Minnesota Minnesota

CFSS Policy Manual

CFSS Policy Manual


PCA/CFSS unit determination

Page posted: 8/26/24

Page reviewed:

Page updated: 8/11/25

Legal authority

Minn. Stat. §256B.0659, subd. 4, Minn. Stat. §256B.85, subd. 10, Minn. Stat. §256B.0651, subd. 1

Comparison of PCA and CFSS

DHS is in the process of replacing PCA with CFSS. For more information about this transition, refer to CFSS Manual – Transition from PCA and CSG to CFSS.

Similarities

In both PCA and CFSS:

  • · A person is eligible for PCA/CFSS if they have at least one activity of daily living (ADL) dependency and/or at least one level I behavior.
  • · The formula to determine a person’s home care rating and total units is the same, with one exception explained in the next section.
  • · There are two types of assessments that use the same criteria and formula.

    • Differences

    In PCA:

  • · People with one ADL dependency and/or one level I behavior received the home care rating LT, were eligible for 0.5 hours per day and were not eligible for additional time.
    Note: As of Oct. 1, 2024, the home care rating LT is no longer available.
  • · All people use units.

    • In CFSS:

  • · People with one ADL dependency and/or one level I behavior receive the home care rating P, Q or R, are eligible for 1.25 hours or more per day and are eligible for additional time.
  • · People can choose to convert some or all units to dollars.

    • Instructions for the transition year

    After the county/tribal nation conducts the person’s assessment during the transition year, they authorize six months of PCA to avoid a gap in services. The PCA authorization is based on the results of the new assessment.

    If the person has not transitioned to CFSS by their next reassessment on or after Oct. 1, 2025, the county/tribal nation authorizes additional PCA services. For more information, refer to the transition section of CFSS Manual – Assessment for PCA/CFSS services.

    As of Oct. 1, 2024, the home care rating LT is no longer available for PCA or CFSS. The county/tribal nation cannot assign the home care rating LT and instead must use CFSS eligibility policy for people with:

  • · One ADL dependency.
  • · Zero ADL dependencies and a level one behavior.

    • For more information, refer to the instructions in the home care rating section of this page.

    Definitions

    Activities of daily living (ADL) dependency: A need for assistance to begin and complete an ADL, as defined by the assessment. For more information, refer to the ADL dependencies section.

    Complex health need: Interventions ordered by a medical practitioner, as defined by the assessment. For more information, refer to the complex health needs section.

    Behavior: A specific action that requires assistance at least four times per week. For more information, refer to the behaviors section.

    Level I behavior: Physical aggression toward self or others, or destruction of property that requires the immediate response of another person. For more information, refer to the behaviors section.

    Ventilator dependence: A need for a mechanical ventilator for life support at least six hours a day for at least 30 days. This includes both invasive and non-invasive ventilation.

    Unit: 15 minutes. On this page, all times are listed in hours.

    Overview

    This page is a resource for lead agency assessors who complete the CFSS Assessment, DHS-6893A.
    Note: Assessors used PCA Assessment and Service Plan, DHS-3244 (PDF) for PCA legacy assessments.

    This page explains how the assessment determines a person’s home care rating and units based on their:

  • · ADL dependencies.
  • · Complex health needs.
  • · Behaviors.

    • The information on this page also applies to MnCHOICES assessments. MnCHOICES uses this information to calculate the person’s home care rating and units. The formula for PCA/CFSS eligibility is the same in both assessments. MnCHOICES is a comprehensive assessment that also determines eligibility for many programs. This means questions about the items relevant to PCA/CFSS eligibility are integrated with questions relevant to other programs.

    Home care rating

    If a person is eligible for PCA/CFSS, they receive a home care rating. Their home care rating helps determine their units. This section explains the criteria for each home care rating.

    For a visual representation of the information in this section, refer to CFSS Home Care Rating/Units Reference Tool, DHS-6893H (PDF).

    Home care rating for a person who is ventilator-dependent

    A person who is ventilator-dependent receives home care rating EN. This is true for all people who are ventilator-dependent, regardless of their ADL dependencies, level I behaviors and complex health needs.

    Home care rating for a person who is not ventilator-dependent

    A person who is not ventilator-dependent receives a home care rating based on:

  • · Number of ADL dependencies.
  • · Level I behavior(s).
  • · Complex health need(s).

    • No ADL dependencies

    A person who has no ADL dependencies and at least one level I behavior receives the home care rating P.

    Note: As of Oct. 1, 2024, the home care rating LT is no longer available.

