reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart D - Hearings and Appeals › Chapter 41 - MEDICAL ASSISTANCE PROVIDER APPEAL PROCEDURES › AGENCY ACTION › Section 41.191 - Determinations and recommendations by the Bureau

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Bureau will conduct a de novo review
					 of the factual and legal issues that are timely raised and properly preserved
					 in a provider appeal. Except as provided in subsection (b), the Bureau will
					 issue a determination adjudicating the contested issues of law and fact within
					 its jurisdiction, and issue an appropriate order, decree or decision.
(b) If a request for hearing includes a
					 waiver request, the Bureau will make a written recommendation for consideration
					 by the Secretary proposing that the waiver be either granted or denied and
					 stating the Bureau's reasoning in support of its position. If the request for
					 hearing raises factual and legal issues in addition to the waiver request, the
					 Bureau will issue its written recommendation together with its final
					 determination adjudicating the remaining factual and legal issues, as specified
					 in subsection (c). If the request for hearing does not raise other issues, the
					 Bureau's written recommendation on the waiver request will be issued within the
					 time limits and served on the parties as specified in subsection (c).
(c) The Bureau will issue a determination in
					 a provider appeal within 30 days of the filing of the posthearing briefs, or,
					 if the parties waive the filing of posthearing briefs, within 30 days of the
					 close of the record or receipt of the transcript, whichever is later. The
					 Bureau will serve a copy of its determination on the parties to the proceeding
					 or their representatives.
(d) A
					 party aggrieved by a determination of the Bureau may request the Secretary to
					 review the determination under §
											41.212 (relating to review of
					 Bureau determinations). For purposes of this section, a program office will be
					 deemed to be aggrieved if the Bureau determination does one or more of the
					 following:
(1) Sustains the provider's appeal
					 in whole or in part.
(2) Interprets
					 a statute, regulation, statement of policy or bulletin applied by the program
					 office in a manner inconsistent with the interpretation of that
					 office.
(3) Alters a policy of the
					 program office or purports to impose a new or different rule or policy on the
					 program office.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart D - Hearings and Appeals › Chapter 41 - MEDICAL ASSISTANCE PROVIDER APPEAL PROCEDURES › REOPENING OF RECORD › Section 41.201 - Reopening of record prior to adjudication

Current through Register Vol. 54, No. 28, July 13, 2024
(a) After the conclusion of the hearing on
					 the merits and before the Bureau issues an adjudication, the Bureau, upon its
					 own motion or upon a motion filed by a party, may reopen the record as provided
					 in this section.
(b) The record may
					 be reopened upon the basis of recently discovered evidence when each of the
					 following circumstances are present:
(1)
					 Evidence is discovered that conclusively establishes a material fact of the
					 case or that contradicts a material fact that had been assumed or stipulated by
					 the parties to be true.
(2)
					 Evidence is discovered after the close of the record and could not have been
					 discovered earlier with the exercise of due diligence.
(3) Evidence is not
					 cumulative.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart D - Hearings and Appeals › Chapter 41 - MEDICAL ASSISTANCE PROVIDER APPEAL PROCEDURES › RECONSIDERATION AND REVIEW BY THE SECRETARY › Section 41.211 - Reconsideration of interlocutory orders

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A motion for reconsideration by the
					 Secretary of an interlocutory order or ruling of the Bureau must be filed
					 within 10 days of the order or ruling. The petition must demonstrate that
					 extraordinary circumstances justify immediate consideration of the matter by
					 the Secretary. A party may file a memorandum of law at the time the motion or
					 response is filed.
(b) A copy of
					 the motion shall be served upon the parties. A party wishing to file an answer
					 may do so within 10 days of service or as ordered by the Bureau or the
					 Secretary.
(c) The failure of a
					 party to file a motion under this section will not result in a waiver of an
					 issue.
(d) Subsections (a)-(c)
					 supersede 1 Pa. Code §
											35.241 (relating to application
					 for rehearing or reconsideration).
This section cited in 55 Pa. Code §
													41.5 (relating to jurisdiction of
						  the Bureau).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart D - Hearings and Appeals › Chapter 41 - MEDICAL ASSISTANCE PROVIDER APPEAL PROCEDURES › RECONSIDERATION AND REVIEW BY THE SECRETARY › Section 41.213 - Review of Bureau recommendations

