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Personal Care Assistance (PCA) Services

Revised: 06-05-2017

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Overview

Minnesota Health Care Programs (MHCP) covers personal care assistance (PCA) services provided to children and youths with disabilities in the least restrictive environment, so the child or youth may attend school and receive a free appropriate public education (FAPE) just as other children and youths without disabilities.

For MHCP to reimburse for the federal share of the cost of school-based PCA services, the service must be identified in the child’s or youth’s Individualized Education Program (IEP) plan or Individualized Family Services Plan (IFSP). Also, the service must be medically necessary and provided by a qualified personal care assistant who is trained and supervised by a qualified licensed health-related service professional (Minnesota Statutes, Chapter 148) or trained and supervised by a special education teacher with the core skills for licensure (Minnesota Administrative Rule, Chapter 8710.5000).

Note: In the remainder of this manual section, we will use IEP to mean both the IEP and the IFSP.

The procedures, tasks or activities that are performed by a personal care assistant must fall within the scope of practice or professional responsibilities of the qualified professional who is training and supervising the personal care assistant.

Eligible Providers

People Eligible to Provide PCA Services

To be eligible to provide personal care assistance, the person must meet all of the following requirements:

  • • Complete the required Department of Human Services (DHS) MHCP online training for PCA providers
  • • Receive training and supervision from a qualified professional (QP) on how to meet the child’s or youth’s needs
  • • Be at least 18 years of age
  • • Not be a consumer of PCA services
  • • Have the ability to effectively communicate with the child or youth and with the QP who is providing training and supervising the health-related PCA services the child or youth receives during the school day
  • • Be able to effectively provide PCA services according to the child’s or youth’s PCA plan of care
  • • Be able to appropriately respond to the child’s or youth’s needs and immediately report significant changes in the child’s or youth's condition to the supervising QP
  • • Maintain required daily written records including, but not limited to, PCA activity check lists or logs, and communication with the QP and emergency contacts
  • • Be employed by the school district to provide PCA services or be under contract with an agency that has a PCA service agreement with the district
  • Required Training

    To provide IEP PCA services, the personal care assistant must complete the following training activities:

  • • View and complete the online DHS Individual Personal Care Assistant Training and submit a certificate of completion of training to the school or employing agency and keep a copy for themselves
  • • Complete training and orientation given by the QP on the specific needs of the individual child or youth as identified in the IEP and written in the PCA plan of care
  • • Be aware of the other support services provided for this child or youth
  • • Be knowledgeable about the PCA plan of care before performing services
  • • Display competency in providing the required service
  • • Understand the documentation requirements for the services provided
  • Scope of PCA Services

    PCA services and activities

    Service

    Activity

    Assist

    Provide hands-on assistance with an ADL task

    Cue

    Remind or stand by and direct the completion of an ADL

    Observe and Intervene/Redirect

    Identify and deescalate episodes of behavior

    Monitor

    Perform delegated health related procedures and tasks

    Eligible Recipients

    To be eligible for PCA services in school, the child or youth must be dependent and need assistance for one or more of the activities of daily living (ADL), or require intervention or redirection from another person for Level 1 Behavior(s).

    A child may not be found to be dependent in an activity of daily living if the child’s need for assistance is age appropriate.

    Covered Services

    Activities of Daily Living (ADLs)

    Dependent in an ADL means the child requires cuing and stand-by supervision or hands-on assistance from a personal care assistant to begin and complete an activity of daily living.

    Activities of daily living include health and hygiene needs that are part of daily living, as well as activities integral to the activity (for example, cleaning up spills, laundering soiled clothing, and cleaning up toileting accidents). ADLs include the following:

  • Dressing: Assistance with choosing, putting on and changing clothing and with application of special appliances, wraps or clothing
  • Grooming: Assistance with basic hair care, oral care, shaving, applying cosmetics and deodorant; ensuring clothes are clean and properly fastened; and care of eyeglasses and hearing aids (confirming batteries work, positioning aids). Nail care is included, except for a child or youth who has diabetes or poor circulation
  • Bathing: Assistance with basic personal hygiene and skin care
  • Eating: Assistance with hand washing and applying orthotics required for eating, transfers and feeding
  • Transfers: Assistance with transferring the child or youth from one seating or reclining area to another
  • Mobility: Assistance with ambulation, including use of a wheelchair. Mobility does not include providing transportation for a child or youth
  • Positioning: Assistance with positioning or turning a child or youth for necessary care and comfort
  • Toileting: Assistance with bowel or bladder elimination and care, including transfers, mobility, positioning, feminine hygiene, use of toileting equipment or supplies, cleansing the perineal area, inspection of the skin, and adjusting clothing
  • Level 1 Behaviors

    A child or youth qualifies as having the need for assistance from a personal care assistant through observation, redirection or intervention of a behavior episode if the episode is due to a medical or mental health condition and requires the immediate response of another person to prevent injury to self or others, or damage to property.