    Low ADL dependencies

    A person with 1-3 ADL dependencies receives one of the following home care ratings:

  • · Home care rating P: No complex health needs or level I behaviors.
  • · Home care rating Q: Level I behavior and no complex health need.
  • · Home care rating R: Complex health need, with or without a level I behavior.

    • Note: As of Oct. 1, 2024, the home care rating LT is no longer available.

    Medium ADL dependencies

    A person with 4-6 ADL dependencies (PCA and CFSS) receives one of the following home care ratings:

  • · Home care rating S: No level I behaviors or complex health needs.
  • · Home care rating T: Level I behavior and no complex health needs.
  • · Home care rating U: Complex health need, with or without a level I behavior.

    • High ADL dependencies

    A person with 7-8 ADL dependencies (PCA and CFSS) receives one of the following home care ratings:

  • · Home care rating V: No level I behaviors or complex health needs.
  • · Home care rating W: Level I behavior and no complex health needs.
  • · Home care rating Z: Complex health need, with or without a level I behavior.

    • Units

    The base number of units for which a person is eligible depends on their home care rating. A person can receive additional units based on critical ADL dependencies, complex health needs and behaviors.

    Home care rating EN

    A person with the home care rating EN is eligible for 96 units (i.e., 24 hours) per day and up to 16 additional units (i.e., 4 hours) if they require some two-person cares.

    Home care rating LT

    A person with the home care rating LT is eligible for 2 units (i.e., 30 minutes) per day and is not eligible for additional time.

    Other home care ratings

    Each home care rating has the following base units per day:

  • · Home care rating P: 5 units (i.e., 1.25 hours)
  • · Home care rating Q: 6 units (i.e., 1.5 hours)
  • · Home care rating R: 7 units (i.e., 1.75 hours)
  • · Home care rating S: 10 units (i.e., 2.5 hours)
  • · Home care rating T: 11 units (i.e., 2.75 hours)
  • · Home care rating U: 14 units (i.e., 3.5 hours)
  • · Home care rating V: 17 units (i.e., 4.25 hours)
  • · Home care rating W: 20 units (i.e., 5 hours)
  • · Home care rating Z: 30 units (i.e., 7.5 hours)

    • For a person who is not ventilator dependent, their total units is the sum of:

  • · Base units per day for their home care rating.
  • · 2 units (i.e., 30 minutes) per day for each critical ADL dependency, with a maximum of 8 units per day.
  • · 2 units (i.e., 30 minutes) per day for each complex health need, with a maximum of 16 units per day.
  • · 2 units (i.e., 30 minutes) per day for each behavior, with a maximum of 8 units per day.

    • Home care nursing

    Some people eligible for PCA/CFSS are also eligible for home care nursing (HCN). Their use of HCN can affect their use of PCA/CFSS. The assessor does not assess the person for HCN or consider their use of HCN as a part of their PCA/CFSS assessment.

    For more information, refer to CBSM – HCN.

    Assessment criteria

    The following sections describe the criteria for:

  • · ADL dependencies.
  • · Complex health needs.
  • · Behaviors.

    • Additional resources

    CFSS Assessment, DHS-6893A
    CFSS Home Care Rating/Units Reference Tool, DHS-6893H (PDF)
    CFSS Manual – Eligibility for PCA/CFSS services
    CFSS Manual – PCA/CFSS age-appropriate dependencies
    CFSS Manual – Transition from PCA and CSG to CFSS
    CBSM – HCN

    ADL dependencies

    Definitions

    ADL dependency: A need for both:

  • · Hands-on assistance and/or cueing and constant supervision to begin and complete the activity.
  • · Assistance on a daily basis or on the days the person completes the activity.

    • For children younger than age 18, ADL dependencies vary by age. For more information, refer to CFSS Manual – PCA/CFSS age-appropriate dependencies.

    Cueing: Verbal instructions to begin and complete the entire task.

    Constant supervision: Continued interaction (i.e., not as needed, episodic or intermittent) and/or visibility to ensure a person completes the task safely.

    Hands-on assistance: Help from another person to start and complete a task. This includes the person being able to participate in the task but unable to start and complete it without assistance.

    Policy

    The assessor determines ADL dependencies at the assessment. The assessor does not have to observe the person attempting to do the task.

    When assessing for ADL dependencies:

  • · The length of time a person needs to complete a task does not factor into if they are dependent in that ADL.
  • · A person’s inability to complete a task due to cognitive disabilities and/or mental illness may meet the definition of dependency in that ADL.
  • · A person’s use of a mobility device to complete a task does not indicate a dependency in mobility if they can use the mobility device safely and independently.

