PURPOSE: This rule establishes the criteria and procedures for determining an applicant eligible to receive personal care assistance program services.

1. (1) Subject to legislative appropriations, the Division of Vocational Rehabilitation (DVR) shall provide financial assistance for the personal care assistance (PCA) program services through eligible providers to each client/consumer selected to participate and meeting the criteria:

   1. (A) All clients/consumers must meet the following general criteria for eligibility under the PCA program:

      1. 1. Be at least eighteen (18) years of age;
      2. 2. Able to direct their own care (partic-

ipant directed);

1. 3. Employed, ready for employment, or

capable of living independently with PCA; and

1. 4. Physically disabled;

2. (B) In addition to the above general criteria, persons eligible for non-Medicaid eligible (NME) PCA services shall meet the following:

   1. 1. Document need for a minimum of

seven (7) or maximum of forty-two (42) hours per week of PCA. If more than fortytwo (42) hours per week are required, substantial documentation may be used to support a request for additional time;

1. 2. Demonstrate financial need based

upon the client/consumer adjusted gross income level of the most recent tax records less living expenses as approved by DVR and compared to three hundred percent (300%) of the U.S. Department of Health and Human Services poverty level for Missouri and the Consumer Price Index as updated on an annual basis; and

1. 3. Participate in an evaluation conducted

by the assessment team to assess the individual’s qualifications to be eligible for PCA services:

1. A. The initial evaluation shall be con-

ducted in the individual’s home or current place of residence at the time of application. If the individual is in the process of relocation, the assessment shall be conducted at the new residence; and

1. (C) In addition to the above general criteria, persons eligible for Medicaid PCA services shall meet the following:

   1. 1. Document proof of Medicaid eligibil-

ity under Title XIX of the Social Security Act pursuant to federal/state laws and regulations; and

1. 2. Participate in an assessment with the

assessment team or the Department of Health and Senior Services, Division of Senior Services (Division of Senior Services) that utilizes a level of care evaluation tool that is approved by the state Medicaid agency and assigns a point value pursuant to federal/state laws and regulations.

1. A. The initial assessment shall be

conducted in the individual’s home or current place of residence at the time of application. If the individual is in the process of relocation, the assessment shall be conducted at the new residence.

1. (2) Individuals eligible for Medicaid under Title XIX of the Social Security Act who do not meet the above criteria for PCA shall be referred to the Division of Senior Services or other agencies as appropriate, to determine eligibility for PCA services pursuant to state laws and regulations.

2. (3) The assessment team must consist of an independent living specialist, rehabilitation counselor, and a medical professional from physical therapy, occupational therapy, or a registered nurse. Other team members may include additional service providers, including Division of Senior Services personnel. When a client/consumer is currently receiving PCA services from another agency and wishes to transfer PCA services to DVR, the other agency’s case manager should be consulted for planning purposes:

   1. (A) The independent living specialist will serve as a team member, consultant on independent living, and must be qualified as follows:

      1. 1. Understand basic principles of case

management;

1. 2. Possess previous experience in an

independent living program or a related field (that is, case services, peer counseling, etc.);

1. 3. Possess the ability to communicate

effectively;

1. 4. Possess skills in training others to live

independently; and

1. 5. Participate in assessment and evalua-

tion training provided by DVR;

1. (B) The medical professional will be contracted by DVR, serve as team leader, conduct the assessment, and must be qualified as follows:

   1. 1. If a physical therapist, the individual

shall possess a valid and unencumbered license as a registered physical therapist, in accordance with state law and regulation, and be approved as a contractor with DVR;

1. 2. If an occupational therapist, the indi-

vidual shall possess a valid and unencumbered license as a registered occupational therapist, in accordance with state law and regulation, and be approved as a contractor with DVR; or

1. 3. If a registered nurse, the individual

shall possess a valid and unencumbered license as a registered nurse in accordance with state law and regulation, and be approved as a contractor with DVR; and

1. (C) The rehabilitation counselor will serve as a team member, reviews and approves all assessments.