    Behaviors may occur at different levels and in different situations. To qualify for PCA services, the display of a Level 1 Behavior must be current, and determined to be either daily or episodic and ongoing (for example, four times a week).

    Level 1 behaviors are defined as:

  • • Physical aggression toward self (self-injurious behaviors)
  • • Physical aggression toward others (physical injury to others)
  • • Destruction of property
  • Examples of Level 1 Behaviors

    Self-Injurious

    Physical Injury to Others

    Destruction of Property

  • Hitting
  • • Hitting
  • • Breaking windows, lamps or furniture
  • Biting oneself
  • • Biting
  • • Tearing clothes
  • Head banging
  • • Pinching
  • • Setting fires
  • Burning oneself
  • • Scratching
  • • Using tools or objects to damage property
  • Self-poking or stabbing
  • • Kicking
  • Ingesting foreign substances
  • Pulling out hair
  • Suicide threats
  • When determining the level of need for behavior intervention, address the following considerations:

  • • Are the behaviors related to the medical need that qualified the child for IEP services?
  • • How current are the behaviors?
  • • Are there times when the behavior does not occur?
  • • Are there identifiable triggers that are likely to induce the behavior?
  • • Is it possible to modify the school or classroom environment to avoid the triggers that might make the behavior more likely?
  • • What are the reasonable expectations of the behavior reoccurring throughout the school day?
  • If a current, but infrequent, (less than four times per week or less than once daily) Level 1 Behavior is identified in the IEP plan that will require the immediate response of another person to intervene and redirect the physical aggression toward self or others or destruction of property, a personal care assistant may be assigned to intervene or redirect the child or youth during that episode. Medical Assistance (MA) will pay for this response time. The time allowed is when the personal care assistant is fully engaged, working face-to-face or hands-on with the child or youth.

    Once a child or youth qualifies for PCA services, he or she may also receive assistance from a personal care assistant for redirection or intervention during a behavioral episode, when the child or youth displays increased vulnerability due to cognitive deficits or socially inappropriate behaviors, and for other delegated health related procedures and tasks.

    Determine how the lack of cognitive skill or vulnerability is affecting the child or youth behavior and what assistance must be provided to redirect or intervene during a behavioral episode.

    For example: A child with Down Syndrome has qualified for PCA service for two ADLs: toileting and eating. Because the child qualifies for PCA services, the child or youth can receive PCA services because of his or her increased vulnerability due to cognitive deficits. The child has a history of elopement (wandering away) from the past school year and is currently displaying episodes of elopement when given the opportunity. In this case, it may be necessary to have a personal care assistant with the child, during times such as recess, lunch, in the halls and going to the restroom. During these times, there is a reasonable expectation that the child may find the opportunity to elope and MA will cover PCA services during these periods.

    However, once the child is in the classroom, a teacher or paraprofessional is watching over the room and a personal care assistant does not need to be available to observe the child in case the child may elope.

    Other situations may require a personal care assistant to assist with ADLs and monitor a child for health related concerns for the full day at school. Such situations may be for a child or youth who is medically fragile and needs assistance with multiple ADLs, needs constant intervention or redirection of behaviors, or both. Documentation must clearly identify the child‘s or youth’s specific medical needs, why constant continuous care is needed throughout the school day, and how the services provided relates to the child or youth’s medical needs. MHCP does not pay to have a PCA sit with a child or youth to watch for a behavior that occurs infrequently or to keep the child on task with his or her educational activities or assignments.

    The increased vulnerability due to cognitive deficits or socially inappropriate behavior of a child and youth who is verbally aggressive or resistive to care must relate back to:

  • • The medical need of the child or youth
  • • Whether the need would otherwise prevent the child or youth from attending school
  • • Whether the behavior would put the child or youth, another person or property in harm’s way that is beyond what is expected for the child’s age
  • If the child or youth is not staying on task with the lesson plan, listening to the teacher, or is speaking out of turn, making comments out loud, grabbing for other children’s property or generally disrupting the class, it is the responsibility of the school to have the teacher, teaching assistant or paraprofessional assigned to the classroom or to that child or youth to keep the child or youth on task for his or her educational needs and classroom behavior protocol. Classroom support of this type is not an MA covered PCA service.

