DHS Home Care Advisory Work Group Provider Standards and PCA Training Topic Tackler Team July 15, 2008, 9:00 AM 12:00 PM Draft Meeting Notes

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1 DRAFT NOTES not approved Page 1 of 8 DHS Home Care Advisory Work Group Provider Standards and PCA Training Topic Tackler Team July 15, 2008, 9:00 AM 12:00 PM Draft Meeting Notes Team Members Present: Barb Burandt, Mary Cahill, Sue Grattan (alternate for Staci Grattan), Janice Jones, David Sams (by phone), Kim Tyler. DHS Staff: Katie Linde, Christine Davis, Jill Johnson. Facilitators: Maren Hayes, Audrey Fischer. Notes: Renee Raduenz. Observers: Jeff Bansberg, Shirley Welch. Welcome and Introductions Maren opened meeting with welcome and introductions. She reviewed the agenda and meeting objectives; there were no additions or questions. Members reviewed and approved the notes from the July 8 meeting. Discussion: Minimum PCA Requirements Pass criminal background check Recommendation keep requiring criminal background checks for all PCAs. Recommendation: Centralize system between DHS and health plans so that background checks do not have to be redone during the year when PCAs are assigned to different payers (health plans). There should be a consistent process so that agencies do not acquire the administrative burden. Overall, they work well. There is an approximate two day turn around for providers, which is quite timely and an improvement from the past. PCA background checks cover convictions (versus arrests or charges) related to the industry (256B); they do not cover preponderance of evidence and generally do not cover convictions non related to health care. Fingerprints are not taken and the check is not from a national/federal database; they only cover convictions in the state of Minnesota. There is a $25.00 provider fee for each background check. If PCAs change agencies or if there is a lapse of employment, the PCA must undergo another background check. DHS suggests that providers conduct background checks annually for their employees, but it is not required. For nursing home background checks, if a drug conviction is triggered, they will ask for the person s fingerprints and a national database check is conducted. A background check is required if a PCA is assigned to different payers (health plans) and an agency is billing a health plan for PCA services and they haven t billed the particular health plan within a 12 month time period for that PCA. As a result, checks can be done more frequently than once/year. Providers would prefer not re doing background checks when PCAs are reassigned to different payers. Katie check with Jerry K. about the process. Is there a trigger in the system to notify agencies if something pops up on an individual s background check after the check is completed, or does the provider only find out when they conduct another check? This will help clarify the frequency for which background checks should be conducted.

2 DRAFT NOTES not approved Page 2 of 8 Legally employable This is already covered by I 9 form. 1 Keep as is; agencies currently require employees to sign all the necessary forms at time of hire. Time sheet sign statement of understanding fraud Recommendation: At orientation (or training at time of employment) require that the PCA (employee) and consumer sign a statement (or legal agreement) that they understand what the fraud policy is and that they understand the consequences of not abiding by it. Put the agreement in the employees personnel files and give a copy of the agreement to the PCA and consumer. That way, only one form is required to be signed at one time. The agreement should be considered like a contract and cover the entire time the PCA is employed by the agency. The agreement could be signed at the same time as the care plan is reviewed and signed, at the employees performance review, or at the same time the HIPAA forms are signed. Recommendation: Do not require that providers (or PCAs) attend an annual training to cover this information. In 2005 there was a law that stated that providers have to include a fraud statement on the timesheet for the PCA to sign. Since then, many providers have changed to electronic timesheets. To require agencies who have converted to electronic time sheets to get the PCA signature at each payroll is an extra administrative burden that is difficult and costly to obtain (optical technology, etc.). Currently, DHS has a standard timesheet with all of the required elements. If a provider chooses to use their own timesheets, they have to get DHS approval to ensure that all standards are included. In 2015 all health care providers in Minnesota will be required to have electronic health records; if changes are made to the requirements, be consistent across health care systems/providers. HIPAA (Health Information and Portability Accountability Act) Consumer signs HIPAA forms annually. PCA signs HIPAA at time of employment (this is not a requirement of DHS it is suggested). Are there differences in health care agencies in how they communicate with their employees about HIPAA forms/training/requirements? (Check on this) CMS is looking at requirements that DHS is including in state plan amendments and asking them to demonstrate how they can ensure the requirements are being done. Should the forms be signed annually as part of an enrollment process/annual Standards Review? 1 The Employment Eligibility Verification Form I 9 is a U.S. Citizenship and Immigration Services form. It is used by an employer to verify an employee's identity and to establish that the worker is eligible to accept employment in the United States.