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Secretary will review and issue a
					 final order adopting, rejecting or modifying a recommendation of the Bureau
					 issued under §
											41.191(b)
					 (relating to determinations and recommendations by the Bureau).
(b) A party to the provider appeal in which
					 the Bureau's recommendation was issued may file a brief with the Secretary
					 setting forth its position regarding the recommendation at the same time the
					 party requests review of the Bureau's related determination under §
											41.212 (relating to review of
					 Bureau determinations) or, if the party is not seeking review of the Bureau's
					 determination, within 30 days of the date of the mailing date of the Bureau
					 recommendation.
(c) A brief
					 supporting or opposing the Bureau's recommendation must state concisely the
					 reasons for the party's position on the recommendation, set forth proposed
					 findings of fact and conclusions of law for consideration by the Secretary and
					 specify what relief should be granted or denied by the Secretary. The brief may
					 not exceed 25 pages.
(d) The
					 Secretary's final order regarding a recommendation issued under §
											41.191(b) will be
					 issued in accordance with the following:
(1)
					 If review is granted under §
												41.212, the date on which the
					 Secretary issues a final order.
(2)
					 If review is not granted under § 41.212, 180 days from the date of receipt
					 of the written recommendation.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart D - Hearings and Appeals › Chapter 41 - MEDICAL ASSISTANCE PROVIDER APPEAL PROCEDURES › RECONSIDERATION AND REVIEW BY THE SECRETARY › Section 41.214 - Appeals

Current through Register Vol. 54, No. 28, July 13, 2024
A provider aggrieved by a final adjudication of the
						Department issued under §
											41.212(a), (e) or
						(f) (relating to review of Bureau
						determinations), or a final order of the Secretary issued under §
											41.212(e), (h) or
						(i) or §
											41.213(a) or (d)
						(relating to review of Bureau recommendations) may petition for judicial review
						in accordance with 2 Pa.C.S. Chapter 7, Subchapter A (relating to judicial
						review of Commonwealth agency action).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter A - GENERAL PROVISIONS › Section 52.1 - Purpose

Current through Register Vol. 54, No. 28, July 13, 2024
This chapter specifies the provider qualifications and
						payment provisions for providers rendering services under the Aging, Attendant
						Care, COMMCARE, Independence and OBRA Home and Community-Based Service waivers
						and the Act 150 program.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter A - GENERAL PROVISIONS › Section 52.2 - Scope

Current through Register Vol. 54, No. 28, July 13, 2024
This chapter sets forth the regulations which apply to
						providers applying to participate and render MA-funded waiver services under
						the Federally-approved Aging, Attendant Care, COMMCARE, Independence and OBRA
						Home and Community-Based Service waivers or the Act 150
						program.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter A - GENERAL PROVISIONS › Section 52.4 - Incorporation by reference

Current through Register Vol. 54, No. 28, July 13, 2024
The approved applicable Federal waivers, including
						approved waiver amendments, are incorporated by reference and can be found on
						the Department's web site at
						http://www.portal.state.pa.us/portal/server.pt?open=514&objID=733116&mode=2.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter B - PROVIDER QUALIFICATIONS AND PARTICIPATION › Section 52.12 - Prerequisites for existing provider enrolling in a new service

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If an existing
					 provider enrolled in a waiver program wants to enroll to provide an additional
					 waiver service, the provider shall submit the following to the Department:
(1) A written request to enroll as a provider
					 of the additional service.
(2) A
					 copy of the license required to provide the service if the service requires
					 licensure.
(3) A completed and
					 signed waiver addendum to the MA provider agreement for the new
					 service.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter B - PROVIDER QUALIFICATIONS AND PARTICIPATION › Section 52.13 - Review of application