    Other Health-Related Procedures and Tasks

    Health-related procedures and tasks may be delegated or assigned by a licensed health care professional under state law to be performed by a person providing PCA services.

    Document the delegation of health-related procedures and tasks and training in the PCA plan of care for the child or youth and in the file of the person providing the PCA services. These PCA services include, but are not limited to the following:

  • • Range of motion and passive exercise to maintain a child’s or youth's strength and muscle function
  • • Assistance with self-administered medication, including reminders to take medication, bringing medication to the child or youth, and assistance with opening medication containers under the direction of the child or youth, including medications given through a nebulizer. A PCA must not determine the medication dose or time for medication.
  • • Interventions for seizure disorders that occur more than two times per week and require physical assistance to maintain safety
  • • Procedures for complex health-related needs, including tracheostomy suctioning, services to a child or youth needing ventilator support and other direct cares. These are covered PCA services if delegation, training and supervision is by a registered nurse (RN), the service can be competently and safely completed, training is specialized and individualized to the needs of the child or youth, and delegation and training are documented.
  • Noncovered Services

    MHCP does not cover the following:

  • • Assistance provided to a child or youth by a personal care assistant who is not qualified as a personal care assistant or has not been trained or supervised by a QP
  • • Services provided by substitutes who have not received the required training and supervision
  • • Services provided by a parent, stepparent, paid legal guardian or foster parent
  • • Care that requires the skill of a trained nurse or other trained medical professional, for example, re-inserting g-tubes, sterile procedures, giving injections, administering medication, and nurse assessments either delegated or provided by someone who is not a nurse
  • • Classroom support by a paraprofessional to ensure children stay on task
  • • Hearing aid check (programming such as setting and resetting volume, calibrating or making other adjustment)
  • • Services that are provided to a child or youth that would reasonably require assistance for a child of that age
  • • Helping a child or youth with school assignments and class activities or redirecting, cueing and intervening to help a child stay on task to complete school assignments, projects or activities
  • • Monitoring and assisting the child or youth to perform assigned “jobs” at school, job training or coaching or vocational services
  • • Services provided to a child or youth as a before and after school activity, including sports, clubs, class projects, tutoring, music lessons and child care
  • • Activities that teach anything, including teaching a child to grocery shop, manage finances, get around in the community by taking buses
  • • Instrumental Activities of Daily Living (IADL)
  • • Continuous monitoring or observation in case a child might run away if there is no reasonable expectation that the child will have the opportunity to elope (for example, in a classroom setting where a teacher and paraprofessional are present)
  • • Continuous monitoring or observation of a child who may have a behavioral episode occur infrequently
  • • Monitoring juvenile offenders to prevent harm to others or inappropriate behavior
  • • Restraining a child or youth, applying restraints or monitoring a child or youth who is placed in isolation or time-out
  • • Services provided by drivers of vehicles used to transport eligible children
  • • Services provided by a bus monitor
  • • Services provided in the home of the child or youth, including but not limited to direct service, homemaker services, babysitting or child care
  • • The work of a mental health behavioral aid provided by a personal care assistant
  • Documentation

    To be eligible for Medicaid payment, state and federal regulations require schools to maintain fiscal records that support the nature and extent of health related service they provide to children and youths eligible for services under the Individuals with Disability Education Act (IDEA).

    The school must maintain required documentation listed in this section and have it readily available. It is the responsibility of the school to determine where the documentation is maintained and available.

    Documentation may be web-based, electronic or paper records.

    Activities Checklist

    The activity record must correspond to the current PCA plan of care and be reviewed by the QP. Documentation for PCA services must include the following:

  • • Full name of the child or youth
  • • Date of birth
  • • Date, including month, day and year that the personal care assistant provided the task or service
  • • Notation of reason no service was provided on a given day (example: child or youth absent from school)
  • • Description of task or activity, the initials of the personal care assistant, and then mark or tally of the number of times the task is conducted on a given day
  • • Any shared care provided (number of children in a group), if applicable
  • • Total time per day based on time study or the exact time if child is at school for a shortened day
  • • Full name, signature and initials of each person providing PCA services to the child or youth
  • • A statement that the time allocated to each task or activity has been determined by the most recent time study of PCA services
  • • Date of QP evaluation of PCA services if conducted in the time period of the report
  • • Signature of designated person who can verify services were performed
  • • A statement that it is a federal crime to provide false information on personal care service billings for Medical Assistance payments
  • PCA Time Studies

    School districts may select how they gather time for reporting service time on the PCA Activities Checklist. Schools may use the exact time in minutes per task or episoide or use an averaged time based on a time study. Time studies should be conducted over a two-to-four week time period by documenting the actual time spent per task or episoide when performed by a trained PCA who has or will be working with the child. To be considered a recent time study, a time study should be reviewed annually, and a new time study conducted if the needs of the child change or at least every two years.

