OAR 410-172-0780: Temporary rule language in effect until 02/15/2027. State Plan Personal Care Services and Limitations

(1) The State Plan Personal Care (SPPC) program provides essential personal care services that enable an individual to move into or remain in their own home, family home, another private residence or temporary living arrangement. (a) Personal care services available through the SPPC program are provided directly to an individual who is determined to be eligible in accordance with OAR 410-172-0790. (b) Personal care services are not intended to provide respite and they are not intended to substitute for the individual’s natural or other support systems that are available to them. Personal care services must be medically necessary and appropriate and must not be provided for the purpose of benefiting an individual’s family members or the individual’s household. (2) Eligible individuals who are authorized by the Authority to receive personal care services may be approved to receive up to 270 hours of personal care services in a twelve-month period, unless an exception request is approved by the Authority. (a) The actual number of hours of personal care services that an individual is authorized to receive are identified in the individual’s person-centered service plan (PCSP). An individual’s PCSP is developed as outlined in OAR 410-172-0790. The twelve-month period (PCS plan year) begins on the date the individual is determined eligible for the SPPC program unless otherwise modified through an exception request by the Authority. (b) When an individual’s personal care service needs are assessed as exceeding the annual maximum of 270 hours in a PCSP year, an individual or their authorized representative, has the right to request an exception. Exception requests must be submitted in writing on behalf of the individual by the service coordinator and must identify all of the following: (A) The exceptional personal care needs the individual is experiencing; (B) The tasks that require hands-on assistance or direct supervision and cueing every time they occur; and (C) The start date and duration of the additional personal care services. (c) The Authority has up to 45 days upon receipt of an exception request to determine whether an individual’s assessed personal care needs warrant exceeding the 270-hour per PCS plan year limitation and issue written notice to the individual; (d) The individual id provided a written notice of action or service authorization within 10 days after the Authority’s decision. (3) Personal care services include: (a) Activities of Daily Living (ADLs): (A) Eating includes assisting the individual in feeding or fluid intake by any means from a receptacle into the body. Includes monitoring to prevent choking or aspiration; (B) Bathing includes assisting the individual with cleansing the body, washing hair, shaving, nail care, and using assistive devices when necessary to get in and out of the bathtub or shower; (C) Dressing includes assisting the individual with putting on, fastening, and taking off all items of clothing, braces, and artificial limbs, including obtaining and replacing items from their storage area in the immediate environment; (D) Toileting includes assisting the individual in getting to and from, on and off the toilet, commode or bedpan for elimination of feces and urine. This includes cleansing after elimination and adjusting clothing as necessary; (E) Maintaining Continence includes assisting the individual with external cleansing of Foley catheter, emptying catheter drainage bag, maintenance bowel care, changing and replacing incontinence products, including colostomy or ileostomy bags; and (F) Transferring includes assisting the individual with transfers between positions, ambulation (walking) and repositioning by any means including use of an assistive device and includes turning or adjusting padding for physical comfort or pressure relief and encouraging or assisting with range of motion exercises. (b) Instrumental Activities of Daily Living (IADLs) includes: (A) Personal Hygiene includes performing or assisting the individual with activities required to keep one’s desired appearance including secure or fasten clothing, comb/brush hair, nail care, foot care, skin care, and mouth care and oral hygiene; (B) Light Housework includes performing or assisting the individual with housekeeping tasks necessary to maintain the individual in a healthy and safe living environment; (C) Laundry includes performing or assisting the individual with laundering or cleaning of clothing, bedding and other linens; (D) Meal preparation includes performing or assisting the individual with healthy meal planning and preparation, ensuring special diets are followed; (E) Shopping includes performing or assisting the individual in planning for and purchasing of essential items including clothing, groceries, prescribed medication, hygiene products and basic household necessities; (F) Using the Telephone or other Electronic Communication Devices include performing or assisting the individual in arranging necessary appointments and making desired phone calls using a telephone, smart phone, tablet or other similar electronic device for communication purposes; (G) Medication assistance includes helping individuals with oral medications prescribed for the individual by a licensed medical professional, which are ordinarily self-administered described below: (i) Administering