Abuse: means infliction of or intent to inflict physical pain or injury on or the imprisonment of any incapacitated adult or resident of a nursing home or other residential facility.
Adult Family Care Home: means a placement setting within a family unit that provides support, protection and security for up to three individuals over the age of eighteen.
Adult Family Care Provider: an individual or family unit that has been certified by the Department of Health and Human Resources to provide support, supervision and assistance to adults placed in their home for which they receive payment.
Adult Emergency Shelter Care Home: means a home that is available on a short-term, emergency basis for residential care type clients for whom no other appropriate alternatives currently exist, agreeing to accept placement on a twenty-four (24) hour basis.
Adult Emergency Shelter Care Provider: means an individual or family unit that has been certified by the Department of Health and Human Resources to provide support, supervision and assistance to adults placed in their home at any time on short notice.
Cognitive deficit: means impairment of an individual’s thought processes.
Emergency: means a situation or set of circumstances which present a substantial and immediate risk of death or serious injury to an incapacitated adult.
Incapacitated Adult: means any person who by means of physical mental or other infirmity is unable to independently carry on the daily activities of life necessary to sustaining life and reasonable health.
Neglect: means the failure to provide the necessities of life to an incapacitated adult or resident of a nursing home or other residential facility with the intent to coerce or physically harm such incapacitated adult or resident of a nursing home or other residential facility or the unlawful expenditure or willful dissipation of funds or other assets owned or paid to or for the benefit of an incapacitated adult or resident of a nursing home or other residential facility.
Personal Care Home: A group living facility licensed by the Office of Health Facilities and Licensure and Certification(OHFLAC) providing 24 awake supervision of activities of daily living.
Personal Care Home Provider: A individual, and every form of organization, whether incorporated or unincorporated, including any partnership, corporation, trust, association or political subdivision of the state licensed by OHFLAC as a Personal Care Home Provider.
Residential Board and Care Home: A group living facility licensed by the Office of Health Facility Licensure and Certification to provide accommodations, personal assistance and supervision for a period of more than twenty four(24) hours to four or more individuals.
Residential Board and Care Home Provider: Any person and every form of organization, whether incorporated or unincorporated, including any partnership, corporation, trust, association or political subdivision of the State licensed by OHFLAC to maintain and operate a RB&C.
Physical deficit: means impairment of an individual’s physical abilities.
Personal Care Homes (PCH) are residential settings for adults that provide supervision, support, protection and security in a group living setting. This may be an appropriate option for individuals who are no longer able to safely remain in their own homes due to physical, cognitive, and/or emotional deficits. Although an individual may be experiencing deficits in one or more of these domains, the deficits are not significant enough to warrant the level of care provided in a nursing home.
The Personal Care Home provider must be licensed by the Department of Health and Human Resources, Office of Health Facilities Licensure and Certification. Once licensed, the provider may provide care for the number of residents approved on their license. A Personal Care Home provider receives payment for the care provided. This payment may come from the client placed in the home, the Department or a combination of these two sources. A PCH may provide personal assistance to four (4) or more residents who may need limited and intermittent nursing care. This service is a direct hands-on nursing care of no more than two (2) hours of nursing care per day for a period of no longer than ninety (90) consecutive days per episode
Personal Care Home services and the associated services, including pre-admission evaluation, placement, supportive services, supervision and discharge planning, are available to adults who are no longer able to remain in their own home and require an alternate living arrangement requiring 24 hour awake care due to physical, mental, or emotional limitations. Eligibility for placement in this type of setting is not limited by type and amount of client income. Payment by the department, however, for placement in Personal Care Home is affected by the amount of income received by the client and the level of liquid assets available. Assets can not exceed the established level, currently $2,000. (See Payment and Comprehensive Assessment for detailed information). In order to be eligible to receive a supplemental payment from the department for Personal Care Home services, the individual must meet at least one (1) of the following criteria:
C he/she must be age sixty-five (65) or older;
C he/she must be at least eighteen (18) years of age and have an established disability or a disability may be established by a thorough evaluation and documentation of the person’s condition by a licensed physician and a determination by the social worker that this medical evaluation does indicate the need for supervised care; or,
C he/she be at least eighteen (18) years of age is currently receiving Adult Protective Service or APS Preventive Services from the department.