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
					 Department will only review complete application materials.
(b) The Department will review the
					 application materials submitted under §
											52.11 (relating to prerequisites
					 for participation).
(c) The
					 Department may request additional information from an applicant to verify the
					 applicant is qualified to provide services in accordance with this chapter or
					 other Federal or State requirements.
(d) Incomplete application materials are void
					 after 30 days of receipt.
(e) The
					 Department will notify the applicant if the applicant's application is
					 incomplete.
(f) The Department is
					 not required to return application materials to an applicant.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter B - PROVIDER QUALIFICATIONS AND PARTICIPATION › Section 52.14 - Ongoing responsibilities of providers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An applicant is not a provider until the
					 following are met:
(1) The Department
					 approves the applicant's MA application.
(2) An MA provider agreement including a
					 waiver addendum is signed.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter B - PROVIDER QUALIFICATIONS AND PARTICIPATION › Section 52.15 - Provider records

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
					 following requirements are in addition to the recordkeeping provisions under
					 §
											1101.51(d) and
					 (e) (relating to ongoing responsibilities of
					 providers):
(1) A provider shall use the
					 Department's designated information system to record service plan information
					 regarding the participant as required under §
												52.25 (relating to service
					 plan).
(2) A provider shall
					 complete and maintain documentation on service delivery.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter B - PROVIDER QUALIFICATIONS AND PARTICIPATION › Section 52.16 - Abuse

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Abuse is an act
					 or omission that willfully deprives a participant of rights or human dignity,
					 or which may cause or causes actual physical injury or emotional harm to a
					 participant including a critical incident and one or more of the following:
(1) Sexual harassment of a
					 participant.
(2) Sexual contact
					 between a staff member and a participant.
(3) Restraining a participant.
(4) Financial exploitation of a
					 participant.
(5) Humiliating a
					 participant.
(6) Withholding
					 regularly scheduled meals from a participant.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter B - PROVIDER QUALIFICATIONS AND PARTICIPATION › Section 52.17 - Critical incident and risk management

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The requirements in this chapter are in
					 addition to the reporting requirements under Chapter 2380 or 2390 (relating to
					 adult training facilities; and vocational facilities), 6 Pa. Code Chapter 11
					 (relating to older adult daily living centers) and 28 Pa. Code Chapters 601 and
					 611 (relating to home health care agencies; and home care agencies and home
					 care registries).
(b) A provider
					 shall report a critical incident involving a participant to the Department or
					 the SCE, or both, on a form prescribed by the Department.
(c) A provider shall develop and implement
					 written policies and procedures on the prevention, reporting, notification,
					 investigation and management of critical incidents.
(d) A provider shall meet the risk management
					 requirements as specified in the approved applicable waivers, including
					 approved waiver amendments.
(e) If
					 the Department requires additional follow-up information to a critical
					 incident, then the provider shall submit additional information as requested to
					 the Department.
(f) A provider
					 shall reduce the number of preventable incidents. The methods used by the
					 provider to reduce the number of preventable incidents shall be documented on
					 the provider's QMP.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter B - PROVIDER QUALIFICATIONS AND PARTICIPATION › Section 52.18 - Complaint management

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
					 provider shall implement a system to record, respond and resolve a
					 participant's complaint.
(b) The
					 provider complaint system must contain the following:
(1) The name of the participant.
(2) The nature of the complaint.
(3) The date of the complaint.
(4) The provider's actions to resolve the
					 complaint.
(5) The participant's
					 satisfaction to the resolution of the complaint.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter B - PROVIDER QUALIFICATIONS AND PARTICIPATION › Section 52.19 - Criminal history checks

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The criminal
					 history requirements in this section are in addition to the requirements in
					 Chapter 2380 or 2390 (relating to adult training facilities; and vocational
					 facilities), 6 Pa. Code Chapter 11 (relating to older adult daily living
					 centers) and 28 Pa. Code Chapters 601 and 611 (relating to home health care
					 agencies; and home care agencies and home care registries) for providers
					 licensed under these chapters.
(b)
					 Prior to hiring an employee, a provider shall obtain a criminal history check
					 which is in compliance with the following for each employee who may have
					 contact with a participant:
(1) A report of
					 criminal history record information from the Pennsylvania State Police or a
					 statement from the Pennsylvania State Police that the Pennsylvania State Police
					 Central Repository does not contain information relating to that person, under
					 18 Pa.C.S. Chapter 91 (relating to Criminal History Record Information Act), if
					 the employee has been a resident of this Commonwealth for the 2 years
					 immediately preceding the date of application.
(2) A report of Federal criminal history
					 record information under the Federal Bureau of Investigation appropriation of
					 Title II of the act of October 25, 1972 (Pub. L. No. 92-544, 86 Stat. 1109) if
					 the employee has not been a resident of this Commonwealth for the 2 years
					 immediately preceding the date of application.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter B - PROVIDER QUALIFICATIONS AND PARTICIPATION › Section 52.20 - Provisional hiring

