OAR 410-172-0776: Temporary rule language in effect until 02/15/2027. State Plan Personal Care Program Definitions

In addition to the defined words in OAR 410-172-0600, the definitions in this rule apply to OARs 410-172-0775 through OAR 410-172-0840, which apply to SPPC Program. If a word defined in this rule conflicts with a word defined in 410-172-0600, the word defined in this rule will apply. (1) “Agency with Choice” means an organization licensed by the Oregon Health Authority in accordance with OAR chapter 309, division 045 that provides the Agency with Choice services. (2) “Agency with Choice Services” means personal care and other related services provided to an individual by an Agency with Choice in accordance with OARs 410-172-0776 through 410-172-0845 and OAR chapter 309, division 45. (3) "Assistance” means help needed by and provided to an individual in performing Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs). When provided to an individual, assistance includes hands-on assistance, cueing, and supervision. Supervision includes monitoring, set-up, reassurance, and stand-by. (4) "Assistive Devices" means any category of durable medical equipment, mechanical apparatus, electrical appliance, or instrument of technology used to assist and enhance an individual's independence in performing any task described in OAR 410-172-0780. (5) "Assistive Supports" means the aid of service animals, general household items, or furniture used to assist and enhance an individual’s independence in performing any task described in OAR 410-172-0780. (6) "Background Check" means a criminal history check and abuse check as described in OAR chapter 407 division, 007, including criminal records as adopted in OAR chapter 943, division 007. (7) “Care Coordinator” means the person responsible for referring individuals to qualified providers that can provide authorized personal care services and coordinating the care an individual receives. (8) "Collective Bargaining Agreement (CBA)" means the ratified Collective Bargaining Agreement between the Home Care Commission and the Service Employees International Union, Local 503. The Collective Bargaining Agreement is maintained on the Department's website:https://www.oregon.gov/odhs/providers-partners/homecare-workforce/Pages/default.aspx). Printed copies may be obtained by writing the Oregon Department of Human Services, Aging and People with Disabilities, ATTN: Rules Coordinator, 500 Summer Street NE, E-2, Salem, Oregon 97301. (9) “Consumer-Employer" means an individual, or the individual’s authorized representative, who employs a personal care attendant and performs employer responsibilities under these rules. Individuals who receive in-home services from a direct support worker through an Agency with Choice are not consumer-employers. (10) "Cost Effective" means being responsible and accountable with Authority resources. This is accomplished by offering less costly alternatives while providing choices that adequately meet an individual’s service needs. Those choices consist of all available service options, the utilization of assistive devices or assistive supports, natural supports, architectural modifications, and alternative service resources. Less costly alternatives may include resources not paid for by the Authority. (11) "Developmental Disability" as defined in OAR 411-320-0020 and described in OAR 411-320-0080. (12) “Direct Contact” means services provided by a service coordinator through direct communication with an individual or their authorized representative via phone, email or face-to-face contact, as directed by the individual, for the purposes of care coordination and service-plan monitoring. (13) “Direct Support Worker (DSW)” means a person employed by an Agency with Choice who assists individuals with ADLs and IADLs and health related tasks identified in the individual’s person-centered service plan. A direct support worker is different than “personal care attendant,” which is defined in OAR 309-045-0310. (14) “Duty to Maintain Consumer-Employer Confidentiality” means a personal care attendant will not disclose personally identifiable information about a consumer-employer unless otherwise authorized by law. (15) “Electronic Visit Verification (EVV)” means a system that verifies, in accordance with 42 U.S.C 1396b(I), personal care services provided to an individual under the state plan personal care program, as follows: (a) Type of services; (b) The individual who received the service; (c) The date of service; (d) The location of service delivery; (e) The name of the personal care attendant providing the service; and (f) The time the services began and ended. (16) "Exerts Undue Influence" means a personal care attendant assumes or attempts to assume control of an individual’s decision-making, finances, home, property, medication, social interaction or ability to communicate, through coercion or other non-persuasive, threatening means. Exertion of undue influence may exist whether or not an individual willfully allows the personal care attendant to assume such control. (17) "Fiscal Improprieties" means a personal care attendant committed financial misconduct involving an individual's money, property, or benefits. (a) Fiscal improprieties include, but are not limited to: (A) Financial exploitation, as defined in ORS 430.735 and described in OAR 411-020-0002, including: (i) Wrongfully taking, by means including, but not limited to, deceit, trickery, subterfuge, coercion, harassment, duress, fraud, or undue influence, the assets, funds, property, or medications belonging to or intended for the use of an adult; (ii) Alarming an adult by conveying a threat to wrongfully take or appropriate money or property of the adult if the adult reasonably believes the threat conveyed may be carried out; (iii) Misappropriating or misusing any money from any account held jointly or singly by an adult; (iv) Failing to use income or assets of an adult for the benefit, support, and maintenance of the adult; or (v) The taking, borrowing, or accepting of assets, funds, property, or medications from an adult residing in a facility by an employee of the facility, unless the adult and employee are related and the action described in this paragraph does not constitute a wrongful taking as described in (i). (B) Improper financial transactions with an individual, including but not limited to: (i) Borrowing money, property, or belongings from an individual; (ii) Accepting or receiving funds, or services purchased for the personal care attendant by the individual. (C) Fraudulent or improper billing or payment practices, including but not limited to: (i) Forging an individual’s signature; (ii) Falsifying payment records, including submitting incorrect start and end times of work; (iii) Submitting payment for days that were not worked; or (iv) Claiming to deliver services to an individual during a time also claimed for travel between worksites; (v) Working or claiming to work hours not authorized on a consumer-employer's person-centered service plan or working or claiming hours over the