In the case of eligibility based on an active APS or APS Preventive Services case, Personal Care Home services must be needed to eliminate the abuse, neglect or exploitation that was verified during the APS investigation. Further, the identified problem area(s) and the use of PCH placement to address these must be documented in the client’s service plan.
Basic identifying information and detailed information about the client’s needs are to be
gathered during the Intake process. This information must be sufficient to determine the type of
services and/or assistance being requested, the specific needs of the individual, and other
relevant information. At a minimum, the following must be included:
C name of client;
C date of birth or approximate age of the client;
C social security number;
C client’s current living arrangements;
C household composition;
C physical address of client;
C telephone number of client;
C directions to client’s home;
C significant others - relatives, neighbors, friends;
C legal representative(s), if known;
C reporter/caller information, if different than client;
C type of service(s) reporter/caller is requesting;
C specific needs of the client;
C description of how needs are currently being met; and,
C other relevant information.
When the intake information is completed, the intake worker is to conduct a search to determine if the agency has had prior contact with the client. At a minimum, this search must include the FACTS system. When the search is completed the request to receive Personal Care Home services is to be forwarded to the appropriate supervisor for further action.
Prior to a client being considered for placement in an Personal Care home, the social worker must gain a thorough knowledge of the client, their needs, wishes, strengths and limitations. A comprehensive assessment is essential to gaining this level of understanding.
Upon receipt of the referral, the supervisor will review the information collected during intake. If the intake appears to meet the criteria for Personal Care Home (PCH) services, the supervisor will assign the referral to a social worker for additional follow-up, including completion of a Comprehensive Assessment. If the intake does not appear to meet the criteria for PCH services the supervisor may take one of four actions: C screen the referral out and take no further action; C screen the referral out for Personal Care Home and redirect the referral to another unit
within the department that is appropriate to meet the identified need(s); C screen the referral out and forward a referral to the appropriate entity(ies) outside of the department; or, C assign the intake to a social worker to contact the client and/or referent to gather additional information so a determination may be made.
Whenever a referral is screened out by the supervisor for any reason(s), the reason for the screen out must be documented in FACTS. Finally, if not completed previously by the intake worker, the supervisor is to complete a search of the FACTS system to determine if other referrals, investigations, and/or cases already exist for the identified client.
A thorough assessment must be completed for each individual who has requested to receive Personal Care Home Services and who is subsequently assigned to a social worker. In order to develop a detailed understanding of the client and their needs, the social worker must conduct a face-to-face contact with the client and complete the Comprehensive Assessment. Completion of the Comprehensive Assessment involves interviews with the client and other significant individuals. The information gathered is to be considered during the assessment phase and recorded on various screens in FACTS is outlined below. This information will then be used as the basis for the client’s service plan.
The Comprehensive Assessment must be completed within thirty (30) days following assignment of the case for assessment. Thereafter, completion of a new Comprehensive Assessment is not required. Completion of a new Comprehensive Assessment should, however, be considered whenever there has been a significant change in the client’s circumstance, functioning and/or needs.
Note: The Comprehensive Assessment form, when printed, will not necessarily reflect all of the information outlined in the following sections. It is, however, appropriate to gather all of the information as part of the assessment process.
A Comprehensive Assessment, including face-to-face contact with the client and development of the service plan, must be completed for each individual who is assigned for assessment for Personal Care Home services. This assessment must be completed within thirty (30) calendar days following the date the case is assigned for assessment.
a. Identifying Information
Demographic information about the client, their family and their unique circumstances is to be
documented. This includes information such as (not an all inclusive list):
C name;
C address (mailing and residence);
C telephone number;
C date of birth/age;
C household members;
C other significant individuals;
C legal representatives/substitute decision-makers (if applicable);
C identification numbers (SSN, Medicaid, Medicare, SSA Claim, etc.);
C gender/ethnicity;
C marital status; and,
C directions to the home.
b. Referent Information
Information about the person(s) making the referral is to be documented. With requests to receive Personal Care Home (PCH) services the client frequently will make the request on their own behalf. If this is the case, the social worker must indicate that this is a self-referral and documentation of additional referent information is not necessary. When the referent is someone other than the client, the information to be gathered must include but is not limited to the following:
C referent name;
C referent address;
C referent telephone number
C relationship to the client
C how they know of the client’s needs; and,
C other relevant information.