    • ADLs

    The PCA/CFSS ADLs are:

  • · Dressing (e.g., putting on clothing and special appliances or wraps).
  • · Grooming (e.g., basic hair care, oral care, shaving, basic nail care, applying cosmetics and deodorant, eyeglasses and hearing aids care).
  • · Bathing (e.g., basic personal hygiene and skin care).
  • · Eating (e.g., completing the process of eating, including hand washing and applying orthotics required for eating, transfers and feeding).
  • · Transfers (e.g., helping transfer the person from one seating or reclining area to another).
  • · Mobility (e.g., helping with ambulation and use of a wheelchair).
  • · Positioning (e.g., helping position or turn the person for necessary care and comfort).
  • · Toileting (e.g., helping with bowel or bladder elimination and care, transfers, mobility, positioning, feminine hygiene, use of toileting equipment or supplies, cleansing the perineal area, inspecting the skin and adjusting clothing).

    • Critical ADL dependency

    The PCA/CFSS critical ADLs are:

  • · Mobility.
  • · Transfers.
  • · Toileting.
  • · Eating.

    • If a person is dependent in one of the critical ADLs according to the guidelines described above, they receive an additional 2 units (i.e., 30 minutes) per day. The maximum additional time a person can receive for critical ADL dependencies is 8 units (i.e., 2 hours) per day.

    Complex health needs

    Definition

    Complex health-related needs: Interventions that are both:

  • · Ordered by a medical practitioner.
  • · Required at the time of the assessment.

    • Medical practitioner: For the purposes of this section, this term includes a doctor, advanced practice registered nurse (e.g., nurse practitioner) and physician’s assistant.

    Policy

    The assessor determines if the person’s need(s) meet the definition of complex health needs at the time of assessment. They do not need to verify the medical practitioner’s order for complex health-related needs.

    The following sections describe the complex health needs. If a complex health need has subcategories, the person only needs to meet the definition for one subcategory. A person can only receive additional time once per category.

    Only some tasks related to complex health needs are covered PCA/CFSS services. The assessor does not make their determination based on whether a PCA/CFSS worker will complete the task.

    Impact on eligibility and units

    The presence of a complex health need alone does not make the person eligible for PCA/CFSS. If the person meets PCA/CFSS eligibility requirements as described on CFSS Manual – Eligibility for PCA/CFSS services, having one or more complex health needs affects their home care rating and base units. Each complex health need adds 2 units (i.e., 30 minutes) to the person’s total time.

    Tube feeding

    There are two subcategories of tube feeding, for the purpose of the assessment:

  • · Continuous tube feeding.
  • · Gastrojejunostomy (G-J tube).

    • Continuous tube feeding

    Continuous tube feeding is a tube used to supply liquid food or medication directly to the person’s stomach.

    Meets definition

    The person meets the definition if they require tube feeding that is both:

  • · Required on a continuous basis for 12 or more hours.
  • · A gastric or nasal/gastric tube (i.e., inserted into the digestive system and/or nose).

    • Does not meet definition

    The person does not meet the definition if they need tube feeding for less than 12 hours.

    G-J tube

    A G-J tube is a tube used for liquid food or medication that creates a connection between the person’s stomach and the middle of their small intestine.

    Meets definition

    The person meets the definition if they need a G-J tube. This includes:

  • · Both daily use and non-daily use.
  • · Both people who can and cannot eat orally.

    • Does not meet definition

    The person does not meet the definition if they use any other type of gastric or nasal/gastric tube.

    Note: Other types of tube feeding might meet the definition for continuous tube feeding described above.

    Parenteral/IV therapy

    There are two subcategories types of parenteral/IV therapy, for the purpose of the assessment:

  • · IV therapy.
  • · Total parenteral nutrition (TPN).

    • IV therapy

    IV therapy is a tube to supply medication to their body through their veins. This includes both:

  • · In-patient and out-patient therapy.
  • · Dialysis.

    • Meets definition

    The person meets the definition if the IV therapy is both:

  • · Three or more times per week.
  • · Four or more hours per treatment.

    • Does not meet definition

    The person does not meet the definition if the IV therapy is either:

  • · Fewer than three times per week.
  • · Fewer than four hours per treatment.

    • Note: The presence of an indwelling port alone does not mean the person meets the definition. They must meet the other criteria.

    TPN

    TPN is an IV that provides nutrition directly into the person’s veins.

