Community HealthChoices Operations Manual for Vendors
The Provision of Services in Personal Care Homes, Assisted Living Residences and Domiciliary Care Homes
4-100-18-02
CHC Agreement:
Section V-A-18: Program Requirements, Covered Services, Settings for LTSS.
EXHIBIT A(1) COVERED SERVICES, Long-Term Services and Supports Service Definitions, Residential Habilitation
A. Personal Care Homes
a. Background/General Policy
Background
i. Personal care homes (PCH), governed under 55 Pa. Code Chapter 2600, are designed to provide safe, humane, comfortable and supportive residential settings for adults who do not require the services in or of a licensed long-term care facility, but who do require assistance or supervision with activities of daily living instrumental activities of daily living, or both (see 55 Pa. Code § 2600.1(b)). The PCH regulations define a resident as a person “who resides in a personal care home, and who requires personal care services, but who does not require the level of care provided by a hospital or long-term care facility.”
ii. The Pennsylvania Department of Human Services, through the Bureau of Human Service Licensing, license PCH in the commonwealth.
General Policy
i. The following policy applies to when a CHC-enrolled participant may reside in a PCH:
a. CHC participants who are not receiving LTSS waiver services may reside in a PCH licensed under 55 Pa. Code Chapter 2600. For residents in this population, PCH compliance with the provisions of 42 CFR 441.301 (relating to home and community-based settings and settings that are not home and community-based) are not required.
b. CHC participants residing in a PCH who are not receiving LTSS waiver services at the time that CHC is implemented in their geographic zone, but who subsequently require LTSS waiver services, may not be provided with CHC LTSS waiver services while residing in the PCH unless they need residential habilitation services (see (iv) below under Regulatory Citations).
The CHC-MCO is responsible to work with the participant to identify other possible housing options and to assist with transition to an allowable setting in which to receive CHC waiver services within 90 days of the date of the assessed need, or nursing facility services if the participant cannot be safely served in the community. Once a CHC participant is determined eligible to receive LTSS waiver services, the participant is permitted to receive CHC LTSS waiver services in the PCH during the transition period if the PCH is in compliance with 42 CFR 441.301.
c. CHC participants who are residing in a PCH and receiving LTSS waiver services prior to CHC implementation in their geographic zone may continue to reside in the PCH and are permitted to receive CHC LTSS waiver services if the PCH achieves compliance with 42 CFR 441.301.
The CHC-MCO is to provide CHC LTSS waiver services until such time as the PCH determines that the participant’s needs can no longer be met in that setting. At that time, the CHC-MCO is responsible to work with the participant to identify other possible housing options and to assist with transition to an allowable setting in which to receive waiver services within 90 days of the date of the assessed need or nursing facility services if the participant cannot be safely served in the community.
d. CHC participants receiving residential habilitation services in a PCH which serves eight or fewer residents and meets all other requirements contained in the residential habilitation service definition may receive CHC LTSS waiver services in the PCH if it achieves compliance with 42 CFR 441.301. This applies regardless of when the rollout of CHC occurs in their zone.
b. Definitions
i. N/A
c. Regulatory Citations & Other References
i. 55 Pa. Code Chapter 2600
http://www.pacode.com/secure/data/055/chapter2600/chap2600toc.html
ii. 42 CFR 441.301
https://www.gpo.gov/fdsys/pkg/FR-2014-01-16/pdf/2014-00487.pdf
iii. CMCS Informational Bulletin, May, 9, 2017
https://www.medicaid.gov/federal-policy-guidance/downloads/cib050917.pdf
iv. CHC 1915(c) waiver, Appendix C-1/C-3: Participant Services, Service Specifications
d. Process/Steps
i. N/A
e. Examples
i. N/A
f. Appendices
i. N/A
B. Assisted Living Residences
a. Background/General Policy
Background
i. Assisted living residences (ALR) licensure was established in 2007 with the enactment of Act 56. The intent of Pennsylvania’s ALR law is to provide a long-term care alternative to allow individuals to age in place. The regulations allow adults requiring the services of a nursing facility, including those with mobility needs, to reside in an ALR provided that supplemental health care services are provided, and the design, staffing, and operation of the residence allows for a safe emergency evacuation. Residents may require assisted living services or supplemental healthcare services, or both.
ii. Under 55 Pa. Code § 2800.42(y), an ALR may require residents to use their specified providers of supplemental health care services, or they may allow residents to choose their own providers of these services. Section 2800.229 of 55 Pa. Code also states an ALR may not admit, retain, or serve an individual with certain conditions or health care needs unless it receives an exception from the department; certain excludable conditions may not require an exception if specified conditions are met.
iii. The Pennsylvania Department of Human Services, through the Bureau of Human Service Licensing, license assisted living residences in the commonwealth.