c. Services Requested
Document the specific service(s) being requested. This should include information such as the
following:
C the specific type(s) of assistance being requested;
C why assistance is being requested;
C how needs are currently being met; and,
C other relevant information.
d. Living Arrangements
Document information about the client’s current living arrangements. This should include
information about where the client currently resides such as the following:
C client’s current location (own home, relative’s home, hospital, etc.);
C is the current setting considered permanent or temporary;
C type of setting (private home/residential facility, etc.);
C household/family composition;
C physical description of the current residence (single family dwelling, duplex, townhouse,
apartment, retirement community, foster home, group home, nursing facility, etc.); C interior condition of the residence; C exterior condition of the residence; C type of geographic location (rural, urban, suburban, etc.); C access to resources such as family/friends, transportation, shopping, medical
care/services, social/recreational activities, religious affiliations, etc.
e. Client Functioning
Document information about the client’s current physical and medical conditions. This should
include information about the physical condition and description of the client during the face-to-
face contact as well as information about their diagnosed health status. Included are areas such
as:
C observed/reported physical conditions of the client;
C primary care physician;
C diagnosed health conditions;
C current medications;
C durable medical equipment/supplies used; and,
C nutritional status including special dietary needs, if applicable.
f. Mental/Emotional Health
Document information about the client’s current and past mental health conditions. This should
include information about how the client is currently functioning , their current needs and
supports, and his/her past history of mental health treatment, if applicable. Included are areas
such as:
C current treatment status;
C current mental health provider;
C mental health services currently receiving;
C medication prescribed for treatment of a mental health condition;
C prescribing/treating professional;
C observed/reported mental health/behavioral conditions; and,
C mental health treatment history.
g. Financial Information
Document information about the client’s current financial status. This should include information about the client’s resources and his/her ability to manage these independently or with assistance. The thoroughness and accuracy of financial information is especially critical for clients who will receive PCH services since the payment calculation and much of the individual agreement between the department, the client and the provider is created by FACTS based on this information. Included are areas such as: C financial resources - type, amount and frequency; C other resources available to the client (non-financial); C assets available to the client (can not exceed a maximum of $2,000 to be eligible for a PCH
supplemental payment); C outstanding debt owed by the client; C extraordinary expenses; C health insurance coverage; and, C information about the client’s ability to manage their own finances.
h. Educational/Vocational Information
Document information about the educational/vocational training the client has received or is
currently receiving. This should include information such as:
C last grade completed;
C field of study;
C history of college attendance/graduation; and,
C history of special licensure/training.
i. Employment Information
Document information about the client’s past and present employment, including but not limited to sheltered employment. Information should include:
C current employment status;
C current employer;
C type of employment; and,
C prior employment history.
j. Military Information
Document information about the client’s military history, if applicable. This should include
information such as:
C branch of service;
C type of discharge received;
C date of discharge; and,
C service related disability, if applicable.
k. Legal Information
Document information about the client’s current legal status. This should include information
about all known legal representatives, and the specific nature/scope of that relationship. This
should include information such as:
C assessment of the client’s decision-making capacity by the social worker;
C information about legal determination of competence, if applicable;
C information about efforts to have the client’s decision-making capacity formally
evaluated; and, C identification of specific individuals who assist the client with decision-making.
When the Comprehensive Assessment is completed, all the information and findings are to be documented in FACTS. This, along with the service plan that was developed as a result of the assessment findings, is then to be submitted by the social worker to the supervisor for approval.
It is important for the social worker to complete a thorough assessment of the client in order to determine if Personal Care Home (PCH) is an appropriate placement option. If so, a client who is being considered for this type of placement setting must meet the following criteria. They must be: C in need of supportive living in order to remain in or return to a community living setting; C able to care for his/her own personal needs such as bathing and dressing with minimal
assistance or has the capacity to develop these skills with training from the PCH provider and/or other professional;
C alert and stable enough to be able to express their wishes regarding their living arrangements and able to participate in planning for their needs or has been determined by a medical professional to be in need of PCH and able to benefit from placement; C able, or have a legally appointed representative who is able, to understand what PCH is
and expresses a desire for this type of placement; C willing to contribute to their cost of care to the extent possible; C unable to live alone as a result of physical or mental incapacity; C no other suitable living arrangements are available; C able to meet the established admission criteria for the facility being considered; and, C free from communicable disease that would endanger the health of others.