    Meets definition

    The person meets the definition if they need an IV providing nutrition directly into their veins.

    Does not meet definition

    The person does not meet the definition if the IV does not provide nutrition directly into their veins.

    Wound care

    There is one category of wound care, for the purposes of the assessment.

    Wound care

    Wound care is treatment for:

  • · A wound at any stage that require specific medical interventions to heal.
  • · Open lesions or sites that require specialized care.

    • Meets definition

    The person meets the definition if the wound is one or more of the following:

  • · Wound that requires sterile or clean dressing change.
  • · Wound that requires vacuumed-assisted closure (VAC).
  • · Stasis wound due to poor circulation pressure.
  • · Ulcer.
  • · Burn.
  • · Fistula.
  • · Tube site.
  • · Ostomy site.

    • Does not meet definition

    The person does not meet the definition if the wound is any of the following:

  • · Wound that does not require sterile or clean dressing change.
  • · Preventative skin care.
  • · Insect bite.
  • · Rash.

    • Respiratory interventions

    There are five categories of respiratory interventions, for the purposes of the assessment:

  • · Oxygen therapy.
  • · Respiratory vest.
  • · Bronchial drainage treatment.
  • · Sterile or clean suctioning
  • · Dependence on another to apply respiratory devices.

    • Oxygen therapy

    Oxygen therapy is a procedure that provides a person with supplemental oxygen.

    Meets definition

    The person meets the definition if they need at least one of the following:

    1. Daily supplemental oxygen therapy ordered by a medical practitioner that:

  • · Lasts for eight or more hours per day and/or night.
  • · Requires monitoring of oxygen saturation rate with directions for appropriate intervention(s).

    • 2. BiPAP or CPAP.

    Does not meet definition

    The person does not meet the definition for any of the following:

  • · Fewer than eight hours per day and/or night of oxygen therapy.
  • · Intermittent (i.e., as needed) oxygen therapy.
  • · Use of oxygen monitor or apnea monitor only.
  • · Nebulizer treatment.
  • · CPAP for snoring or sleep apnea only.

    • Respiratory vest

    A respiratory vest is a vest the person wears that vibrates to help loosen mucus.

    Meets definition

    The person meets the definition if they have a respiratory vest ordered by a medical practitioner that:

  • · Is required more than one time per day.
  • · Has a current order specifying the required frequency.

    • Does not meet definition

    The person does not meet the definition if they have a respiratory vest they no longer use.

    Bronchial drainage treatment

    Bronchial drainage treatment is a procedure to drain the person’s bronchial tube to allow for breathing.

    Meets definition

    The person meets the definition if they need bronchial drainage treatment that is required three or more times per day. This includes any method of postural drainage therapy (e.g., positioning with percussion, turning, postural drainage).

    Does not meet definition

    The person does not meet the definition if they require bronchial drainage treatment fewer than two times per day.

    Sterile or clean suctioning

    Sterile or clean suctioning is suctioning to clear the person’s respiratory tract of mucus.

    Meets definition

    The person meets the definition if they require any type of suctioning that is both:

  • · Required seven or more times per day.
  • · Performed through the mouth or a tracheostomy.

    • Does not meet definition

    The person does not meet the definition for suctioning:

  • · Fewer than 6 times per day.
  • · After nebulizer treatment.

    • Dependence on another to apply respiratory devices

    Dependence on another to apply respiratory devices means the person has a respiratory device they cannot use without assistance.

    Meets definition

    The person meets the definition if they need hands-on assistance to put on a respiratory device due to their disability or medical condition. This can include devices listed in this section, even if the person does not otherwise meet the definition for that specific device.

    Does not meet definition

    The person does not meet the definition if they need reminders about using a ventilation augmentation device.

    Catheter insertion and maintenance

    There are two subcategories of catheter insertion and maintenance, for the purposes of the assessment:

  • · Clean self-catheterization.
  • · Bladder irrigation.

    • Clean self-catheterization

    Clean self-catheterization is the insertion of a catheter into the person’s urethra to empty their bladder.

    Meets definition

    The person meets the definition if they use a catheter that is both:

  • · Required more than seven or more times per day.
  • · Internal.

    • Does not meet definition

    The person does not meet the definition for a catheter that is:

  • · Required fewer than seven times per day.
  • · External.

    • Bladder irrigation

    Bladder irrigation is a procedure to flush the bladder with sterile liquids.

    Meets definition

    The person meets the definition if the bladder irrigation is all of the following:

  • · Continuous.
  • · Prevents blood clot formation.
  • · Includes a sterile task.
  • · Used post-surgery.

