Personal Care Assistant Services

1. Personal Care Assistant Services Local Education Agency Medicaid Provider Manual

2. Purpose Common Acronyms Provider Participation Requirements Covered Services Documentation Requirements

3. Commonly Used Acronyms VDOE - Virginia Department of Education DMAS - Department of Medical Assistance Services CMS - Centers for Medicare & Medicaid Services

4. Commonly Used Acronyms cont. EPSDT - Early & Periodic Screening, Diagnosis, and Treatment CHIP – Federal Child Health Insurance Program FAMIS – Family Access to Medical Insurance Security Program – Virginia’s CHIP program FAMIS Plus – Children’s Medicaid in Virginia

5. Commonly Used Acronyms cont. IEP - Individualized Educational Program GAF - Global Assessment of Functioning LEA - Local Education Agency POC - Plan of Treatment/Plan of Care PCP - Primary Care Physician PCA – Personal Care Assistant QMR - Quality Management Review

6. Provider Participation RequirementsChapter II

7. Categories of Services Nursing Occupational Therapy Physical Therapy Speech Language Pathology Behavioral Supports

8. Nursing PCAs Must meet minimum qualifications for unlicensed assistive personnel as required by the Department of Education, Virginia School Health Guidelines, VDH and VDOE, 1999 (page 63) www.doe.virginia.gov/support/health_medical/virginia_school_health_guidelines/developing_program_infrastructure.pdf

9. Nursing PCAs cont. Must receive training for assisting with meeting the specific health needs of the student as outlined in the following: Virginia School Health Guidelines Manual, Specialized Health Care Procedures Manual, Manual for the Training of Public School Employees in the administration of Medication, and Virginia Board of Nursing regarding the scope of licensure of a registered nurse (R.N.) in providing the supervision of a personal care assistant performing functions such as range of motion, massage, strengthening exercises. Jodi P. Power, R.N., J.D., the Deputy Executive Director for the Virginia Board of Nursing stated “professional nursing” in the Code of Virginia (Section 54.1-3000) indicates professional nursing “means the performance for compensation of any nursing acts… in the supervision and teaching of those who are or will be involved in nursing care; in the delegation of selected nursing tasks and procedures to appropriately trained unlicensed persons as determined by the Board….”  (excerpted).  The full definition and law can be accessed directly from the Department of Health Professions (DHP) website: www.dhp.virginia.gov. Ms. Power stated the delegation of a selected nursing task by a R.N. to an unlicensed person on a specific patient is a case-by-case decision following the assessment by the R.N.  The criteria for appropriate delegation are found in the Board of Nursing Regulations.  There are no absolutes, except for the list of what shall NOT be delegated as described in 18 VAC 90-20-460(B) of the Board of Nursing Regulations.  Generally, tasks that shall NOT be delegated include activities involving nursing assessment, problem identification, and outcome evaluation which require independent nursing judgment.   Virginia Board of Nursing regarding the scope of licensure of a registered nurse (R.N.) in providing the supervision of a personal care assistant performing functions such as range of motion, massage, strengthening exercises. Jodi P. Power, R.N., J.D., the Deputy Executive Director for the Virginia Board of Nursing stated “professional nursing” in the Code of Virginia (Section 54.1-3000) indicates professional nursing “means the performance for compensation of any nursing acts… in the supervision and teaching of those who are or will be involved in nursing care; in the delegation of selected nursing tasks and procedures to appropriately trained unlicensed persons as determined by the Board….”  (excerpted).  The full definition and law can be accessed directly from the Department of Health Professions (DHP) website: www.dhp.virginia.gov. Ms. Power stated the delegation of a selected nursing task by a R.N. to an unlicensed person on a specific patient is a case-by-case decision following the assessment by the R.N.  The criteria for appropriate delegation are found in the Board of Nursing Regulations.  There are no absolutes, except for the list of what shall NOT be delegated as described in 18 VAC 90-20-460(B) of the Board of Nursing Regulations.  Generally, tasks that shall NOT be delegated include activities involving nursing assessment, problem identification, and outcome evaluation which require independent nursing judgment.  