In addition, they must NOT:
C be incontinent at time of admission or,
C be dangerous to themselves or others (“dangerous” means a person who currently exhibits or has
exhibited behavior that can or is likely to result in infliction of injury or damage to other persons or property)
Once a client has been opened as a recipient of Personal Care Home services (PCH) through the
department, various case management activities must occur. These include tasks such as:
C advising the client of their approval to receive PCH services;
C location and selection of an appropriate provider;
C arranging pre-placement visits with the potential PCH provider(s) when appropriate;
C arranging placement of the client in the PCH;
C explaining the payment process to both the client and the provider;
C completing all documentation in FACTS necessary to generate the Payment Agreement;
C review the Resident Agreement for Participation with the client and secure the required
signatures; C review the completed Payment Agreement with the client and the provider and secure all necessary signatures; C in conjunction with the client, the provider and other appropriate parties, develop the
service plan; C arrange for additional services for the client and/or provider as appropriate; and, C review and monitor the case as required, making modifications and changes as indicated.
When placement of an adult in a Personal Care Home (PCH) is being considered, it is important to consider both the needs of the client and the characteristics of the PCH. The success of the placement often depends on how good a “match” there is between the client, the provider and other residents of the PCH. Careful consideration of these factors prior to placement can facilitate a successful placement and minimize placement disruptions later.
The successful placement of a client in a Personal Care Home (PCH) will depend largely on assuring a good “match” between the client being placed and the provider. In order to ensure as good a match as possible, the social worker must evaluate the client in the following areas:
| C | current physical health status and medical history; |
| C | current mental/emotional/cognitive status and history; |
| C | individual or special needs as viewed by the client, the physician, and the social worker; |
| C | the client’s expressed wishes regarding his/her living arrangements; |
| C | family, friends and community ties - who these individuals are, where they are located, |
| and assistance they are willing to provide to the client; | |
| C | family experiences of the client such as the kind of home life he/she had and attitude |
| toward any remaining family; | |
| C | educational and employment history; |
| C | religious preferences, interests, hobbies, likes and dislikes, and personal habits; |
| C | household possessions or pets and plans for what will be done with these; |
| C | physical appearance and personal characteristics (e.g. neat/untidy, withdrawn/outgoing); |
| C | behavior problems that are currently present or that have been present in the past; |
| C | problems with any prior placement; |
| C | unusual habits that could be problematic for a provider; and, |
| C | financial resources such as income, medical insurance and assets. |
| 2. | Placement of Clients Being Discharged From a State Institution: |
Individuals who have resided in a state operated facility for an extended period of time will face some unique challenges as they adjust to a Personal Care Home (PCH) setting. In order to ensure a smooth adjustment, it is important for the PCH provider to be aware, not only of the client’s needs, but also of the prior routine and personal habits to which the client has become accustomed. A gradual transition from the familiar routine to a new setting and new routines will make for a smoother and more successful transition to the Personal Care Home.
Because of these unique considerations, clients who are being discharged from a state operated facility for placement in an PCH must meet certain additional requirements before placement will be arranged. Specifically, the discharging facility must arrange for the completion of 1) a thorough current medical history, including both physical and mental health histories and 2) a thorough social history, including a description of the client’s routine at the discharging facility. These reports are to be completed by a representative of the discharging facility who is familiar with the client’s daily habits and activities while they have been placed in the facility. Upon completion, the reports must be submitted to the department along with a request for placement
Effective June 2001 Page 10 of 86
in an PCH setting. The department and the discharging facility are to work in cooperation to arrange a trial visit at the proposed PCH.
A trial visit between the client and the prospective Personal Care Home (PCH) provider should be arranged whenever placement is being considered, prior to making permanent arrangements. This provides the social worker, the potential provider and the client the opportunity to evaluate the client-provider match and the client’s suitability for placement in a PCH setting. Whenever the client is being discharged from a state operated mental health facility to an PCH, a trial visit is required. In this situation, the client is not to be fully discharged from the facility until they are stabilized in the PCH setting.
For adults who are coming from a setting other than a state operated mental health facility, the social worker is responsible for the following tasks in preparation for the trial visit: C provide a summary of the client, his/her needs, and other required information to the
prospective PCH; C consult with the receiving county to arrange/coordinate the trial visit; C arrange transportation of the client to the prospective PCH; C arrange an adequate supply of medication for the client during the visit; and, C arrange for payment of the PCH provider for the trial visit. For adults who are coming from a state operated mental health facility, these tasks are to carried out the jointly by the DHHR social worker and the discharge planner or other appropriate staff from the facility.