1. (4) The PCA services plan (plan of care) is based on the assessment/evaluation performed by the assessment team or Division of Senior Services and determines the appropriateness and adequacy of services, ensures the services furnished are consistent with the nature and severity of the individual’s disability. If a client/consumer transfers from or is shared with the Division of Senior Services, a new evaluation and PCA services plan (POC) is required but must maintain cost neutrality through the next regularly scheduled assessment date, unless undue hardship is documented. The plan of care will be available for review upon proper release by the client’s/consumer’s physician:

   1. (A) The evaluation and re-evaluation shall be conducted in the client’s/consumer’s home or place of residence and include, but not be limited to, the following:

      1. 1. The functions of daily living;
      2. 2. The frequency and duration of the

routine task or activity required to live independently; and

1. 3. A description of met and/or unmet

need;

1. (B) The NME plan of care shall include, but not be limited to, the following:

   1. 1. The maximum number of hours of

PCA to be provided;

1. 2. The maximum amount of financial

assistance to be provided by DVR for PCA services;

1. 3. The date of evaluation, initiation of,

and re-evaluation of the PCA services; and

1. 4. Signatures of the client/consumer,

rehabilitation counselor, and provider; and

1. (C) The Medicaid PCA services plan of care, subject to DVR’s approval, shall include, but not be limited to, the following:

   1. 1. The maximum number of hours of

PCA to be provided based on a client’s/consumer’s unmet need;

1. 2. The description and frequency of ser-

vices provided as documented on the assessment and evaluation;

1. 3. The type of provider who will furnish

each service;

1. 4. The starting date for PCA services;
2. 5. The date for re-evaluation of PCA

services;

1. 6. Consent signatures by the client/con-

sumer and assessment team members and the approval signature by DVR; and

1. 7. If a client/consumer is receiving ser-

vices or transferring from another service provider or agency, the provider is responsible for collaborating and coordinating services through the plan of care.

1. (5) The individual shall be notified by the provider of DVR decision within thirty (30) days of the date of application for eligibility for PCA services.

2. (6) PCA services are participant directed and the client/consumer shall be responsible, at a minimum, for the following:

   1. (A) Selection, hiring, training, and supervision of the client’s/consumer’s PCA attendant;
   2. (B) Preparation of biweekly time sheets, signed by both the client/consumer and PCA which shall be submitted to the provider in a timely manner;
   3. (C) Prompt notification to DVR of any changes in need for PCA services, that affect the amount of PCA received, financial status, and/or place of residence;
   4. (D) Prompt notification of the provider regarding any problems resulting from the quality of services rendered by the PCA attendant; and
   5. (E) Ensure that hours submitted for reimbursement do not exceed the amounts authorized by the plan of care.
3. (7) The client/consumer shall be reassessed and/or re-evaluated for Medicaid eligibility, at least annually, for continued need of PCA services including financial need.

4. (8) A client’s/consumer’s PCA services may be discontinued by a provider in certain circumstances:

   1. (A) The provider may request discontinuation of PCA services in the following situations:

      1. 1. If the provider learns of circum-

stances that require the closure of a client’s/consumer’s case, including but not limited to, death, entry into a nursing home, no longer needing service, and/or the inability to participant direct PCA service;

1. 2. If the client/consumer has falsified

records or committed fraud;

1. 3. If the client/consumer is noncompli-

ant with the plan of care. Noncompliance requires persistent actions by the client/consumer or family/representative which negate the services provided in the plan of care;

1. 4. If the client/consumer or client’s/con-

sumer’s family/representative threatens and/or abuses the PCA attendant and/or provider to the point where the staff’s welfare is in jeopardy and corrective action has failed; and/or

1. 5. If a provider is unable to continue to

meet the maintenance needs of a client/consumer whose plan of care hours exceed availability;

1. (B) The provider shall confer with DVR, the client/consumer and/or their representative prior to requesting termination of PCA services in writing. This may include discussion of alternatives, including but not limited to, a transfer to another agency, institutional placement, or other appropriate care;
2. (C) Prior to termination of PCA services, the provider must notify DVR and client/consumer, in writing, listing the specific reasons, and requesting discontinuation of services; and
3. (D) The client/consumer may request under the rules promulgated by the State Board of Education, informal review and/or a hearing. The provider shall not suspend, reduce or terminate services provided to a client/consumer during this time period, unless the client/consumer or their representative requests in writing that services be suspended, reduced or terminated.

AUTHORITY: sections 161.092, RSMo Supp. 2003, 178.662, 178.666 and 178.673, RSMo ROBIN CARNAHAN (10/31/05)* 2000.* This rule originally filed as 5 CSR 90-7.100. Original rule filed June 28, 2001, effective Jan. 30, 2002. Amended: Filed Sept. 12, 2003, effective April 30, 2004. Moved to 19 CSR 15-8.200, effective Aug. 29, 2005. *Original authority: 161.092, RSMo 1963, amended 1973, 2002, 2003; 178.662, RSMo 1984, amended 1987, 1992; 178.666, RSMo 1984, amended 1992; and 178.673, RSMo 1984, amended 1993.