and meet at least one (1) of the following requirements:

1. A. Have at least six (6) months paid

work experience as an agency homemaker, nurse aide, maid or household worker; or

1. B. At least one (1) years experience,

paid or unpaid, in caring for children or for sick or aged individuals; or

1. C. Successful completion of formal

training in nursing arts or as a nurse aide or home health aide;

1. (D) All advanced personal care aides and advanced respite care workers employed by the provider shall be—

   1. 1. A licensed practical nurse; or
   2. 2. Certified nurse assistant; or
   3. 3. A competency evaluated home health

aide having completed both written and demonstration portions of the test required by the Missouri Department of Health and Senior Services and 42 CFR 484.36; or

1. 4. Documented to have worked success-

fully for the provider for a minimum of three (3) consecutive months while working at least fifteen (15) hours per week as an in-home aide that has received personal care training;

1. (E) All individuals employed to deliver authorized nurse visits shall be currently licensed to practice as a registered nurse or a licensed practical nurse in Missouri;
2. (F) The division does not require employees delivering only optional chore services outside the client’s home as specified in (8)(J) to have experience as required in (19)(C)2. of this rule; and
3. (G) The provider shall inform employees, of applicable requirements for registration with the Family Care Safety Registry (FCSR) pursuant to the requirements of sections 210.900, RSMo to 210.936, RSMo.

1. (20) The RN required by (19)(A) of this rule will be primarily responsible for ensuring that policies and procedures of the in-home service provider meet the clinical standards for proper care of clients, training of staff, and general clinical integrity of the in-home service provider. Such responsibilities shall include, at a minimum, the following functions:

   1. (A) Monitor or provide oversight to staff that supervise in-home workers in the direct provision of services to assure that services are being delivered in accordance with the care plan;
   2. (B) Direct or oversee staff responsible for in-home worker orientation and in-service training required herein; assure all training requirements are met; and ensure that inhome workers are trained to competently perform all basic and advanced service tasks as specified in this rule;
   3. (C) Provide oversight to the process and documents used by the staff who conduct annual supervisory visits and have in place a system that ensures that completed evaluations are reviewed by the nurse when appropriate;
   4. (D) Assure that appropriate recommendations or reports are forwarded to the division including: requests to increase, reduce or discontinue services, changes in the client’s condition, noncompliance with care plan, nondelivery of authorized services, or the need for increased division involvement;
   5. (E) Establish, implement and enforce a policy governing communicable diseases that prohibits provider staff contact with clients when the employee has a communicable condition including colds or flu;
   6. (F) Assure compliance with reporting requirements governing communicable diseases, including hepatitis and tuberculosis, as set by the Missouri Department of Health and Senior Services (19 CSR 20-20.020); and
   7. (G) Monitor or provide oversight of nurse tasks or functions delegated to and performed by the LPN.

2. (21) The in-home service supervisor’s responsibilities shall include, at a minimum, the following functions:

   1. (A) Monitoring the provision of services by the in-home services worker to assure that services are being delivered in accordance with the care plan. This shall be primarily in the form of an at least monthly review and comparison of the worker’s record of provided services with the care plan.
   2. (B) Documentation must be kept on clients with a delivery rate of less than eighty percent (80%) of the authorized units of in-home service. For each client with a delivery rate less than eighty percent (80%) of the authorized units of in-home services authorized for the time period being reviewed, the number of units of service delivered and the nondelivery code will be sent to the division regional manager monthly on a form acceptable to the regional manager. Discrepancies for these clients concerning the frequency of delivered services and/or the in-home service tasks delivered, the corrective action taken, will be signed and dated by the supervisor and be readily available for monitoring or inspection;
   3. (C) Evaluating, in writing, each in-home service aide’s performance at least annually. The evaluation shall be based in part on at least one (1) on-site visit. The aide must be present during the visit. The evaluation will include, in addition to the aide’s performance, the adequacy of the care plan, including review of the care plan with the client. The written report of the evaluation shall contain documentation of the visit, including the client’s name, the date and time of the visit, the aide’s name and the supervisor’s observations and notes from the visit. The evaluation shall be signed and dated by the supervisor who prepared it and by the aide. If the required evaluation is not performed or not documented, the aide’s qualifications to provide the services may be presumed inadequate and all payments made for services by that aide may be recouped;
   4. (D) Communicating with the division case manager and provider RN regarding changes in any client’s condition, changes in scope or frequency of service delivery and recommending changes in the number of units of service per month including written documentation of that communication; and
   5. (E) Assure that all individuals, who may not be considered employees, but work for the provider in any capacity involving direct care of clients have a signed agreement detailing the employment arrangement, including all rights and responsibilities. Such agreement would apply to all individuals hired through contract or other employment arrangement.

3. (22) The in-home service provider shall have a written plan for providing training for new aides, respite care workers and homemakers which shall include, at a minimum, the following requirements:

   1. (A) Twenty (20) hours of orientation training for in-home service workers, including at least two (2) hours orientation to the provider agency and the agency’s protocols for handling emergencies, within thirty (30) days of employment.

      1. 1. Eight (8) hours of classroom training

will be provided prior to the first day of client contact.

1. 2. New employee orientation curricula

shall include an overview of Alzheimer’s disease and related dementias and methods of communicating with persons with dementia pursuant to the requirements of 660.050(22)8, RSMo.