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A provider
					 may hire a person for employment on a provisional basis, pending receipt of a
					 criminal history check, provided that the following are met:
(1) The provider is in the process of
					 obtaining a criminal history check as required under §
												52.19 (relating to criminal
					 history checks).
(2) A provider may
					 not hire a person provisionally if the provider has knowledge that the person
					 would be disqualified for employment under
					 18 Pa.C.S. §
													4911
					 (relating to tampering with public records or information).
(3) A provisionally-hired employee shall
					 swear or affirm in writing that he is not disqualified from employment under
					 this chapter.
(4) A provider shall
					 monitor the provisionally-hired person awaiting a criminal history check
					 through random, direct observation and participant feedback. The results of
					 monitoring must be documented in the person's employment file.
(5) The period of provisional hire may not
					 exceed 30 days for a person who has been a resident of this Commonwealth for at
					 least 2 years.
(6) The period of
					 provisional hire may not exceed 90 days for a person who has been a resident of
					 this Commonwealth for less than 2 years.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter B - PROVIDER QUALIFICATIONS AND PARTICIPATION › Section 52.21 - Staff training

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
					 provider shall meet the training requirements necessary to maintain appropriate
					 licensure or certification, or both, in addition to meeting the training
					 requirements of this chapter.
(b)
					 Prior to providing a service to a participant, a staff member shall be trained
					 on how to provide the service in accordance with the participant's service
					 plan.
(c) A provider shall maintain
					 documentation for the following:
(1) Staff
					 member attendance at trainings.
(2)
					 Content of trainings.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter B - PROVIDER QUALIFICATIONS AND PARTICIPATION › Section 52.22 - Provider monitoring

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
					 Department will monitor a provider at least once every 2 years.
(b) Monitoring may be announced or
					 unannounced.
(c) A provider shall
					 submit documentation as requested by the Department that the provider is in
					 compliance with the following:
(1) This
					 chapter.
(2) The MA provider
					 agreement, including the waiver addendum.
(3) Chapter 1101 (relating to general
					 provisions).
(4) The approved
					 applicable waiver, including approved waiver amendments.
(5) A State or Federal requirement.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter B - PROVIDER QUALIFICATIONS AND PARTICIPATION › Section 52.23 - Corrective action plan

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
					 provider shall respond to the written statement of findings under §
											52.22 (relating to provider
					 monitoring) with a CAP when requested by the Department.
(b) The provider shall submit a CAP to the
					 Department on a form prescribed by the Department.
(c) The CAP must contain at least the
					 following:
(1) The provider's name.
(2) The provider's address.
(3) The provider's MA identification
					 number.
(4) The action steps to
					 address a specific finding.
(5) The
					 dates action steps will be completed.
(6) An explanation on how the action steps
					 will remediate the finding.
(7) The
					 date when a finding will be remediated.
(8) The provider's signature indicating the
					 provider will implement the CAP.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter B - PROVIDER QUALIFICATIONS AND PARTICIPATION › Section 52.24 - Quality management

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
					 provider shall create and implement a QMP to ensure the provider meets the
					 requirements of this chapter and Chapter 1101 (relating to general
					 provisions).
(b) The QMP must
					 contain at least the following:
(1)
					 Measureable goals to ensure compliance with this chapter, Chapter 1101 and
					 other chapters in this title under which the provider is licensed.
(2) Data-driven outcomes to achieve
					 compliance with this chapter, Chapter 1101 and other chapters in this title
					 which the provider is licensed.
(3)
					 The current Department-approved CAP, if the provider has a CAP.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter B - PROVIDER QUALIFICATIONS AND PARTICIPATION › Section 52.25 - Service plan

