The Medicaid HCBS waiver covers adult foster care services. Medicaid waiver payments include a base rate and up to three add-on payments. The state has created separate payment rates for nonrelative and relative adult foster homes. Nonrelative homes received a base payment of $1,229 a month in 2008; relative homes received a base rate of $1,000 a month. Both groups received add-on payments of $237 a month. Add-on payments are made for residents who are dependent in mobility, eating, or toileting; who demonstrate behaviors that pose a risk to the resident or others and require frequent intervention; and residents with complex health conditions who require daily assessment, observation, and monitoring by a licensed health care professional (if the home has the capacity to provide the service). Case managers may submit a request to an “exceptions
committee” for additional payments to serve high-need clients. State officials said they are developing an acuity-based payment methodology and are examining private pay rates and the mix of private pay and Medicaid residents. In June 2008, 2,502 people were served in nonrelative homes, and 1,493 were served in relative homes.
The following rates do not include room and board, which is paid by the resident. The state agency may approve rate exceptions for higher acuity residents.
Adult Foster Care Payment Rates, 2008
Payment Nonrelative Homes Relative Homes
Base $1,229 $1,000
Base plus 1 add-on $1,466 $1,237
Base plus 2 add-ons $1,703 $1,474
Base plus 3 add-ons $1,940 $1,711
Data for September 2006 showed that 24.9 percent of nonrelative foster home residents received the base rate; 37.9 percent received the base rate plus one add-on; 32.0 percent received the base rate plus two add-ons; and 5.3 percent received the base rate plus three add-ons. Comparable rates for relative foster home participants were 56.7 percent,
31.0 percent, 11.0 percent, and 1.5 percent. The percentage of beds occupied by Medicaid beneficiaries ranged between 37 percent and 46 percent.
Distribution by Payment Level, September 2006 Payment Nonrelative AFC Relative AFC
Base 24.9% 56.7%
Base plus 1 add-on 37.9% 31.0%
Base plus 2 add-ons 32.0% 11.0%
Base plus 3 add-ons 5.3% 1.5%
STAFFING
Adult foster care providers must pass a criminal history check, a foster home exam, and a financial background check, and must comply with structural and environmental
requirements. The provider must have a resident manager or 24-hour caregiver on duty. All providers, resident managers, and substitute caregivers must meet educational
standards established by the Department of Human Services and must be at least 21 years old.
TRAINING
Before they are licensed, providers must successfully complete a training curriculum that includes demonstration and practice in physical caregiving; screening for care and service needs; appropriate behavior toward residents with physical, cognitive, or mental
disabilities; and an understanding of architectural accessibility. Providers must pass a test that assesses their ability to manage and respond to emergency situations, changes in medical condition, physicians’ orders, nutritional needs, residents’ needs, and conflict. Providers must complete 12 hours of continuing education credits annually related to the
care of elderly and disabled persons. Four of the hours may cover the business operation of adult foster homes.
OVERSIGHT AND MONITORING
The licensing agency conducts unannounced annual inspections, investigates complaints, and makes unscheduled inspections if it has cause to believe a home is not complying with the regulations. When violations are found, the licensing agency may attach conditions to the license; impose civil penalties; deny, suspend, revoke, or decline to renew a license; or reclassify the license. The licensing agency determines whether the home has corrected the violations.
PENNSYLVANIA
BACKGROUND
The domiciliary care or (dom care) program was created as part of Act 70 of June 1978 to provide a homelike living arrangement in the community for adults 18 years and older who need assistance with ADLs and are unable to live independently. Dom
care providers open their homes to persons who need supervision, support, and encouragement in a family-like setting. The Office of Long-Term Living (OLTL) is responsible for developing regulations, supervising Dom Care services, and providing technical assistance to Area Agencies on Aging (AAAs).
AAAs are responsible for determining resident eligibility, placing residents with their consent, determining and certifying provider eligibility, and arranging for provider training. Before 1990, dom care homes could serve up to 13 residents, but the maximum capacity was reduced to 3 residents in 1990, although homes that already served more than 3 residents were allowed to continue serving up to 13 residents. In January 2008, there were 648 certified homes with a capacity to serve 1,813 residents. Actual occupancy was 1,283, and about 98 percent of residents were SSI beneficiaries. The supply of providers has declined in recent years. Most providers are retirees or older couples. OLTL is considering strategies to increase the supply. The SSI state supplement payment standard was increased by $60 a month in 2007 in an effort to retain providers, and options for covering services under Medicaid are being considered.
The dom care unit in each AAA is generally responsible for recruiting prospective home providers, inspecting homes for certification, assessing potential residents, helping potential SSI beneficiaries obtain the SSI state supplement, and notifying the County Assistance Office to initiate or terminate the state supplement. This unit in the AAA also ensures the appropriateness of placement, the continuing need for the provision of care, and the provision of community services for dom care residents.
The domiciliary care program has the following service goals:
To provide supportive, homelike, community-based living arrangements for adults who cannot live independently in the community.
To encourage and assist residents in developing and maintaining maximum initiative and self-determination in a homelike setting.