10. Nursing PCAs cont. Manual for training of Public School Employees in the Administration of Insulin and Glucagon. VDOE training publications may be found on the VDOE website at www.doe.virginia.gov/support/health_medical/index.shtml Virginia Board of Nursing regarding the scope of licensure of a registered nurse (R.N.) in providing the supervision of a personal care assistant performing functions such as range of motion, massage, strengthening exercises. Jodi P. Power, R.N., J.D., the Deputy Executive Director for the Virginia Board of Nursing stated “professional nursing” in the Code of Virginia (Section 54.1-3000) indicates professional nursing “means the performance for compensation of any nursing acts… in the supervision and teaching of those who are or will be involved in nursing care; in the delegation of selected nursing tasks and procedures to appropriately trained unlicensed persons as determined by the Board….”  (excerpted).  The full definition and law can be accessed directly from the Department of Health Professions (DHP) website: www.dhp.virginia.gov. Ms. Power stated the delegation of a selected nursing task by a R.N. to an unlicensed person on a specific patient is a case-by-case decision following the assessment by the R.N.  The criteria for appropriate delegation are found in the Board of Nursing Regulations.  There are no absolutes, except for the list of what shall NOT be delegated as described in 18 VAC 90-20-460(B) of the Board of Nursing Regulations.  Generally, tasks that shall NOT be delegated include activities involving nursing assessment, problem identification, and outcome evaluation which require independent nursing judgment.   Virginia Board of Nursing regarding the scope of licensure of a registered nurse (R.N.) in providing the supervision of a personal care assistant performing functions such as range of motion, massage, strengthening exercises. Jodi P. Power, R.N., J.D., the Deputy Executive Director for the Virginia Board of Nursing stated “professional nursing” in the Code of Virginia (Section 54.1-3000) indicates professional nursing “means the performance for compensation of any nursing acts… in the supervision and teaching of those who are or will be involved in nursing care; in the delegation of selected nursing tasks and procedures to appropriately trained unlicensed persons as determined by the Board….”  (excerpted).  The full definition and law can be accessed directly from the Department of Health Professions (DHP) website: www.dhp.virginia.gov. Ms. Power stated the delegation of a selected nursing task by a R.N. to an unlicensed person on a specific patient is a case-by-case decision following the assessment by the R.N.  The criteria for appropriate delegation are found in the Board of Nursing Regulations.  There are no absolutes, except for the list of what shall NOT be delegated as described in 18 VAC 90-20-460(B) of the Board of Nursing Regulations.  Generally, tasks that shall NOT be delegated include activities involving nursing assessment, problem identification, and outcome evaluation which require independent nursing judgment.  

11. Nursing PCAs cont. Must be identified in the student’s IEP. Must be included in the Plan of Care (POC) prepared by the licensed registered nurse (RN). Personal care assistants for nursing services must be supervised by a RN. ADL and IADL services do not require physician order.

12. PCAs for Practitioners of the Healing Arts Specific services must be ordered by a Department of Medical Assistance Services (DMAS) qualified practitioner of the healing arts acting within the scope of their licensure Minimum qualifications: Each health regulatory board establishes what the practitioner can delegate and the qualifications of the person delegated to. Minimum qualifications: Each health regulatory board establishes what the practitioner can delegate and the qualifications of the person delegated to.

13. PCAs for Practitioners of the Healing Arts cont. Personal care assistants for the healing arts must be trained and supervised by a DMAS qualified practitioner of the healing arts (OT, PT, SLP, Psychiatrist, Psychologist, Social Worker). Minimum qualifications: Each health regulatory board establishes what the practitioner can delegate and the qualifications of the person delegated to. Minimum qualifications: Each health regulatory board establishes what the practitioner can delegate and the qualifications of the person delegated to.

14. PCAs for Practitioners of the Healing Arts cont. Board of Physical Therapy (18 VAC 112-20-10 et seq.) Licensed PT can supervise support personnel who are designated routine tasks related to physical therapy; however…supervision must be direct. Minimum qualifications: Each health regulatory board establishes what the practitioner can delegate and the qualifications of the person delegated to. Minimum qualifications: Each health regulatory board establishes what the practitioner can delegate and the qualifications of the person delegated to.