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A service
					 plan must be developed for each participant that contains the following:
(1) The participant need as identified on a
					 standardized needs assessment provided by the Department.
(2) The participant goal.
(3) The participant outcome.
(4) Service, TPR or informal community
					 support that meets the participant need, participant goal or participant
					 outcome.
(5) The type, scope,
					 amount, duration and frequency of services needed by the participant.
(6) The provider of each service.
(7) The participant's signature.
(8) Risk mitigation strategies.
(9) The participant's back-up plan.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter B - PROVIDER QUALIFICATIONS AND PARTICIPATION › Section 52.26 - Service coordination services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) To be paid for rendering service
					 coordination services, an SCE shall:
(1)
					 Complete a person-centered assessment.
(2) Complete a level of care re-evaluation at
					 least annually.
(3) Develop a
					 service plan for each participant for whom the SCE renders service coordination
					 services. The provider shall complete the following:
(i) Develop and modify the participant's
					 service plan at least annually.
(ii) Modify the participant's service plan,
					 if necessary, when the participant has a significant medical or social
					 change.
(4) Review the
					 participant need, the participant goal and participant outcome with the
					 participant and other persons that the participant requests to be part of the
					 review as required by conducting the following:
(i) At least one telephone call or
					 face-to-face visit per calendar quarter. At least two face-to-face visits are
					 required per calendar year.
(ii)
					 More frequent calls or visits if the service coordinator or the Department
					 determines more frequent calls or visits are necessary to ensure the
					 participant's health and safety.
(5) Coordinate a service, TPR and informal
					 community supports with the participant to ensure the participant need, the
					 participant goal and the participant outcome are met.
(6) Provide the participant with a list of
					 providers in the participant's service location area that are enrolled to
					 render the service that meet the participant needs.
(7) Inform the participant of the
					 participant's right to choose any willing and qualified provider to provide a
					 service on the participant's service plan.
(8) Confirm with the participant's selected
					 provider that the provider is able to provide the service in the type, scope,
					 amount, duration and frequency as listed on the participant's service
					 plan.
(9) Provide information
					 regarding the authorized type, scope, amount, duration and frequency of
					 services as listed in the participant's service plan to the provider rendering
					 the service.
(10) Ensure and
					 document at least on a quarterly basis that the participant's services are
					 being delivered in the type, scope, amount, duration and frequency as required
					 by the participant's service plan.
(11) Evaluate if the participant need,
					 participant goal and participant outcome are being met by the
					 service.
(12) Ensure a participant
					 exercising participant-directed budget authority does not exceed the number of
					 service hours approved in the participant's service plan.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter B - PROVIDER QUALIFICATIONS AND PARTICIPATION › Section 52.27 - Service coordinator qualifications and training

Current through Register Vol. 54, No. 28, July 13, 2024
(a) To provide service coordination services,
					 a service coordinator shall meet either of the following:
(1) Have a bachelor's degree including or
					 supplemented by at least 12 college-level credit hours in sociology, social
					 welfare, psychology, gerontology or another behavioral science.
(2) A combination of experience and training
					 which adds up to 4 years of experience, and education which includes at least
					 12 semester hours of college-level courses in sociology, social work, social
					 welfare, psychology, gerontology or other social science.
(i) Experience includes:
(A) Coordinating assigned services as part of
					 an individual's treatment plans.
(B) Teaching individuals living
					 skills.
(C) Aiding in therapeutic
					 activities.
(D) Providing
					 socialization opportunities for individuals.
(ii) Experience does not include:
(A) Providing hands-on personal care for
					 people with disabilities or individuals over 60 years of age.
(B) Maintenance of the individual's home,
					 room or environment.
(C) Aiding in
					 adapting the physical facilities of the individual's home.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter B - PROVIDER QUALIFICATIONS AND PARTICIPATION › Section 52.28 - Conflict free service coordination

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An SCE may not provide other waiver or
					 Act 150 services if the SCE provides service coordination services unless one
					 of the following is applicable:
(1) The SCE
					 is providing the service as an OHCDS under §
												52.53 (relating to organized
					 health care delivery system).
(2)
					 The SCE is providing community transition services to a participant
					 transitioning from a nursing facility or an ICF/ORC.
(3) The SCE is providing financial management
					 services to a participant.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter B - PROVIDER QUALIFICATIONS AND PARTICIPATION › Section 52.29 - Confidentiality of records