Following the trial visit the social worker is to confer with the client and the provider individually to determine whether or not the placement is suitable. Results of the trial visit must be documented in FACTS and the results reported to the social worker in the receiving county. If both the client and the provider agree to making the placement permanent, all documentation and case activity must be completed in FACTS by the social worker in the sending county. Upon completion and approval by the sending county supervisor, the case may be transferred to the appropriate supervisor in the receiving county. The case may then be assigned to a social worker for ongoing case work activity. (See also Case Management - Transfers for detailed information about the case transfer process).
If the client is coming from another county or is being discharged from an institutional setting, the sending county/discharge planner must provide the social worker in the receiving county with written, detailed summary of the client’s characteristics and needs, prior to arranging a trial visit. This summary must include the following information, at a minimum: client identifying information, description of client’s current functioning, areas of need, description of support/assistance required, strengths, limitations, medical and psychological history, current medical/psychological needs, explanation of why placement is being sought, and other relevant information. For clients currently receiving adult services from the department, the completed Comprehensive Assessment in FACTS may be used to meet this requirement.
For clients who are being discharged from an institutional setting, it is essential that the social worker receive thorough and accurate information regarding the client, his/her functioning and their needs prior to placement. Upon receipt of this information, the social worker must discuss the client and their needs with the prospective provider. In doing so the social worker is to prepare the provider for accepting the client for the trial visit and possible placement. In addition, clients who are coming from an involuntary commitment in a state operated mental health facility are required to be released from the mental health facility on convalescent status and placed on a provisional basis in the Personal Care Home (PCH). This provisional placement may last for a period of up to six (6) months. The purpose of the provisional placement with this population is to ensure a smooth transition from the institutional setting to the community and to facilitate the return of the client to the institution in the event of a failed placement without requiring another hearing before the mental hygiene commissioner. Upon completion of a successful provisional placement, the client may be fully discharged from the mental health facility and permanently placed in the PCH. In no instance shall the department authorize placement in a PCH for an institutionalized client who is fully discharged from the institutional setting on the date of initial placement in an PCH.
OHFLAC licensure requirements for PCH requires a health assessment by a licensed physician or other health care professional not more then forty-five (45) days prior to admission or no more than five (5) working days following admission and at least annually thereafter. Completion of this assessment serves two purposes. First, it documents the current health status of the client and second, it indicates that the resident is free of communicable diseases to the best of the physician’s knowledge.
There may be situations when an individual is in need of the level of care available in a Personal Care Home (PCH) setting but his/her financial resources exceed the determined cost of care. These types of placement will be handled as private pay arrangements and the payment arrangements are to be made by the individual or his/her family. In situations where the individual is not capable of making these arrangements independently and has no relative or interested party who can or will make the arrangements on his/her behalf, the department may assist in arranging the private pay placement. The procedures regarding placement in an approved PCH are applicable when placing an individual for whom there will be no supplemental payment made by the department. The differences are as follows:
C In private pay arrangements, the department shall not be a party to the payment
arrangements between the client and the PCH; C clients who are placed in PCH as a private pay placement are not eligible for special
medical authorization to cover medical expenses for which they may have no coverage
unless a policy exception is granted by the Office of Social Services (See Special
Medical Authorization and Exceptions to Policy for detailed information; and, C when the department is not making a supplemental payment, the adult residential service
case is to remain open if the department is providing case management or other
supportive services. If no other services are being provided by the department, the adult
residential services case is to be closed.
The social worker should inform the client and provider about possible benefits that may be available at the time placement is being arranged or approved by the department. Once the initial placement is made, the social worker is to assist in arranging social services as needed. The business arrangement between the client and the provider concerning payment is not the social worker’s responsibility. It must be made clear to the provider at the time of placement that the payment arrangements for private pay clients is a private arrangement and the department will not provide payment to the provider in the event the client or his/her representative fails to make payment as agreed.
At the time of placement of the adult in the Personal Care Home (PCH) is completed, the social worker must send/ensure notification of the placement to certain parties. Specifically, if the adult is receiving any services through Office of Family Support (e.g. Food Stamps, Medicaid, Emergency Assistance, etc.), written notification is to be provided advising that office/unit of the placement. This notification is to be done using the Interdepartmental Referral Form (DHS-1) and must include the type of placement the client resides in, the date placement became effective, the client’s new address and telephone number, client identifying numbers such as SSN, SSA Claim number, Medicaid number, etc., the name of the provider, and the monthly amount paid by the client to the provider for his/her care.