15. PCAs for Practitioners of the Healing Arts cont. OT - Board of Medicine (18VAC85-80-110-111 ) Unlicensed occupational therapy personnel may be supervised by an OT or a COTA. An occupational therapist may provide clinical supervision for up to six occupational therapy personnel…

16. PCAs for Practitioners of the Healing Arts cont. Board of Audiology & Speech Language Pathology 18VAC30-20-240 Supervision of unlicensed assistants A SLP…shall ensure that ‘PCA’ perform only those activities …which are appropriate with their level of training. The identity of the ‘PCA’ shall be disclosed… prior to treatment and…made a part of…the file.

17. PCAs for Practitioners of the Healing Arts cont. Board of Psychology (18VAC125-20-10 ) …monitors the performance of the person supervised and provides regular, documented individual consultation, guidance and instruction with respect to the skills and competencies of the person supervised.

18. Provider Requirements cont. The DOE training manuals may be found on the DOE website at under the ‘Board of Education Guidance Documents’ www.doe.virginia.gov/boe/guidance/index.shtml

19. Covered ServicesChapter IV Services to assist the child with disabilities in self-sufficiency, communications, and mobility skills.

20. Nursing PCAs Must be identified in the student’s IEP. Must be included in the Plan of Care (POC) prepared by the licensed registered nurse (RN). Personal care assistants for nursing services must be supervised by a RN. ADL and IADL services do not require physician order.

21. Covered Services Services provided by the assistant are related to the child’s physical and behavioral health requirements, including: assistance with eating, dressing, hygiene, activities of daily living, bladder and bowel needs; use of adaptive equipment; ambulation and exercise;

22. Covered Services cont. behavioral issues; and other remedial services to promote reduction of a child’s disabilities. monitoring of a health related service i.e.: bus driver aide or monitoring the need for suctioning

23. Authorization for Services Services must be authorized by the current Individualized Education Program (IEP) The student shall have a current order from a physician, physician assistant or nurse practitioner for specialized nursing procedures (i.e. tube feedings, catheterizations, and seizure monitoring) The service cannot be provided by a parent or a step-parent If the aide is hired to monitor a student for a specific condition, then the order must state “monitoring.” Medicaid regulations will not allow parents or step parents to be the health care provider. If the aide is hired to monitor a student for a specific condition, then the order must state “monitoring.” Medicaid regulations will not allow parents or step parents to be the health care provider.

24. Documentation Requirements Chapter VI

25. Documentation Requirements Documentation must be in accordance with requirements of individual licensing board within DHP, VDOE and DMAS. Quality management reviews follow requirements noted in Chapter VI of the DMAS LEA Provider manual.

26. Documentation Requirements DMAS forms are recommended and available online http://dmasva.dmas.virginia.gov under Search Forms / Local Education Agency. May be completed electronically and printed out to place in record.

27. Documentation Requirements Records must be made available to authorized state and federal personnel and include: Current IEP pages which document actual services; Need for assessment must be documented when it does not result in determination that services are indicated in the IEP (such as on Present Level of Performance or Considerations Page)

28. PCA Plan of Care DMAS 46 Developed by a licensed practitioner of the healing arts within the scope of their license. A separate plan of care should be developed per discipline based on the services needed.

29. PCA Plan of Care cont. If percentages are used for measuring goals, percentages should change based on student’s progression, not a set time frame. IEP may serve as POC only if it includes all elements of the POC.

30. PCA Plan of Care cont. The plan of care developed by the qualified provider should be consistent with the health conditions and functional limitations documented on the individual’s IEP.

31. PCA Plan of Care cont. Medical condition and diagnosis being address Specific to needs identified in assessment Goals and objectives Treatment intervention and which goal addressed

32. PCA Plan of Care cont. Type, amount and frequency of service Anticipated duration of service Signed and dated by individual performing service Reviewed at least annually

33. PCA Service Log – DMAS 37 Progress notes/Student Log - DMAS DMAS qualified provider must initial, sign and date each form. Entries must be initialed and dated by responsible provider of service each time service is provided. Providers requiring supervision require documentation of supervision per requirements of licensing board, VDOE and DMAS.