Current through Register Vol. 54, No. 28, July 13, 2024
Participant records must be kept confidential and, except
						in emergencies, may not be accessible to anyone without the written consent of
						the participant or if a court orders disclosure other than the following:
(1) The participant.
(2) The participant's legal
					 guardian.
(3) The provider staff
					 for the purpose of providing a service to the participant.
(4) An agent of the Department.
(5) An individual holding the participant's
					 power of attorney for health care or health care proxy.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter B - PROVIDER QUALIFICATIONS AND PARTICIPATION › Section 52.30 - Waiver of a program qualification

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department may grant a waiver to a
					 provision of this chapter which is not otherwise required by Federal and State
					 law and does not jeopardize the health, safety or well-being of a
					 participant.
(b) The waiver request
					 must be on a form prescribed by the Department.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter C - PAYMENT FOR SERVICES › GENERAL REQUIREMENTS › Section 52.41 - Provider billing

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
						provider shall submit claims in accordance with §
												1101.68 (relating to invoicing for
						services).
(b) A provider shall use
						the Department's designated claims processing system to submit
						claims.
(c) An applicant may not
						bill for a service prior to being enrolled as a provider by the
						Department.
(d) The provider shall
						enroll in the Department's designated claims processing system upon receiving
						notice that the application is approved.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter C - PAYMENT FOR SERVICES › GENERAL REQUIREMENTS › Section 52.42 - Payment policies

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
						Services will be paid as either a fee schedule service under §
												52.45 (relating to fee schedule
						rates) or as a vendor good or service payment under §
												52.51 (relating to vendor good or
						service payment).
(b) The
						Department will publish services specific to each waiver and the Act 150
						program as a notice in the
Pennsylvania Bulletin
.
(c) The Department will only pay for a
						service in accordance with this chapter and Chapters 1101 and 1150 (relating to
						general provisions; and MA Program payment policies).
(d) The Department will only pay for a
						service in the type, scope, amount, duration and frequency as specified on the
						participant's service plan as approved by the Department.
(e) A provider who accepts supplementary
						payment for an Act 150 service from a source other than the Department shall
						return the Act 150 payment to the Department. If the supplementary payment pays
						only a portion of the cost of the Act 150 service, the provider shall return an
						amount equal to the supplementary payment to the Department. This subsection
						does not apply to copayments.
(f)
						The Department will recoup payments which are not made in accordance with this
						chapter.
(g) The Department may
						limit the type of service available in accordance with Federal and State laws,
						the waiver program requirements or Act 150 program requirements.
(h) The Department will not reimburse a
						provider who renders a service to a participant who does not have an approved
						service plan for the date when the service was rendered.
(i) To be paid the MA Program fee schedule
						rate or receive reimbursement for a vendor good or service, a provider shall
						comply with this chapter.
(j) The
						Department will not pay for a service which is rendered to a participant who is
						enrolled in a waiver or the Act 150 program that does not include the
						service.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter C - PAYMENT FOR SERVICES › GENERAL REQUIREMENTS › Section 52.43 - Audit requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
						provider shall comply with Federal audit requirements including the following:
(1) The Single Audit Act of 1984
						(31 U.S.C.A. §§
														7501-7507).
(2) The revised Office of Management and
						Budget Circular A-133.
(3) Section
						74.26 of 45 CFR (relating to
						non-Federal audits).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter C - PAYMENT FOR SERVICES › GENERAL REQUIREMENTS › Section 52.44 - Reporting requirements for ownership change

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A provider assuming ownership shall
						report a change in ownership or control interest of 5% or more in writing to
						the Department at least 30 days prior to the effective date of the
						change.
(b) If the provider is
						unable to report an ownership or controlling interest change at least 30 days
						prior to the effective date of the change because of an emergency, then the
						provider shall report the change as soon as possible, but no later than 2
						business days after the effective date of the change. The provider shall also
						inform the Department as to why the provider was unable to report the change 30
						days prior to the change's occurrence.
(c) The provider assuming ownership shall
						report the following:
(1) Effective date of
						sale or controlling interest change.
(2) A copy of the sales agreement or other
						document effectuating the change.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter C - PAYMENT FOR SERVICES › GENERAL REQUIREMENTS › Section 52.45 - Fee schedule rates