1. 3. Twelve (12) hours of required orien-

tation training may be waived for aides and homemakers with adequate documentation in the employee’s records that s/he has received similar training during the current or preceding year or has been employed at least halftime for six (6) months or more within the current or preceding year.

1. 4. All orientation training (except the

required two (2) hours provider agency orientation) may be waived with documentation, placed in the aide’s personnel record, that the aide is a licensed practical nurse, registered nurse or certified nurse assistant. The documentation shall include the employee’s license or certification number which must be current and in good standing at the time the training was waived;

1. (B) Ten (10) hours of in-service training annually are required after the first twelve

1. (12) months of employment. In-service training curricula shall include updates on Alzheimer’s disease and related dementia; and

   1. (C) Additional training requirements for in-home workers providing advanced respite must be determined and provided by a provider agency RN following assessment of the client’s condition and needs.

2. (23) The in-home service provider shall have written documentation of all basic and in-service training provided which includes, at a minimum:

   1. (A) A report of each employee’s training in that employee’s personnel record. The report shall document the dates of all classroom or on-the-job training, trainer’s name, topics, number of hours and location, the date of the 19 CSR 15-7

first client contact and shall include the aide’s signature.

1. (B) If a provider waives the in-service training, the employee’s training record shall contain documentation sufficient to support the waiver. In-service training shall not be waived, unless the employee’s record contains documentation that the employee has received Alzheimer’s disease and related dementias training.

2. (C) The provider agency shall keep a training record or folder that contains:

   1. 1. A list of all training sessions held by

the provider to fulfill training requirements;

1. 2. A copy of all agendas showing date,

time and duration of training sessions; and

1. 3. Qualifications of trainer(s), if other

than the provider agency RN.

1. (24) The in-home service provider shall maintain, at a minimum, the following records in a central location for five (5) years. Records must be provided to the department staff or designees upon request, and must be maintained in a manner that will ensure they are readily available for monitoring or inspection. Records include:

   1. (A) Individual client case or clinical records including records of service provision. These are confidential and shall be protected from damage, theft and unauthorized inspection and shall include, at a minimum, the following:

      1. 1. The authorization for services forms

from the division which documents authorization for all units of service provided;

1. 2. Individual worker delivery records

that accurately document the client’s name, dates of service delivery, beginning time and ending time for each service delivery date activities or tasks performed, aide’s signature and the client’s signature verifying each date(s) of service. If the client is unable to sign, another responsible person present in the home during service delivery may sign to verify the time and activities reported or the client may make his/her mark (x) which shall be witnessed by a minimum of one (1) person who may be the aide or homemaker. If these documents are not filed in the client’s case record, they must be readily available for monitoring or inspection;

1. 3. Documentation explaining discrepan-

cies between authorized and delivered services including a description of corrective action taken, when applicable, and documentation of information forwarded to the division;

1. 4. All registered nurse clinical notes

concerning the client;

1. 5. Documentation of all correspondence

and contacts with the client’s physician or other care providers;

1. 6. Copies of written communication

transmitted to and from the division case manager; and

1. 7. Any other pertinent documentation

regarding the client.

1. (B) Individual personnel record for each employee which is a confidential record and shall be protected from damage, theft and unauthorized inspection and shall include, at a minimum, the following:

   1. 1. Employment application containing

the employee’s signature and documentation sufficient to verify the employee meets age, education, and work experience requirements. The record shall document employment and termination dates;

1. 2. Documentation of at least two (2)

credible reference contacts;

1. 3. Documentation concerning all train-

ing and certification received;

1. 4. Documentation supporting any waiv-

er of employment or training requirements;

1. 5. Annual performance evaluation which

includes observations from one (1) on-site visit;

1. 6. A signed statement documenting that

the employee received and reviewed a copy of the client’s rights, the code of ethics and the service provider’s policy regarding confidentiality of client information and that all were explained prior to service delivery;

1. 7. A signed statement verifying that the

supervisor received and reviewed a copy of the in-home service standards;

1. 8. Statement identifying the employee’s

position, including whether the employee performs administrative duties for the provider or delivers services to clients;

1. 9. Returned permanent ID for a termi-

nated employee or documentation of why it is not available; and

1. 10. Verification of the current Missouri

certified nurse assistant, licensed practical nurse or registered nurse license including, at least, the license or certificate number;

1. (C) Accurate records documenting dates and amount of contributions received and expended. Records of contributions received should list the name of each contributor and the date and amount of the contribution. The contribution expenditure records should list the name and amount of the contribution. The contribution expenditure records should list the name and address of each client, dates of service delivery, time spent on each date, activities performed, aide’s name and the client’s signature for each date of service; and
2. (D) Documentation of each Employee Disqualification List and criminal background screening sufficient to show the identity of the person who was screened, the dates the screening was requested and completed and the outcome of the screening.

AUTHORITY: section 660.050, RSMo 2000.* Original rule filed Sept. 1, 1994, effective April 30, 1995. Amended: Filed Dec. 15, 1997, effective July 30, 1998. Moved to 19 CSR 15-7.021, effective Aug. 28, 2001. Amended: Filed Sept. 14, 2001, effective April 30, 2002.

*Original authority: 536.023, RSMo 1975, amended 1976 and 660.050, RSMo 1984, amended 1988, 1992, 1993.