medication; (ii) Supervision or cueing to ensure the individual is taking medication as prescribed; (iii) Documenting and monitoring any notable side effects; (iv) Refilling prescriptions; and (v) Assisting with use, maintenance, and cleaning of in-home medical equipment authorized by a licensed medical professional, monitoring the individual’s condition, ordering and maintaining necessary supplies. Use, maintenance and cleaning of in-home medical equipment must be performed by PCA in compliance with manufacturers guidelines or the PCA must have received prior training and education from an RN, when applicable, in how to correctly perform these tasks. Providing assistance with insulin injections and other similar medical tasks requires prior training and education from an RN, which is a delegated nursing task. (H) Money Management includes performing or assisting the individual with budgeting, making payments for monthly expenses and use of personal funds for desired items and activities; and (I) Transportation includes assisting the individual, due to a functional limitation, in getting to and from medically appropriate and necessary appointments and community activities, consistent with the individual’s authorized PCSP and personal care needs, and does not duplicate services otherwise available through non-Medicaid transportation benefits. Transportation benefits may include: (i) Scheduling non-emergent medical transportation (NEMT) for their OHP-covered medical service appointments; (ii) Scheduling non-medical rides through public transportation or other modes of transportation; (iii) Accompanying the individual to and from appointments or community activities; (iv) Transporting the individual in the PCA’s or DSW’s personal vehicle in accordance with section (4) below of this rule. (4) PCAs and DSWs may use their personal vehicles to transport individuals as outlined in this section. (a) Both PCAs and DSWs must: (A) Prior to transporting the individual, submit proof of current vehicle registration and insurance for the personal vehicle used to transport the individual and a current valid driver’s license to: (i) The individual's service coordinator for PCAs; or (ii) Agency with Choice (AWC) for DSWs; and (B) Claim mileage and request reimbursement only when the transportation provided is authorized in the individual’s current PCSP. (i) PCAs must submit their claims for mileage reimbursement to the Authority, which will be paid at the rate identified in the current collective bargaining agreement. (ii) DSWs must submit their claims for reimbursement to the AWC that employs them. (b) Mileage may be reimbursed by the Authority for OHP covered medical appointments when: (A) One or more providers have documented in the individual's medical record that the individual will need non-emergency medical transportation for future, specific dates of service using the PCA’s or DSW’s vehicle; (B) The need for non-emergency medical transportation is included in the individual's PCSP or made a part of the PCSP after receipt of the documentation provided under (A) but before the specified date(s) of services; and (C) As determined by OHA in its reasonable discretion after a review of all the circumstances, including whether the denial by NEMT was reasonable. (c) PCAs will be paid for travel time between individual’s homes or initial service-related sites (e.g., pharmacy, grocery store) occurring on the same day. Travel time will be calculated based on the most direct route possible. PCAs using public transportation, the posted time between stops will be used to calculate and validate travel time. Travel time will be paid at base pay for Providers as defined in Appendix A of the collective bargaining agreement. Travel time pay is not subject to Oregon Home Care Commission (OHCC) certification pay differentials. This subsection (c) does not apply to DSWs. (5) Personal Care Services include other services as follows: (a) Delegated nursing includes nursing tasks that are delegated by a Registered Nurse currently licensed and in good standing with the Oregon Board of Nursing, to a licensed provider or other non-licensed persons in accordance with OAR chapter 851, division 47. Skilled services delegated by a Registered Nurse (RN) under Oregon’s Nurse Practice Act may be considered personal care services when the RN provides appropriate training and delegation of the listed nursing tasks in accordance with the Oregon Nurse Practice Act; and (b) Personal care services may be required when an individual has the physical capability to perform ADL or IADL tasks but due to mental health conditions the individual does not know how or when to carry out those tasks. In such situations, personal assistance may include cueing along with supervision to ensure the individual performs the task safely. An individual may also have co-occurring physical disabilities that contribute to the need for assistance. (6) Services that are not outlined in sections (3) through (5) above are not eligible for payment. The Authority will not pay a PCA or an AWC when the PCA or the DSW provides any of the following excluded services: (a) Shopping for entertainment purposes or non-essential items; (b) Social companionship; (c) Day care, partial hospitalization, respite or baby-sitting services; (d) Care, grooming, or feeding of pets or other animals except those incidental to other authorized ADL or IADL tasks; or (e) Yard work, gardening or home repair.