To provide an alternative to institutionalization, and to help adults remain in the community or return to the community and, if possible to their own homes.
Web Site Content
http://www.aging.state.pa.us/aging/cwp/view.asp?a=284&q=176977 http://www.pacode.com/secure/data/006/chapter21/chap21toc.html http://www.aging.state.pa.us/aging/lib/aging/Dom_Care_101_Master_copy_pdf_ version.pdf Tools, forms Regulations Training guide
DEFINITION
Domiciliary care is a protected living arrangement in the community that includes room and board and services for persons 18 years and older who cannot live independently because of their social and economic situation (Act 70, 1978). The definition in the regulations states that domiciliary care is “a premises certified by an AAA for the purpose of providing a supervised living arrangement in a homelike setting for a period exceeding 24 consecutive hours to residents placed there by the AAA.”
ADMISSION/RETENTION CRITERIA
To receive domiciliary care service, an applicant must be 18 years or older; be
independently mobile or semi-mobile; not require skilled or intermediate nursing care, or general or special hospital care on a 24-hour residential basis; have no relative or other person whose relationship with the applicant is important to the applicant’s continued well-being and who is willing or able to provide the necessary support for independent living; and be incapable of living alone regardless of available services, or requires services to live alone and the services are not available. In general, dom care homes may not serve persons who meet the nursing facility level-of-care criteria. However, a waiver of the admission/retention criteria may be approved by OLTL on the basis of individual circumstances. About 40 residents have received a waiver.
Applicants must also meet one or more of the following criteria:
Have demonstrated difficulties in accomplishing activities of daily living—such as purchasing and preparing meals, bathing and grooming, housekeeping and laundry, financial management and taking medication in proper doses at proper times—to an extent that prevents independent living in the community.
Have demonstrated difficulties in social or personal adjustment, usually associated with mental disability, as demonstrated by reduced, lost, or undeveloped capabilities for developing and maintaining appropriate personal relationships; dealing
constructively with others; and maintaining or attaining a maximum level of functioning.
Have demonstrated difficulties resulting from disabilities—such as blindness, deafness, amputation, paralysis, or birth defects—if the person is independently mobile or semi-mobile.
ASSESSMENT AND CARE PLANNING PROCESS
Area Agencies on Aging are responsible for the development and implementation of a plan of care for each resident. The AAA, in consultation with the resident, develops the plan, which describes the problems or needs of the resident, desired outcomes (long- and short-term goals), services or providers (informal or formal), pattern of service delivery, follow-up monitoring, and reassessment updates. Arrangements to supplement services given by the provider are included in the care plan and may be made by the AAA directly or by referral to another agency. The purpose of the supplemental service is to address special resident needs that provide the support necessary to maintain the resident in the domiciliary care home.
A follow-up assessment is required with 15 days of placement and every six months thereafter to evaluate the resident’s adjustment and to modify the care plan if necessary. The AAAs conduct comprehensive annual reassessments of residents.
SERVICES
Providers help the resident develop or maintain self-help skills, personal hygiene skills, and other skills related to activities of daily living in accordance with the care plan established by the AAA.
MEDICATIONS
The provider may assist with medications by helping the resident remember the schedule in accordance with the prescription, storing the medication in a secure place, and offering the medication at the prescribed times.
RESIDENT AGREEMENT/CONTRACT/DISCLOSURE
A written agreement between the provider and the resident is required that specifies the monthly charge for dom care services in accordance with the amounts established by OLTL. The agreement is completed on a form provided by OLTL and must be fully explained to the prospective resident before placement. The agreement is subject to approval by the AAA; at minimum, it includes the house rules and describes basic furnishings. The agreement outlines when the resident is expected to be present in the home and when he or she is expected to be away from the home. The purpose of this provision is to allow the resident and provider the freedom to participate in activities that are not related to dom care.
PUBLIC FINANCING
The SSI program and a state supplement cover dom care services. The supplement payment standard in 2008 was $1,071.30, from which $914 was paid to the provider and $157.30 retained as a personal needs allowance. About 98 percent of the 1,283 residents are SSI beneficiaries. Private pay residents may not be charged more than the SSI beneficiaries for room and board and services. Domiciliary care is not a covered waiver service; however, residents may receive waiver services in this setting if the home receives a waiver of the admission/retention requirements from OLTL.
STAFFING
Domiciliary care home providers must 21 years or older and must live in the domiciliary care home.
At least one provider or staff person must be present and available on the premises when one or more residents are present in the home. The AAA may waive this requirement if the residents are independently mobile and the provider or staff absences would be of limited duration and not during hours when the residents are sleeping. This waiver, if granted by the AAA, is made in writing and recorded in the case record.
Staff must be 18 years or older; capable of performing home provider services; and never have been convicted of a crime involving assaultive behavior or moral turpitude.
TRAINING
AAAs are required to arrange training based on course materials identified by the Department of Aging. They must ensure that providers achieve competencies through educational programs in the following areas: major health problems of older persons; accident prevention; nutrition; the psychology of aging; interpersonal communication; general principles of cleanliness and hygiene; and recognition and response to crises and emergency situations.
OVERSIGHT AND MONITORING