34. PCA Service Log cont. The personal care assistant shall document: On a daily basis for non-nursing services For nursing assistants the documentation is per occurrence Date and amount of time

35. PCA Service Log cont. Procedure Comments N = Normal V = variance from normal or standard. Include written explanation in ‘Comment’ section Initials of the assistant Documentation of supervisory visit signed by applicable supervisor

36. Supervision Supervision provided by the appropriate qualified provider. Supervisory visits are required as often as needed to ensure both quality and appropriateness of services. Review the child’s progress and make any adjustment to goals or treatment modalities.

37. Supervision cont. Supervising licensed provider must document supervisory visits with student and PCA at a minimum of every 30 to 90 calendar days, or as often as needed. Purpose is to ensure quality and appropriateness of services being provided.

38. Supervision cont. Condition of the child as well as qualified provider’s license requirements determines whether the supervision is direct versus indirect and the frequency of supervision visits.

39. Supervision cont. An on-site visit must be conducted at least every 90 calendar days. Supervisor shall identify any gaps in aide’s ability to function competently and shall provide training as indicated.

40. Billing A unit of services equals 15 minutes for no more than 8.5 hours a day The number of units billed is not to exceed the number of units in a day that the student is in the care of the school

41. Billing cont. While more than one assistant may attend the student during a school day, the unit for a particular period of the day shall not be billed for the services of more than one assistant.

42. Billing cont. If the total number of units billed ends up with a fraction of a unit, round to the nearest unit 50 minutes of care / 15 = 3.33 = 3 units 100 minutes of care / 15 = 6.66 = 7 units Regular school year is 180 days May vary among school divisions Services during the summer school sessions are billable as well.

43. Resources Amy Edwards Medicaid in Schools Specialist, DOE 804-692-0150 Amy.edwards@doe.virginia.gov Ashley Barton, LCSW Maternal & Child Health Specialist, DMAS 804-371-7824 Ashley.barton@dmas.virginia.gov

44. School Health Medical Evaluations Local Education Agency Medicaid Provider Manual

45. Child Focused IEP Medical Evaluations should determine: If the child’s IEP is appropriate to meet the health needs of the child; or If there are medical services required for the student to receive a free and appropriate education

46. Providers of Medical Evaluations Medical evaluation services are covered as physicians’ services Persons performing these services must be licensed practitioners (physicians, physician assistants, and nurse practitioners) acting within the scope of practice

47. Providers Requirements, cont. Schools must enroll as a health services provider Have a school provider agreement completed and on file with DMAS Provide DOE Medicaid Specialist (Amy Edwards) with copy of practitioner’s license requesting to provide medical evaluation services Practitioner may be either employed or contracted with the school

48. Covered Services Identifying the nature or extent of a recipient’s medical or other health related condition; May be face-to-face, chart review or telephonic consultation; Review of a recipient’s initial IEP as necessary to determine the medical necessity for the medical/mental health related services designated by the IEP team;

49. Covered Services, cont. Annual review of a recipient’s IEP as necessary to determine continuing medical necessity for the medical/mental health related services designated by the IEP team; Review of additional documents related to at recipient’s medical/mental health status either for consultative purposes or to determine medical necessity for services;

50. Covered Services, cont. Participating in meetings with IEP providers or families to provide medical input concerning a recipient’s disability and medical/mental health-related services needed;

51. Covered Services, cont. Coordinating medical/mental health related services rendered outside the school setting. For example, talking to a recipient’s primary care physician about medication needs; and Completion of referral reports and documentation relative to the IEP.

52. Medical Evaluation Billing Code: T1024 Maximum Interim Rate: $96.51 Unit: Per encounter

53. Documentation Requirements Positive and negative examination findings; Diagnostic tests ordered and the results of the tests; Diagnoses;

54. Documentation Requirements cont. An indication of whether further treatment is needed; Referrals, including the name of the referring physician; and Any recommended IEP changes.