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
						Department will establish a fee schedule rate for a waiver or Act 150 program
						service.
(b) The Department will
						publish the fee schedule rate under the MA Program fee schedule as a notice in
						the
Pennsylvania Bulletin
.
(c) The Department will publish a change in
						the methods and standards for setting a fee schedule rate as a notice in the
Pennsylvania Bulletin
.
(d) The Department will publish the services
						specific to each waiver and the Act 150 program as a notice in the
Pennsylvania Bulletin
.
This section cited in 55 Pa. Code §
														52.42 (relating to payment
							 policies).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter C - PAYMENT FOR SERVICES › VENDOR GOOD OR SERVICE › Section 52.51 - Vendor good or service payment

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
						The Department will only pay for the actual cost of a vendor good or service
						which may not exceed the amount for a similar vendor good or service charged to
						the general public.
(b) A provider
						shall retain documentation of the amount charged for the vendor good or
						service.
(c) The provider shall
						submit verification of subsection (b) to the Department upon request.
(d) The Department will publish the list of
						vendor goods or services as a notice in the
Pennsylvania
						Bulletin
.
(e) The
						Department will publish the list of vendor goods or services specific to each
						waiver or the Act 150 program as a notice in the
Pennsylvania
						Bulletin
.
This section cited in 55 Pa. Code §
														52.42 (relating to payment
							 policies); and 55 Pa. Code §
														52.52 (relating to subcontracting
							 for a vendor good or service).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter C - PAYMENT FOR SERVICES › VENDOR GOOD OR SERVICE › Section 52.52 - Subcontracting for a vendor good or service

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Only an OHCDS may subcontract with an
						entity to purchase a vendor good or service. A provider who subcontracts shall
						have a written agreement specifying its duties, responsibilities and
						compensation.
(b) Only a vendor
						good or service may be subcontracted.
(c) If an OHCDS subcontracts with an entity
						to provide a vendor good or service, the OHCDS shall ensure the entity complies
						with §
												52.51(a)
						(relating to vendor good or service payment).
(d) The Department will not pay an
						administrative fee or additional cost for a vendor good or service
						subcontracted by an OHCDS.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter C - PAYMENT FOR SERVICES › VENDOR GOOD OR SERVICE › Section 52.53 - Organized health care delivery system

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An OHCDS shall be an SCE in compliance
						with this chapter.
(b) An OHCDS may
						not be reimbursed for rendering service coordination services if it contracts
						with an entity which is listed on the LEIE, EPLS or Medicheck list.
(c) An OHCDS may not be reimbursed for
						rendering service coordination services if the OHCDS contracts with an entity
						which employs a person who is listed on the LEIE or EPLS.
(d) An OHCDS shall complete and sign an OHCDS
						enrollment form.
This section cited in 55 Pa. Code §
														52.28 (relating to conflict free
							 service coordination).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter D - PROVIDER DISQUALIFICATION › Section 52.61 - Provider cessation of services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If a provider is no longer able or
					 willing to provide services, the provider shall perform the following:
(1) Send written notification to each
					 participant, the Department and other providers with which the provider works
					 that the provider is ceasing services at least 30 days prior to the provider
					 ceasing services.
(2) Notify
					 licensing or certifying entities as required.
(3) Send the Department a copy of the
					 notification sent to a participant and service providers as required under
					 paragraph (1). If the provider uses a general notification for all participants
					 or service providers, a single copy of the notification is
					 acceptable.
(4) Cooperate with the
					 Department, new providers of services and participants with transition planning
					 to ensure the participant's continuity of care.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter D - PROVIDER DISQUALIFICATION › Section 52.62 - Prohibition of services

