New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter E - Medical Care › Article 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 505 - Charges For Professional Health Services › Section 505.14 - Personal care services

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
Definitions and scope of services.
(1)
Personal care services
means assistance with nutritional and environmental support functions and
			 personal care functions, as specified in clauses (5)(i)(
a
) and
			 (5)(ii)(
a
) of this subdivision. Such services must be
			 medically necessary for maintaining an individual's health and safety in his or
			 her own home, as determined by the social services district or Medicaid managed
			 care organization in accordance with this section; ordered by a qualified
			 independent practitioner; based on an assessment of the individual's needs and
			 of the appropriateness and cost-effectiveness of services specified in
			 subparagraph (b)(2)(iii) of this section; provided by a qualified person in
			 accordance with a plan of care; and supervised by a registered professional
			 nurse.
(2)
Continuous
			 personal care services
means the provision of uninterrupted care, by
			 more than one personal care aide, for more than 16 hours in a calendar day for
			 a patient who, because of the patient's medical condition, needs assistance
			 during such calendar day with toileting, walking, transferring, turning and
			 positioning, or feeding and needs assistance with such frequency that a live-in
			 24-hour personal care aide would be unlikely to obtain, on a regular basis,
			 five hours daily of uninterrupted sleep during the aide's eight hour period of
			 sleep.
(3) Personal care services,
			 as defined in this section, can be provided only if the individual meets
			 applicable minimum needs requirements described in subparagraph (iv) of this
			 paragraph, and the social services district or Medicaid managed care
			 organization reasonably expects that the individual's health and safety in the
			 home can be maintained by the provision of such services, as determined in
			 accordance with this section.
(i) The
			 patient's medical condition shall be
stable,
which shall be
			 defined as follows:
(a) the condition is not
			 expected to exhibit sudden deterioration or improvement; and
(b) the condition does not require frequent
			 medical or nursing judgment to determine changes in the patient's plan of care;
			 and
(c)
(1) the condition is such that a physically
			 disabled individual is in need of routine supportive assistance and does not
			 need skilled professional care in the home; or
(2) the condition is such that a physically
			 disabled or frail elderly individual does not need professional care but does
			 require assistance in the home to prevent a health or safety crisis from
			 developing.
(ii) The patient shall be self-directing,
			 which shall mean that he/she is capable of making choices about his/her
			 activities of daily living, understanding the impact of the choice and assuming
			 responsibility for the results of the choice. Patients who are
			 nonself-directing, and who require continuous supervision and direction for
			 making choices about activities of daily living shall not receive personal care
			 services, except under the following conditions:
(a) supervision or direction is provided on
			 an interim or part-time basis as part of a plan of care in which the
			 responsibility for making choices about activities of daily living is assumed
			 by a self-directing individual living within the same household; or
(b) supervision or direction is provided on
			 an interim or part-time basis as part of a plan of care in which the
			 responsibility for making choices about activities of daily living is assumed
			 by a self-directing individual not living within the same household;
			 or
(c) supervision or direction is
			 provided on an interim or part-time basis as part of a plan of care in which
			 the responsibility for making choices about activities of daily living is
			 assumed by an outside agency or other formal organization. The local social
			 services department may be the outside agency.
(iii) Personal care services, including
			 continuous personal care services and live-in 24-hour personal care services, shall not be authorized to the extent that the social services district or
			 Medicaid managed care organization determines that any of the services or
			 supports identified in subclauses (11) through (13) of subdivision
			 (b)(2)(iii)(a) of this section are available and appropriate to meet the
			 individual's needs and are cost-effective if provided instead of personal care
			 services.
(iv) Individuals must
			 meet minimum needs requirements in accordance with state statute to be eligible
			 for personal care services. For purposes of this section, minimum needs
			 requirements means:
(a) for individuals with
			 a diagnosis by a physician of dementia or Alzheimer's, being assessed in
			 accordance with subdivision (b) of this section as needing at least supervision
			 with more than one activity of daily living.
(b) for all other individuals, being assessed
			 in accordance with subdivision (b) of this section as needing at least limited
			 assistance with physical maneuvering with more than two activities of daily
			 living.
