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February 12, 2008

**Centers for Medicare & Medicaid Services**

**Department of Health and Human Services**

Attn: CMS -- 2229-P

P.O. Box 8016

Baltimore, MD 21244-8016

Re: Medicaid Program: Self-Directed Personal Assistance Services Program
State Plan Option

Dear Sirs:

On behalf of more than 750 locations of home health agencies and private
home care providers in the State of California, we are writing to
comment on the above referenced proposed rule published in the January
19, 2008 Federal Register.

We support the ability of Medicaid recipients to self-direct their care
if the caregiver is trained and qualified and suitable controls are in
place for financial management, quality assurance and risk management.

Following are our specific comments:

**Section 441.450 [Basis, scope and definitions]{.underline}**

[Assessment of need]{.underline}

The definition of assessment of need is quite vague. Since the service
plan and budget are dependent upon the assessment of need, we recommend
the assessment be further defined. The definition should speak to use of
a standardized assessment instrument.

[Legally liable relatives]{.underline}

We feel that legally liable relatives who are caregivers being paid to
provide PAS, should be subject to requirements for training, competency
evaluation and criminal background checks.

[Service plan]{.underline}

The service plan is a critical component in meeting the needs of the
participant receiving self-directed care. The definition as proposed
contains no qualifications for the person or persons involved in
development of the service plan. At a minimum, the persons involved
should be qualified and competent to develop such a plan.

**Section 441.456 [Voluntary disenrollment]{.underline}**

We support the requirement that a participant be allowed to voluntarily
disenroll at any time and return to a traditional service delivery
system.

**Section 441.464 [State assurances]{.underline}**

The section on necessary safeguards is sufficiently vague that it is
unlikely to assure financial accountability. A serious problem in
California's current In-Home Supportive Services (IHSS) program is the
lack of controls and accountability in the timekeeping system. Without
additional safeguards, the same problems are likely to occur in the PAS
program.

[Notification of feasible alternatives]{.underline}

In order to understand the feasible alternatives and make an informed
choice, the participant must be given information about the differences
between agency-delivered care and self-directed care. This includes
information about licensure and certification of agency staff, required
training and competency evaluation, criminal background checks, and the
ability to contact the agency and request a substitute caregiver if the
initial caregiver does not show up.

[Freedom of choices of providers]{.underline}

While this is a very important provision to include, no information or
requirements are provided to explain how this concept will be
operationalized. For example, will the participant be given a list of
agencies which are available to provide care if they elect not to
self-direct?

[Annual Report]{.underline}

We believe the annual report should indicate the number of individuals,
units of service, and cost of those receiving self-directed services,
agency delivered services and a mix of modes.

**Section 441.472 [Budget methodology]{.underline}**

Item (4) states "The State's method includes a calculation of the
expected cost of the self-directed PAS and supports, if those services
and supports were not self-directed". It is not clear what this means.
To afford true freedom of choice, the participant should be given the
opportunity to receive the same amount of services under both the
self-directed mode and the agency-delivered mode.

**Section 441.474 [Quality assurance and improvement plan]{.underline}**

We believe that quality assurance and improvement plan should contain a
requirement that the State create a log of all critical events and
report the results of this log in the annual report.

**Section 441.478 [Qualifications of providers of personal
assistance]{.underline}**

This section states participants may have "any individual capable of
providing the assigned tasks". This implies that the individual is
trained and competent to provide the assigned tasks. We think the
training and competency evaluation requirements should be explicit.

Thank you for the opportunity to comment on this proposed regulation.

Sincerely,

![](media/image3.jpeg){width="1.6784722222222221in"
height="0.6180555555555556in"}

Joseph H. Hafkenschiel

President