Also, notification of the client’s change of address and living arrangements must be sent to all of the client’s sources of income. This notification may be done by the client, the provider, or another responsible party. The social worker, however, should follow up with the individual designated to provide this notification to ensure that this is done promptly. If not handled promptly, problems may result in the provider receiving payment from the client in a timely manner. In the event the social worker sends this notification, the Interagency Referral Form is to be used.
Note: The social worker should encourage the client and/or provider to complete a “Change of Address” card with the with the appropriate post office.
During the first several weeks following placement, the client and provider will need regular guidance and support from the social worker to ensure a smooth adjustment. The social worker is to maintain regular contact with the client and provider during this adjustment period to monitor the client’s and the provider’s adaptation to the new placement and to assess the client’s functioning in the PCH. At a minimum, the social worker must conduct a visit to the facility when the client first arrives, and a follow-up visit within one (1) week following placement. Thereafter for the first six (6) months, visits are to be conducted on a regular basis. The frequency of visits should be determined by the level of support and contact needed by the client and provider in order to facilitate a smooth adjustment and, to resolve any problems that arise in a timely manner. Depending on the individual needs, this visitation may be conducted weekly, bi-weekly, or monthly. Contact during the first six (6) months must be made at least once every month.
9. Resident Agreement for Participation:
At the time of placement, a Resident Agreement for Participation must be completed. In order to complete this document the social worker must review the terms of participation with the client. To participate in the Personal Care Home services offered by the department, the client must be willing to agree to the terms set forth and to signify his/her agreement by his/her signature. If the client has a legally appointed representative, this individual must sign on the client’s behalf. After obtaining the signature of the client or his/her representative, the social worker is to sign on behalf of the department. A copy of the signed document is to be provided to the client and/or their representative. The completed document is then to be filed in the client’s case record with a notation in FACTS as to the location of the original signed document.
Note: The Resident Agreement for Participation is available as a merge document on the hard drive of your PC (C:\).
10. If the PCH Placement Fails:
It is essential that the social worker carefully consider the characteristics and needs of the client and the characteristics and resources of the provider in order to ensure as good a match as possible. If, after placement, problems arise, the social worker will recommend/encourage the provider to arrange the assistance and/or training necessary to enable them to furnish appropriate care to the client. If these efforts are unsuccessful and the arrangement remains unworkable, the social worker may assist in placement of the client with another provider who is better able to address the client’s needs.
As part of the process of arranging the new placement, the social worker must include a trial visit with the prospective new provider whenever possible. (See policy section on Trial Visits for detailed information) After a successful match is found and the client is placed with a new provider, the social worker must monitor the new placement carefully. While it is important to maintain regular contact with both the provider and client during the weeks immediately following any placement, this is especially important when the placement has occurred as a result of a failed placement in another setting. Regular contact with the client and provider will ensure the support and opportunity necessary to promptly identify problems, should these occur, and seek appropriate resolution.
B. Payment by the Office of Social Services
Providers of Personal Care Home (PCH) services may receive reimbursement from the department in two ways, automatic payment and demand payment. Reimbursement to the provider for the care and supervision furnished to the client will be done by automatic payment, in accordance with the term of the Payment Agreement in effect.. Demand payments are available for a very limited and specific set of expenses that may occur in the PCH setting.
1. Rate of Payment:
Personal Care Home (PCH) providers are paid a flat rate for the care and supervision furnished to each adult placed in the facility by the department. An additional payment of up to $100 may be made for each individual placed by the department who has been determined to be Hartley eligible. The payment is calculated by FACTS and is based on a variety of information entered in the system by the social worker. Key areas used in calculating the rate of payment include: C employment information, including sheltered employment; C income and asset information; C debt and expense information; and, C Hartley eligibility. Complete and accurate documentation in each of these areas is essential in determining the rate of payment. This information must be entered before calculation of the payment can occur and before the Payment Agreement can be created.