    Supervision

    QP Qualifications

    The qualifications for a person providing supervision of a personal care assistant who is providing PCA services are based on the service provided, and the license, certification, scope of practice, professional responsibilities and professional experience of the supervisor.

    For example, ADLs such as positioning, transfers or toileting may be taught and supervised by a physical therapist or professional nurse. These ADLs may not be taught or supervised by a speech pathologist, audiologist, school psychologist, social worker or certain special education teacher, because it is not within the scope of practice of those professionals.

    Responding to Level 1 Behaviors is the scope of practice of school personnel such as, but not limited to, school social workers, school psychologists and some special education teachers.

    A QP may be any of the following:

  • Audiologist
  • Licensed school psychologist
  • Licensed school social worker
  • Mental health professionals (MHP)
  • Occupational therapist
  • Physical therapist
  • Professional nurse
  • Special education teacher
  • Speech language pathologist
  • QP Duties

    A QP must supervise anyone providing personal care assistance through use of direct training, observation, return demonstrations and consultation with school staff, the child or youth, and the parent or guardian of the child or youth.

    The QP trains and supervises the person providing PCA services and evaluates the effectiveness of the services. The QP must do the following:

  • • Confirm that the personal care assistant meets the qualifications to provide the services
  • • Appropriately assign tasks to the personal care assistant
  • • Provide training and ensure competency of the personal care assistant in meeting the individual needs of the child or youth before services are provided
  • • Verify that the PCA plan of care, based on the needs of the child or youth as described in the IEP plan, is completed within the first week after the start of services and updated as needed
  • • Review the personal care assistant’s documentation of services provided
  • • Document training, communication, initial and periodic evaluations of the PCA services, and what actions are needed to improve services provided by the personal care assistant
  • PCA Plan of Care

    As a part of the IEP planning process that includes the parent or guardian, the IEP team identifies and records in the IEP plan the needs of the child or youth, the expected goals and outcomes, and the plan to meet those needs. Include the type and amount of PCA services and that a QP supervises the person providing PCA services. Each child or youth must have a current PCA plan of care based on the needs of the child or youth and the services identified in the IEP plan.

    The QP must list his or her qualifications (such as, school nurse, occupational therapist, special education teacher with certificate) to train and supervise the PCA services needed by the child or youth. The same procedures, tasks or activities performed by the personal care assistant are within the license, certification and scope of practice, professional responsibilities and professional experience of the QP and could be provided by the QP in the absence of the PCA.

    A copy of the most current PCA plan of care, including emergency contact information, must be in the child’s or youth’s IEP file and immediately available to the personal care assistant while services are being provided. The PCA plan of care must be completed within the first week after the start of services being provided and updated as needed to clarify instructions or when there is a change in the need for PCA services. Update the PCA plan as changes occur and review it annually.

    The PCA plan of care must have the following components:

  • • A start and end date of the care plan
  • • New start and end dates when the plan changes or to reflect the date of the annual review
  • • Child’s or youth’s name, date of birth and other information such as student identification number if needed to clearly identify the child or youth
  • • Emergency contact information readily available, including parent’s or guardian’s name and telephone number, primary health care provider and contact information. Include instructions for making emergency contacts
  • • A clear summary of the essential needs of the child or youth, that:
  • • Identifies the ADL’s, Level 1 Behaviors or health-related tasks
  • • Describes what the PCA will do to meet the needs of the child or youth
  • • List of special instructions or procedures required, such as meeting communication needs of the child or youth who has a hearing impairment or language barrier or requires a personal care assistant of the same gender
  • • Steps to address safety and vulnerability issues of the child or youth, including but not limited to, responding immediately to predictable, identifiable triggers to Level 1 Behavior episodes or instructions to notify the QP about concerns and changes to the child’s condition or behavior
  • • Directions about personal care assistant and QP communication with the child’s and youth’s primary teacher, IEP teachers, and parent or guardian
  • • Instructions for daily documentation by the person providing the PCA services
  • • Backup staffing plan to meet the needs of the child (Personal care assistant substitutes need training and supervision if services are to be billed to MHCP)
  • • Signature of QP and personal care assistant and date
  • Evaluation of the Person Providing PCA Services

    Initial Evaluation

    The QP must complete an initial evaluation of the personal care assistant through direct observation of the personal care assistant’s work within the first 14 days (or sooner as determined by the QP) of starting to provide regularly scheduled services to the child or youth.