3 DRAFT NOTES not approved Page 3 of 8 Health precautions & training (universal precautions) Recommendation: (?) Provide list of items that agency needs to accomplish (requiring documentation of completion). The training could be accomplished by QP. Recommendation: Do not allow health plans to change or revise the public health nurses PCA assessment (units of PCA eligible for, etc.). Requiring training for PCAs takes away from PCA wages. It is not affordable for agencies to provide the training because the reimbursement rate is not sufficient ($15.92). When you take out taxes, workers compensation, etc. it brings down rate to $ Then you add UMPI numbers, and this brings down rate to around $ If a provider wants to make a profit, the wages for PCAs goes down to about $11.00 or less/hour (and this is not including extra training). DHS asked members to consider other sources for training. If training is important, but providers have a difficult time affording to provide it, where should it come from? Options: use Qualified Professional (QP) for training (as a standard service); have staff at agencies receive Red Cross trainings, which are less expensive. PCPOs are required to have a QP on staff, PCA Choice agencies are not required to have a QP on staff. DHS has been awarded a grant of 100 hours of technical assistance from CMS to look into best practices across the country to see how other states are providing PCA training (curriculum, medication administration, etc.). There could be different levels of training to meet health and safety/qa needs (for example, providing extra training for PCAs to work who work with consumers with complex medical needs); DHS could possibly increase reimbursement rates so that providers can be reimbursed for the extra cost of training. Home health aides are not required to take CPR training. A standardized curriculum would be incredibly beneficial for providers. It is important to pass along health plan issues to the contract managers at DHS. Agencies may not get a copy of the consumers service plan (from managed care plans). Providers are working in the dark and they aren t even aware how many hours are authorized. Verify PCA is physically able to work Standard employment practice whereby employees verify that they are able to fulfill the physical demands and requirements of the job they are applying for; no changes need to be made. Prior to employment pass a drug test? No; drug tests are expensive to administer. How helpful would it be? What would it accomplish? There are some regulations already outside of home care; the process be applied consistently to avoid discrimination. Literate what level of reading understanding English? If the PCA can pass the QA reviews and SIRS everything is fine. It is challenging for QPs to communicate with LEP (Limited English Proficient) families; however, interpreters are billable and they should be used. The current PCA laws/statute state that the PCA must have the ability to communicate to the person (or Responsible Party) they are providing services to. Should we beef up this language? How does the PCA document provision of services (when English is a second language/or they are LEP)? This task is technically a requirement of the employer.

4 DRAFT NOTES not approved Page 4 of 8 Discussion: Qualified Professional Agency demonstrates that training is provided to the QP Recommendation: The PHN should identify the scope of practice for the individual QP and determine the most appropriate QP for the consumer (social worker, therapist, registered nurse, etc.) based on their individual needs. There has been feedback to the department that QPs aren t aware of what they are responsible for in terms of overseeing/training PCAs. It is the agencies responsibility to provide QPs with appropriate training and inform the QPs of their roles/expectations for training and supervising PCAs. Currently, a RN, Mental Health Professional, or LISW can qualify as a QP. Members shared some other ideas for who they thought could perform the role of a QP: independent skills specialists (not certified); someone with a certain experience level in a specific health related field; a behavioral analyst; occupational therapist, physical therapist, speech therapist, respiratory therapist (home care supervision allows OT, PT and ST as professionals that can direct care); LPN (however, a representative from MDH later stated that under their license from the Board of Nursing LPNs are not allowed to supervise other staff). How do we honor the Nurse Practice Act (in regards to supervision and delegation)? Allowing other professionals to be a QP depends on the individuals needs. If you are delegating nursing functions, a registered nurse must supervise. Consider the use of technology and what is allowed as QP billable time. Requiring QP to attend the three day provider enrollment training Do not require three day training for QPs. However, someone in the agency should attend and share the information to their staff (including QPs). Require orientation for QPs or set them up as an independent provider Recommendation: provide a list of qualifications on the QP job description and make it the QPs responsibility to meet the qualifications. What could be changed or expanded to the QP position to improve program integrity and ensure health and safety? If we could expand their role, what would it look like? Should agencies be required to provide training for QPs so they have the opportunity to leave their agency and work by themselves? Keep in mind the remote areas of the state that do not have the access to QPs. Would the QP bill on a separate line? YES. This is also required for mental health professionals. If a QP is set up as an independent contractor, PCAs may not look to the QPs as an authority figure (even though the QP is supervising the PCA, they don t necessarily have an authoritative role). Require QP to get NPI # or UMPI # NPI National Provider Identifier UMPI Unique Minnesota Provider Identifier (DHS set up this number for non conforming entities). We don t want to re create the system/issues. Alternate way to assure credentialing without requiring the UMPI #.