General Policy
i. The following policy applies to when a CHC-enrolled participant may reside in an ALR:
a. A CHC participant who is not receiving LTSS waiver services may reside in an ALR licensed under 55 Pa. Code Chapter 2800. For residents in this population, ALR compliance with the provisions of 42 CFR 441.301 is not required.
b. A CHC participant who is receiving LTSS waiver services may reside in an ALR if it is in compliance with 42 CFR 441.301, if the resident does not have an excludable condition for which the department has not granted an exception, and if the ALR allows for participant choice of providers of waiver services.
c. An individual who is a resident of an ALR that limits participant choice of providers for supplemental healthcare services will not be permitted to receive CHC waiver services.
b. Definitions
Age in Place – Receiving care and services at a licensed assisted living residence to accommodate changing needs and preferences in order to remain in the assisted living residence.
Excludable Condition - The following conditions or health care needs, unless an exception is granted by the department:
(1) Ventilator dependency.
(2) Stage III and IV decubiti and vascular ulcers that are not in a healing stage.
(3) Continuous intravenous fluids.
(4) Reportable infectious diseases, such as tuberculosis, in a communicable state that requires isolation of the individual or requires special precautions by a caretaker to prevent transmission of the disease unless the Department of Health directs that isolation be established within the residence.
(5) Nasogastric tubes.
(6) Physical restraints.
(7) Continuous skilled nursing care 24 hours a day.
Resident - An adult, unrelated to the legal entity, who resides in an assisted living residence, and who may require assisted living services or supplemental healthcare services, or both.
Supplemental Healthcare Services – Services that include, but are not limited to, the following:
(1) Hospice services.
(2) Occupational therapy.
(3) Skilled nursing services.
(4) Physical therapy.
(5) Behavioral health services.
(6) Home health services.
(7) Escort service if indicated in the resident’s support plan or requested by the resident to and from medical appointments.
(8) Specialized cognitive support services as defined in 55 Pa. Code § 2800.4 (relating to definitions).
c. Regulatory Citations
i. 55 Pa. Code Chapter 2800 http://www.pacode.com/secure/data/055/chapter2800/055_2800.pdf
ii. 42 CFR 441.301 https://www.gpo.gov/fdsys/pkg/FR-2014-01-16/pdf/2014-00487.pdf
d. Process/Steps
i. N/A
e. Examples
i. N/A
f. Appendices
i. N/A
C. Domiciliary Care Homes
a. Background/General Policy
Background
i. The Pennsylvania Department of Aging, through the Area Agencies on Aging (AAAs), certify domiciliary (Dom) care homes in the commonwealth.
ii. Dom care homes, which are governed by 6 Pa. Code Chapter 21, provide a supervised living arrangement in a homelike setting in the community for adults age 18 and older who need assistance with activities of daily living and are unable to live independently on their own. Individuals who live in a Dom care home cannot require a nursing facility level of care and must be independently mobile or semi-mobile.
Individuals residing in a Dom care home receive supervision, a bedroom with basic furnishings, three nutritious meals a day, personal care as specified by their care plan, laundry service, transportation to non-emergency medical appointments, and assistance with medications prescribed for self-administration.
iii. The local AAA is responsible for determining Dom care client eligibility, placing clients in Dom care homes based on their needs and preferences, certifying Dom care homes and providers, and maintaining on-going contact with clients placed in Dom care homes to assure the adequacy of care and continued appropriateness of the setting.
iv. The Department of Aging may issue regulatory waivers to allow some individuals who have had a change in condition and become nursing facility clinically eligible (NFCE) to continue to reside in the Dom care home if the individual can be safely served. These individuals may receive home and community-based LTSS waiver services while residing in a Dom care home; however, the LTSS waiver services cannot duplicate the services provided by the Dom care provider. The Department of Aging will not approve a waiver allowing an individual who is assessed as NFCE to be placed in a Dom care home
v. Traditional Dom care homes are the private home of the provider and are certified by the AAA for three or fewer Dom care residents. There are some Dom care homes, under special exception, that are certified for more than three residents.
General Policy
i. The following policy applies when a CHC-enrolled participant may reside in a Dom care home:
a. A CHC participant who is not receiving LTSS waiver services may reside in a Dom care home certified under 6 Pa. Code Chapter 21. For residents in this population, Dom care compliance with the provisions of 42 CFR 441.301 (relating to home and community-based settings and settings that are not home and community-based) is not required.
b. A CHC participant residing in a Dom care home who is not receiving LTSS waiver services, but who subsequently has a change in condition requiring LTSS waiver services, may receive CHC LTSS waiver services in the Dom care home if the Department of Aging has issued a regulatory waiver allowing the NFCE participant to continue to reside there, the home is in compliance with 42 CFR 441.301, and there is no duplication of service.
c. When a CHC participant residing in a Dom care home who is not receiving LTSS waiver services, but who subsequently has a change in condition requiring LTSS waiver services and can no longer be safely served in the home, the CHC-MCO is responsible to work with the participant and the AAA to identify other possible housing options and assist with the transition to an allowable setting in which to receive CHC LTSS waiver services.
b. Definitions
i. N/A
c. Regulatory Citations
i. 6 Pa. Code Chapter 21 http://www.pacode.com/secure/data/006/chapter21/chap21toc.html
ii. 42 CFR 441.301
https://www.gpo.gov/fdsys/pkg/FR-2014-01-16/pdf/2014-00487.pdf
d. Process/Steps
i. N/A
e. Examples
i. N/A
f. Appendices
i. N/A
04/06/2018