    • Does not meet definition

    The person does not meet the definition if the bladder irrigation is not continuous.

    Bowel program

    There is one category of bowel program, for the purposes of the assessment.

    Bowel program

    A bowel program is a procedure for stimulating bowel movements for a person who cannot eliminate their bowels due to medical condition (e.g., spinal cord injury, paralysis).

    Meets definition

    The person meets the definition if the bowel program is both:

  • · Required three or more times per week.
  • · More than 30 minutes per intervention.

    • Does not meet definition

    The person does not meet the definition if the bowel program is:

  • · Required fewer than three times per week.
  • · 30 minutes or less per intervention.
  • · PRN (i.e., as needed) or a daily need for laxatives, suppositories or enemas.
  • · Colostomy and ileostomy care.
    Note: The person may meet the definition of the toileting ADL.

    • Neurological Intervention

    There are two subcategories of neurological interventions, for the purposes of the assessment:

  • · Seizure intervention.
  • · Swallowing disorders intervention.

    • Seizure intervention

    Seizure intervention is intervention during a seizure to keep the person safe.

    Meets definition

    The person meets the definition if all of the following are true:

  • · The seizures occur three or more times per week.
  • · The person has had a seizure within the last year.
  • · The person requires hands-on assistance to maintain safety before, during and after a seizure.

    • Does not meet definition

    The person does not meet the definition if they:

  • · Have seizures fewer than three times per week.
  • · Are seizure-free for one year or more, including if they are on medications.
  • · Do not require hands-on assistance.

    • Swallowing disorders intervention

    Swallowing disorders intervention is intervention required due to a swallowing disorder diagnosed by a medical provider so the person can eat and/or drink safely.

    Meets definition

    The person meets the definition if they require daily specialized assistance from someone to eat and/or drink. This includes:

  • · Support for swallowing disorders that are congenital, neurological, or trauma-related.
  • · Need for oral stimulation program.
  • · Special diet, including thickening agents due to the swallowing disorder.

    • Does not meet definition

    The person does not meet the definition if they:

  • · Do not require daily specialized assistance.
  • · Require stand-by assistance to observe for choking.
    Note: The person may meet the definition of the eating ADL.

    • Increased need to complete ADLs

    There is one category for increased need to complete ADLs, for the purposes of the assessment.

    Increased need to complete ADLs

    Increased need to complete ADLs means the person’s health interventions create an increased need for help to perform ADLs.

    Meets definition

    The person meets the definition if all of the following are true:

  • · The person meets the definition for six to eight ADL dependencies.
  • · The person has a significantly increased need for direct hands-on assistance and interventions in six to eight ADLs.
  • · The increased need is due a medical condition (e.g., muscular dystrophy, multiple sclerosis, cerebral palsy, stroke, brain injury, end stages of cancer, ALS).

    • Does not meet definition

    The person does not meet the definition if:

  • · The person does not have increased need for direct hands-on assistance and interventions in six to eight ADLs
  • · The need is not due to a medical condition.

    • Behaviors

    Definitions

    Level I behavior: Physical aggression toward self or others, or destruction of property that requires the immediate response of another person.

    Immediate response: Intervention required at the time of the behavior to prevent injury to self, others or property.

    Policy

    A person might be eligible for additional PCA/CFSS units if they have:

  • · Level I behavior.
  • · Increased vulnerability due to cognitive deficits or socially inappropriate behavior.
  • · Resistance to care, including verbal aggression that interferes with care completion.

    • For the purposes of the assessment, this includes behavior that is:

  • · Actually occurring.
  • · Prevented through redirection or positive behavioral supports.
  • · Intentional or unintentional.

    • The following is not considered a behavior:

  • · The need for a 24-hour plan of care and supervision due to age.
  • · Sibling rivalry/challenges, unless they meet the definition of the behavior.

    • Impact on eligibility

    Level I behaviors

    If a person has a level I behavior, they are eligible for PCA/CFSS. Their level I behavior helps determine their home care rating and base units.

    The frequency of the level I behavior might make the person eligible for additional time/units. If the level I behavior occurs at least four times per week, the person is eligible for an additional two units (i.e., 30 minutes) per day.

    Other behaviors

    A person is not eligible for PCA/CFSS based solely on other non-level-I behaviors. Their other behaviors do not help determine their home care rate.

    The frequency of other behaviors might make the person eligible for additional time/units. Each behavior that occurred at least four times in the last seven days adds two units (i.e., 30 minutes) to a person’s total time.

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