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
					 provider may be sanctioned, prohibited or disenrolled from providing services
					 for failure to perform any of the following:
(1) Protect the health and welfare of a
					 participant during service delivery.
(2) Comply with applicable Federal or State
					 laws and this chapter.
(3) Comply
					 with a provision of the MA provider agreement, including the waiver
					 addendum.
(4) Deliver a service in
					 the type, scope, amount, duration and frequency required by the approved
					 service plan when the participant is available for the delivery of the
					 service.
(5) Develop or implement a
					 CAP.
(6) Maintain licenses or
					 certifications, or both, as required by Federal or State agencies.
(7) Maintain accurate records.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter D - PROVIDER DISQUALIFICATION › Section 52.63 - Provider misutilization and abuse

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If the Department's audit, financial
					 review or monitoring indicates that a provider has been billing for services in
					 a manner inconsistent with this chapter, unnecessary or inappropriate to a
					 participant's needs, or contrary to customary standards of practice, the
					 Department will notify the provider in writing that payment on all invoices
					 will be delayed or suspended for a period not to exceed 120 days pending a
					 review of billing and service patterns.
(b) A provider may have its invoices reviewed
					 prior to payment.
(c) A provider's
					 records may be reviewed.
(d) A
					 provider may be required to submit a written explanation of billing
					 practices.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter D - PROVIDER DISQUALIFICATION › Section 52.64 - Payment sanctions

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If the
					 provider fails to submit an acceptable attestation engagement or pass a
					 financial review, in accordance with this chapter, the Department may initiate
					 sanctions against the provider including the following:
(1) Disallowing all or a portion of a
					 payment.
(2) Suspending a current
					 or future payment pending compliance.
(3) Recouping a payment for a service the
					 provider cannot verify as being provided in the amount, duration and frequency
					 billed.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part I - Department of Human Services › Subpart E - Home and Community-based Services › Chapter 52 - LONG-TERM LIVING HOME AND COMMUNITY-BASED SERVICES › Subchapter D - PROVIDER DISQUALIFICATION › Section 52.65 - Appeals

Current through Register Vol. 54, No. 28, July 13, 2024
A provider may file an appeal of a Departmental action in
						accordance Chapters 41 and 1101 (relating to Medical Assistance provider appeal
						procedures; and general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart A - Assistance Policies and Procedures › Chapter 100 - STATEMENTS OF POLICY › Section 100.2 - Health insurance provisions for Single Point of Contact (SPOC)

Current through Register Vol. 54, No. 28, July 13, 2024
The Department will provide health insurance coverage
					 through a new type of Medically Needy Only-MNO-coverage.
(1)
Eligibility for
				  coverage.
An individual, or the individual's spouse, children under
				  21, or other dependents in the household, may elect health insurance coverage
				  if that individual meets the following requirements:
(i) Participated in a SPOC program.
(ii) Enters employment during or within 90
				  days of completion of SPOC activities.
(iii) No longer qualifies for Medicaid
				  benefits.
(iv) Elects the insurance
				  coverage by signing a written statement consenting to pay premiums for the
				  coverage.
(v) Is not covered-or
				  could not have elected coverage-under a group health plan of the individual or
				  spouse, if a contribution toward the plan's cost is being made by an employer,
				  former employer, union or entity other than the individual or the spouse. If
				  employers or other entities pay any part of a health plan's costs, the clients
				  are not eligible for this SPOC health insurance coverage. If the employer makes
				  a contribution toward the cost of the employe's coverage but not the employe's
				  dependents' coverage, the dependents may be covered by SPOC health insurance,
				  if otherwise eligible.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart A - Assistance Policies and Procedures › Chapter 101 - GENERAL PROVISIONS › Section 101.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Scope.
The policies, procedures and standards for determining
				  eligibility, the amount of the grant and for making payments for all types of
				  assistance administered by the Department are included in this part. The types
				  of assistance are TANF, General Assistance and State Blind Pension. Social
				  services in Public Assistance, medical care, including nursing home care,
				  burial and employment are also included.
(1)
				  Although the TANF Program replaces the AFDC Program, most of the rules and
				  procedures under which the Department administered AFDC, including those for
				  the job opportunities and Basic Skills (JOBS) Training Program, will continue
				  in effect as part of the new TANF Program.
(2) The references to AFDC found within this
				  title are to be read and considered as applicable to the TANF Program or to a
				  TANF applicant or recipient, unless doing so would be inconsistent with the
				  TANF requirements or with this section.