(4)
Live-in 24-hour personal care services
means the provision of
			 care by one personal care aide for a patient who, because of the patient's
			 medical condition, needs assistance during a calendar day with toileting,
			 walking, transferring, turning and positioning, or feeding and whose need for
			 assistance is sufficiently infrequent that a live-in 24-hour personal care aide
			 would be likely to obtain, on a regular basis, five hours daily of
			 uninterrupted sleep during the aide's eight hour period of sleep.
(5) Personal care services shall include the
			 following two levels of care, and be provided in accordance with the following
			 standards:
(i) Level I shall be limited to
			 the performance of nutritional and environmental support functions.
(a) Nutritional and environmental support
			 functions include assistance with the following:
(1) making and changing beds;
(2) dusting and vacuuming the rooms which the
			 patient uses;
(3) light cleaning of
			 the kitchen, bedroom and bathroom;
(4) dishwashing;
(5) listing needed supplies;
(6) shopping for the patient if no other
			 arrangements are possible;
(7)
			 patient's laundering, including necessary ironing and mending;
(8) payment of bills and other essential
			 errands; and
(9) preparing meals,
			 including simple modified diets.
(b) The authorization for Level I services
			 shall not exceed eight hours per week.
(ii) Level II shall include the performance
			 of nutritional and environmental support functions specified in clause
			 (i)(
a
) of this paragraph and personal care functions.
(a) Personal care functions include
			 assistance with the following:
(1) bathing of
			 the patient in the bed, the tub or in the shower;
(2) dressing;
(3) grooming, including care of hair, shaving
			 and ordinary care of nails, teeth and mouth;
(4) toileting; this may include assisting the
			 patient on and off the bedpan, commode or toilet;
(5) walking, beyond that provided by durable
			 medical equipment, within the home and outside the home;
(6) transferring from bed to chair or
			 wheelchair;
(7) turning and
			 positioning;
(8) preparing of meals
			 in accordance with modified diets, including low sugar, low fat, low salt and
			 low residue diets;
(9)
			 feeding;
(10) administration of
			 medication by the patient, including prompting the patient as to time,
			 identifying the medication for the patient, bringing the medication and any
			 necessary supplies or equipment to the patient, opening the container for the
			 patient, positioning the patient for medication and administration, disposing
			 of used supplies and materials and storing the medication properly;
(11) providing routine skin care;
(12) using medical supplies and equipment
			 such as walkers and wheelchairs; and
(13) changing of simple dressings.
(b) Before more than 12 hours of
			 personal care services per day on average, including continuous personal care
			 services or live-in 24-hour personal care services, may be authorized,
			 additional requirements for the authorization of such services, as specified in
			 subdivision (b)(2)(v) of this section, must be satisfied.
(iii) The personal care aide may perform
			 nutritional and environmental support functions and personal care functions for
			 the recipient and may also assist the recipient to perform such tasks
			 themselves. Assistance may include supervision and cueing to help the recipient
			 perform a nutritional and environmental support function or personal care
			 function if the recipient could not perform the task without such assistance.
			 Supervision and cueing are not standalone personal care services and may not be
			 authorized, paid for or reimbursed except for providing assistance with
			 nutritional and environmental support functions or personal care
			 functions.
(6)
Shared aide
means a method of providing personal care services
			 under which a social services district authorizes one or more nutritional and
			 environmental support functions or personal care functions for each personal
			 care services recipient who resides with other personal care services
			 recipients in a designated geographic area, such as in the same apartment
			 building, and a personal care services provider completes the authorized
			 functions by making short visits to each such recipient.
(7)
Medicaid managed care
			 organization
or
MMCO
means an entity, other than an
			 entity approved to operate a Program of All-inclusive Care for the Elderly
			 (PACE) plan, that is approved to provide medical assistance services, pursuant
			 to a contract between the entity and the Department of Health, and that is:
(i) certified under article forty-four of the
			 Public Health Law, or
(ii) licensed
			 under article forty-three of the Insurance Law.
(8)
Medical assistance
or
Medicaid
or
MA
means the program to provide
			 services and benefits under title 11 or article 5 of the Social Services
			 Law.
(9)
Activities of
			 daily living
means those activities recognized as activities of daily
			 living by the evidence based validated assessment tool in accordance with
			 section 2-a of part MM of chapter 56 of the laws of 2020.
(10) For the purposes of this section
individual
and
patient
are used
			 interchangeably, except as otherwise dictated by context.