    After the initial evaluation, subsequent visits do not require direct observation of each person providing PCA services unless determined by the QP based on the needs of the child or youth and the personal care assistant’s ability to meet those needs.

    Periodic Evaluations

    The QP must complete periodic evaluations as follows:

  • • At least every 90 days for the first year of service to the child or youth. After the first two 90-day evaluations (total of 180 days) of a PCA providing service to the same child, the supervisory visits may alternate between unscheduled phone or internet technology and in-person visits, unless the in-person visits are needed according to the care plan
  • • Every 120 days in the second and succeeding years that the same person is providing the PCA services to the same child
  • Sign, date and indicate the supervision visit on the PCA Activity Checklist when a periodic evaluation and supervision visit is conducted during the period identified on the activity checklist.

    Conduct evaluations more often if:

  • • The QP determines more are necessary based on the needs of the child or the personal care assistant’s ability to meet those needs
  • • The child or youth, parent or guardian, teacher, IEP case manager or other educator makes a request for increased supervision of the PCA services
  • • The PCA plan of care requires more frequent evaluations
  • Documentation of Evaluations

    At the initial and each periodic supervisory visit, the QP must evaluate whether the PCA services:

  • • Meet the needs of the child or youth as identified in the IEP or IFSP
  • • Help the child or youth participate in and benefit from regular and special education
  • The QP evaluation must include review and documentation of the following:

  • • Satisfaction level of the child or youth and parent or guardian with the PCA services
  • • Adequacy of the tasks and activities in the PCA plan of care to meet the needs of the child or youth
  • • The personal care assistant’s understanding of the child’s or youth’s needs, knowledge of the care plan, when to notify the QP of concerns or changes in the condition or behavior of the child or youth, and when emergency actions and contacts are required
  • • The personal care assistant’s demonstrated ability to competently carry out the tasks and activities to meet the needs of the child or youth as trained
  • • Documentation by the personal care assistant of the services provided, the personal care assistant’s communication with the QP and emergency contacts made, if any
  • • Changes in the needs of the child or youth requiring change in the level of service, revision of the PCA care plan or additional training of the person providing PCA services
  • At the conclusion of the evaluation, the QP must document the above and the following:

  • • Actions necessary to correct any deficiencies in the work of a person providing PCA services, actions taken and timeline for actions planned
  • • Hands-on training or individualized training for the care of the child or youth that was conducted or assignments and timeline for training to occur
  • • Revision of the PCA plan of care as necessary to meet the needs of the child or youth
  • Refer to the Covered and Noncovered Services section of this Provider Manual for an overview of noncovered services that apply to all IEP services.

    Record Keeping and Documentation

    Review the Record Keeping and Documentation section for an overview of the basic IEP record keeping, documentation of services time and encounter reporting requirements.

    Billing

    Submit claims using the 837P Professional claim type. Refer to the MN–ITS IEP User Guide for step-by-step instructions for direct data entry claims. Batch billers submitting X12 837P claims may review the MHCP 5010/D.0 Compliance webpage and the AUC Minnesota Uniform Companion Guide for transaction guideline.

    MHCP is the payer of last resort for all other liable parties except school districts. Bill MHCP for covered IEP services (except transportation and PCA services) only after receiving payment or a denial of coverage from all other liable health care plans.

    IEP PCA services are not covered by private health care plans; therefore, it is not necessary to obtain a denial of coverage for these services before billing MHCP.

    Retain copies of all correspondence with private health plans regarding determinations for IEP services coverage, including phone conversations for five years.

    Billing for PCA services:

  • • Do not use place of service 12 (home) to bill PCA services
  • • Nursing and PCA services, provided to children who require nursing or PCA services in-route, are covered under the appropriate service. These services are not included in the costs reported to DHS by MDE
  • Review the Billing and Authorization Requirements section for general billing requirements.

    Legal Reference

    Minnesota Statutes 256B.0625, subd. 26 Covered Services – Special Education
    Minnesota Statutes 256B.0625, subd.19 (c)
    Covered Services – Personal Care Assistance Services
    Minnesota Statutes 256B.0659
    Personal Care Assistance Program
    Minnesota Statutes Chapter 148
    – Public Health Occupations
    Minnesota Administrative Rule, Chapter 8710
    – Teacher and Other School Professional Licensing (see 8710.5000 – 6300)

    Minnesota Statutes 125A.08 (c. 1-3) IEP Programs, Paraprofessionals
    Minnesota Statutes 125A.21
    Third Party Payment
    Minnesota Statutes 125A.74
    Medical Assistance Payments to School Districts

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