5 DRAFT NOTES not approved Page 5 of 8 Require background check for each agency or affiliate Currently, there is no requirement that a QP pass a background study. For the health, safety and integrity of the program, we should possibly consider requiring background checks. Recommendation: require that QPs receive a background check. Providers are currently required to notify DHS when consumers change QPs (but this is not happening). What can the department do? Improve communication about the requirement for providers to do this. Some were not aware that they were supposed to notify the department when a consumer s QP changed. Some asked why DHS has to know when QPs change. It is a quality assurance measure; the department tells CMS that they are monitoring provider agencies and this is one way of monitoring and ensuring that the consumer s health and safety are being met. Update from Department of Health Janice from MDH provided an update to the group. MDH and DHS are collaborating to make recommendations to the legislature regarding provider standards. Currently, the Department of Health has a home care regulatory workgroup that is meeting to discuss some of these issues. And in 1999, MDH did some extensive work and pulled together recommendations on licensure for PCA providers. However, the administration of the state was not supportive of setting up a licensing system at that time. DHS also has a number of activities going on around PCA (OLA study, CMS, RFP, Home Care Reform, etc.). Consequently, MDH has decided not to set up another process of meetings to gather input from stakeholders; instead, they will work closely with DHS and utilize the information generated from the workgroups currently meeting and other reports to incorporate feedback into the process. They will start by looking at recommendations from 1999 to see what has changed since then and how it fits with the information they receive from the workgroups and reports. They will sit down with DHS at the end and put together their report to the legislature. MDH will make copies of information available and will provide the opportunity for stakeholders to give their feedback/input into the issues along the way. MDH has not developed a licensure process for PCAs. There could be alternatives to licensure (for example, requiring providers to re enroll with DHS every other year, etc.). Next Steps The last meeting is scheduled for Thursday, July 24, 9:00 AM 12:00 PM, DHS Andersen Building, Room Agenda: review recommendations that will go forward to the Home Care Advisory Work Group on August 5. Staff will put together a first draft of recommendations based on the July 8 and 15 meetings and will send them to the Topic Team at least a day prior to the meeting to review.

6 DRAFT NOTES not approved Page 6 of 8 Flip-chart notes July 15, 2008 Provider Standards and PCA Training Meeting Background Checks Working Two-day clear expectation (less timely than week) by providers HC facilities have additional criteria No national database - Drug convictions - Fingerprints Relates to health care $20 fee Lapse of employment (currently sufficient); six months? one year; must do again Suggest do yearly UMPI# Not redoing every time assigned to recipient Centralize system DHS and PMAP different for serving different recipient If PCA consistently involved with the agency, omit frequent rechecks due to change in PMAP; decreases cost to PCA agency administrative burden...; confirm what is included in background review... Legally employable I9 covers naturalization, citizenship legal and able to work Deal with non-compliant agencies without making more laws Time sheet and signature of employee Electronic vs. paper additional administrative work as written signature of employee Fraud statement in personnel file vs. every time sheet Problems in electronic administration 2015 all need to be electronic call from phone where provide services Be consistent across HC services Orientation training to include PCA and recipient, and sign statement at this time (one time) PCA choice both sign and get copy of statement Look at redoing at Care Plan time (annually)... simple statement specifying time period... At time of employment for individual PCA done and document Two sign PCA and recipient HIPAA currently consumer gets notice annually at PHN assessment Open to training tools for PCA for provider agencies Currently no authority to demand HIPAA HC agencies is there a difference HIPAA privacy and security issues?

7 DRAFT NOTES not approved Page 7 of 8 Annual standard reviews Agency Individual PCA Could this cover some topics? Annually/agency/PCA PCA choice consumer choice Consistency how to best establish Health precautions annually... cost to agencies to administer annual reimbursement rising Providers none currently Built in with providers more so this is included annual options; rising QD with individual PCA CPR HHA not required to have consistency Use QP to assist with training Require QP for all recipients With requirements requires proof Grant money Standardized cirr. PCAs may be willing to use own time... money; internal motivation QP and HP units PHN s determination be universal so HP cannot decrease QP time or process for disagreement. Agency trains QP (licensed professional). What does supervision look like? What s communicated and how? QP now RN, MGP, licensed SW Suggestions: OT, PT, speech included in home care supervision. Respiratory, independent living, skills spec., experienced level in Behavioral analysis LPN? Not allowed to supervise nursing function What can bill for responsibility Define QP If supervision rules out LPN, delegated nursing function language OT, PT therapies not necessarily Supervise ADL s Two years experience PSY in HHA Medicare agency requirement QP requirements and documented in provider records Sometimes these are PT employees Individual agencies decide Do QP understand responsibilities? Appropriate QP according to recipient needs and licensing of professional Orientation for QP or independent provider Expand QP role? Already training and licensing List of expectations

8 DRAFT NOTES not approved Page 8 of 8 Could be included in job description QP Rural availability not there; shortage of RNs and MH professionals Use of technology Tela... Change on-site language Background check for QP, especially if expand scope, reasonable QP include NPI number on claim How do it so reasonable process, alternate way to accomplish Responsibility, yet no authority if independent... also bonding? Insurance issues Notifying DHS if change in QP Clarify expectation for agency when change Identify scope of practice for QP... and who says who is appropriate PCA prior to employment Physically able to work, employer responsibility outside PCA itself Pass drug test, expensive for providers, how helpful, how often? Regulations outside of HC need policies Reading level understand English? HS graduate? Requirements; online training if no English first language; may be difficult