In unique situations the client may be allowed to keep a portion of his/her monthly resources
rather than using these to pay for his/her care. Granting a resource deduction may be considered
only when the following criteria are met:
C client has a special need (if a medical need - must be documented by their physician);
C granting the deduction would prevent the client from moving to a higher level of care;
and, C there are no other resources to pay the costs for which the resource deduction is being
granted. When it has been determined by the social worker that these three criteria are met, the social worker may show that a resource deduction is being granted by completing the required information on the debt/expense screen of FACTS. Whenever a resource deduction is being granted, the expense that the deduction is allowed for, the amount of deduction to be allowed, and the reason(s) the resource deduction is being granted must be documented. Completion of the debt/expense information is required as part of the process to create a Payment Agreement. When completed, the social worker must submit the debt/expense information along with other information required to create a Payment Agreement to the supervisor for approval.
Upon receipt, the supervisor must review all applicable information prior to approving the Payment Agreement. (See Payment Agreement for detailed information about creating the Payment Agreement) In addition to approval by the supervisor, resource deductions also require approval by the Office of Social Services (two-tiered approval). The Payment Agreement can not be generated by FACTS until the required approval(s) are done.
Some examples of situations for which the social worker may consider granting a resource deduction are:
1) Example: a client in a PCH who, according to a physician’s statement, must take numerous/expensive medications or use medical supplies that are not reimbursable by Medicaid, other insurance carrier, or special medical authorization. A resource deduction may be considered to allow the client to retain the portion of their income necessary to purchase these medications/supplies. The balance of their income, after this deduction, would then be applied to payment of their cost of care.
Example #1:
Total monthly income ..............................................$512.00
Personal Expense Allowance ....................................$ 61.00
Un-reimbursable medication expenses ......................$150.00
Resource deduction granted .....................................$150.00
Disposable income to be applied to care ...................$301.00
2) Example: a client is temporarily placed in a PCH while recovering from an illness. The client is unable to manage without some assistance but according to their doctor’s statement, prognosis
Effective June 2001 Page 16 of 86
for full recovery and return home is very good. Anticipate return home in 3 months. Client needs to continue to pay utilities until return home to avoid termination of services and re-connect fees. In this case the social worker should negotiate with the various utilities before requesting a resource deduction to see if they will offer a reduced rate for these types of situations. In addition the social worker should explore other resources for assisting with these payments. If no other resources are available, a resource deduction could be requested as outlined in the example below:
Example #2:
Total monthly income ..............................................$512.00
Personal Expense Allowance ...................................$ 61.00
Total monthly utility expense ...................................$100.00
Discounts/church assistance available ........................$ 75.00
Resource deduction granted ......................................$ 25.00
Disposable income to be applied to care ...................$426.00
(Note: As shown in example #2, it is not necessary to grant a resource deduction for the full “monthly payment amount”)
The personal expense allowance is the amount a client placed in a Personal Care Home (PCH) is permitted to retain from the total monthly income they receive in order to meet their personal expenses. The amount of the personal expense allowance is established by the Office of Social Services and may be adjusted periodically. All clients placed by the department in a PCH shall receive the full personal expense allowance amount each month or have this amount readily available for their use.
Note: OHFLAC regulations require a PCH to set up an accounting system so as not to co-mingle residents funds with the facility funds. If the resident’s fund exceeds two-hundred dollars ($200), these funds shall be deposited for the resident in an interest bearing account at a local bank. The resident account record shall show in detail, with supporting documentation, all monies received on behalf of the resident and the disposition of all funds received. Persons shopping for the resident shall provide a list showing a description and price of items purchased if the purchase exceeds $10.00, along with payment receipts for these items. This record must be available for review by the department at any time and by the resident at least quarterly.
The client may use his/her personal expense allowance to purchase any item(s) they choose so long as the purchases do not conflict with established house rules or regulations applicable to operation of a PCH. The allowance must be available to the client and used as he/she desires. The personal expense allowance shall NOT be used to obtain basic necessities such as food, clothing, shelter costs, medication, transportation, or medical care unless it is the desire of the client to do so.
Examples of items that may be purchased with the personal expense allowance, if the client so
desires, include:
C tobacco products;
C extra clothing;
C jewelry;
C radio or television;
C games, books and other recreational items of unique interest to the client;
C postage stamps and stationary;
C cosmetics;
C pre-need burial trust fund;
C hair styling/permanents;
C hair spray, cologne, aftershave; and,
C hair care above and beyond the basic care that must be provided to maintain c