maximum weekly hours permitted under the Collective Bargaining Agreement; (vi) Claiming hours worked for an individual while taking time off or when a relief care provider, as described in the CBA, is paid for providing services; (vii) Requesting or demanding payment for services from either the Authority or the individual in excess of the amount paid following the submission and processing of a properly completed claim; (viii) One or more intentional acts of dishonesty for purposes of unearned financial gain; or (ix) Creating an overpayment whether intentionally or unintentionally and not paying it back within six months. (b) Fiscal Improprieties do not include the exchange of money, gifts, or property between a personal care attendant and an individual with whom the personal care attendant is related unless an allegation of financial exploitation, as defined in OAR chapter 411-020-0002 or ORS 430.735, has been substantiated based on an adult protective services investigation. (18) “Information and Referral” means providing referral and related activities, such as assisting the individual to schedule appointments, obtain needed services, and connect the individual with medical, social, and educational providers or other programs and services that can provide services to address the identified needs of the individual. (19) "Mandatory Abuse Reporter" means any public or private official, including personal care attendants who are required by state abuse statutes, to report alleged abuse. Rules related to Mandatory Reporter for Agencies with Choice, and direct support workers are referenced in OAR chapter 309 division 045. (20) “Notice of Action” means a written document that is sent by the Authority or its designee to the individual and as applicable, the individual’s referring provider or Authorized Representative, that outlines why an individual’s request for personal care services has been denied in full or in part and complies with the requirements set out in OAR 410-120-1865. (21) “Personal Care Attendant (PCA)” means a type of personal support worker, as defined in ORS 410.600, who is hired to provide personal care services to an individual with a behavioral health condition or disability who resides in their own Home, Family Home or community setting. A PCA can be hired by the individual, a parent of a child, or the individual’s legal or authorized representative. (22) "Provider" or "Qualified Provider" for the purposes of these rules means: (a) A personal care attendant who is an enrolled provider with the Authority, meets the training and education and qualifications in OAR Chapter 418 Division 020, and performs personal care services for individuals not residing in a facility; or (b) An Agency with Choice that is an enrolled provider with the Authority, meets the qualifications in OAR chapter 309 division 045 and employs direct support workers who perform personal care services for individuals not residing in a facility. An Agency with Choice assumes co-employer responsibilities with the individual receiving personal care services. The co-employer responsibilities include worker training, payroll, and compliance with Electronic Visit Verification requirements as described in chapter 309 division 045. (23) “Person-Centered Service Plan” means the written document prepared by the IQA service coordinator that details the supports, desired outcomes, activities, and resources required for an individual to achieve and maintain personal goals, health, and safety as described in OAR 410-173-0025. (24) "Provider Number" means a unique identifying number issued to an Agency with Choice and each personal care attendant who is enrolled with the Authority as a Medicaid provider. (25) "Service Authorization" means the written documentation issued by the Authority to the individual informing them of the services approved in the individuals’ service plan. Sometimes, a service authorization may also be a Notice of Action as defined in this rule. A service authorization identifies: (a) The qualified provider who is authorized to provide personal care services to the individual; (b) The date the individual is authorized to begin receiving personal care services from the qualified provider; and (c) The specific personal care services the individual is authorized to receive from the qualified provider; and (d) The maximum hours an individual is authorized to receive personal care services during a service period. (26) "Service Coordination” means the functions performed by a service coordinator and includes determining service eligibility for home and community-based services, including personal care services, based on program criteria, conducting a needs-based assessment for services and developing a person-centered service plan. (27) “Service Coordinator” means a qualified mental health practitioner employed by the Authority’s IQA who: (a) Determines eligibility for services in accordance with program requirements; (b) Conducts needs-based assessment to identify individual’s functional needs for services; (b) Develops person-centered service plan with individuals based on their assessed needs; (c) Informs individuals of available service options and assists individuals in identifying appropriate services and supports based on assessed needs and the person-centered service plan, including potential qualified providers, coordinating with the individual’s care coordinator or community mental health program when applicable; and (d) Monitors the delivery of authorized services. (28) "Service Need" means the amount, scope, and duration of personal care and supportive services that are medically necessary and appropriate for an individual as determined through a personal care services’ needs-based assessment and documented with specificity in the individual’s person-centered service plan. (29) "Service Period" means two consecutive work weeks for a total of 14 days. (30) "Skills, Knowledge, and Ability to Adequately or Safely Perform the Required Work" means a personal care attendant or direct support worker possesses and demonstrates the physical, mental, organizational, and emotional skills or abilities necessary to perform services which safely and adequately meet the service needs of individuals. (31) “Termination” means a sanction prohibiting a provider’s participation in the Authority’s programs by cancelling the Authority-assigned billing number and agreement for a personal care attendant or Agency with Choice. No payments, Title XIX, or state funds will be made for services provided on and after the date of termination. An Agency with Choice may also have their license denied, suspended, or revoked as outlined in OAR 309-045-0320. (32) "Unwelcome Nuisance to the Workplace" includes, but is not limited to, unwelcome guests or pets invited by a personal care attendant or a direct support worker into an individual’s home, unwelcome behaviors, or unwelcome items resulting in the individual’s dissatisfaction or a personal care attendant’s or a direct support worker's inattention to the individual's required service needs.