Personal Care Assistant (PCA) Policies and Procedures

PCA Provider Agencies are required by law to have certain policies and procedures. For starters, per PCA Agency Applicant Assurance Statement, DHS 6005, the PCA Provider agrees to have the following polices and procedures, which DHS will check during an on-site visit before enrollment (and also on a random periodic basis to check for compliance). Any violations of the following rules are grounds for termination of your enrollment and assessment of an over-payment (you have to pay DHS back, even if you paid the money to your employees.) DHS is generally very aggressive in their enforcement of these rules.

Employee Hiring and Termination Policy
_______ Employee application for employment
_______ Employee background study request and results
_______ Employee orientation about agency policies
_______ Evaluations of employee’s performance
_______ Employee’s signature on fraud statement

Recipient Grievance Policy
_______ Written plan for documenting recipient’s receipt of grievance/appeal process
_______ Internal grievance policy and procedures, including any outside resources to assist the recipient in filing a grievance or appeal
_______ Timelines for investigation and resolution
_______ Investigation procedures
_______ Resolution procedures
_______ Communication of resolution to recipient
_______ Grievances and Resolution Record (must be submitted at annual enrollment review) that include:
_______ Date complaint received
_______ Intake person (who received complaint)
_______ Description of grievance (what was reported)
_______ Date(s) investigated
_______ Name of investigator
_______ Investigation results
_______ Date of resolution
_______ Resolution of grievance, including any quality improvement changes
_______ Date resolution communicated to recipient

PCA Service Delivery
_______ Internal controls and processes about PCA service delivery, quality assurance and remediation action
Recipient and Employee Safety Practices
_______ Identification and prevention of communicable diseases
_______ Emergency contact and back-up plans
Training Requirements for Employees
_______ Required agency employee training (this training is beyond the training required by law, such as agency orientation training)
_______ Demonstration of competence
_______ Training timelines
Employee Misconduct
_______ Types of misconduct
_______ Types of discipline
_______ Procedures for disciplinary actions

Agency Business Templates
Agency business templates that include a PCA Timesheet and a Care Plan

PCA Timesheet Template
PCA timesheet template must include the following information:
Provider Information
_______ Provider name and telephone number
Recipient Information
_______ Recipient name and MHCP ID number or date of birth
Individual PCA Information
_______ Individual PCA name and UMPI
Dates of Service
_______ Date (MM/DD/YYYY) of each service, in consecutive order
_______ Dates (MM/DD/YYYY) and locations of recipient stays in a hospital, care facility, or detention center
Total Time
_______ Daily total time
_______ Timesheet total time
Service Information
_______ Arrival and departure time(s) of all visits, including AM and PM notations
_______ Shared services: ratio of PCA to recipients, locations and documentation per visit
Activities (all activities provided must contain the same or
similar categories as below):
_______ Bathing
_______ Behavior
_______ Dressing
_______ Eating
_______ Grooming
_______ Health Related
_______ Mobility
_______ Positioning
_______ Toileting
_______ Transfers
_______ IADLs (Instrumental activities of daily living)
_______ Light housekeeping
_______ Laundry
_______ Other

Care Plan Template
The agency care plan template may be a single document or combination of documents containing all of the
following information:
_______ Month-to-month plan of projected use of PCA units. Home health agencies must also include all required
PCA care plan elements if not already included in home health agency plan
_______ Start and end date of the care plan
_______ Recipient demographic information, including: name, telephone number

_______ Emergency procedures including:
• emergency numbers
• a description of measures to address identified safety and vulnerability issues
• backup staffing plan
_______ Name of responsible party and instructions for contact
_______ Description of the recipient’s individualized needs for assistance including:
• ADLs (activities of daily living)
• IADLs
• Health-related tasks
• Behaviors
_______ Dated signatures of recipient or responsible party and qualified professional
_______ Instructions and comments about the recipient’s needs for assistance and any special
instructions or procedures required
_______ A month-to-month plan for the use of personal care assistance authorized units
_______ A record of:
• Whether the recipient requested a PCA of the same gender
• If that request was successfully accommodated
• If not, the efforts made to accommodate that request

PCA Choice Agreement Template
PCA Choice agreement template (PCA Choice Providers only) that includes:
_______ Duties of the recipient, qualified professional, personal care assistant, and personal care assistance choice
provider agency
_______ Salary and benefits for the personal care assistant and the qualified professional
_______ Administrative fee of the personal care assistance choice provider agency and services paid for with that
fee, including background study fees
_______ Grievance procedures to respond to complaints
_______ Procedures for hiring and terminating the personal care assistant
_______ Documentation requirements including, but not limited to, time sheets, activity records, and the personal
care assistance care plan

Also, at a minimum, per the MHCP Provider Agreement (DHS 4138), the PCA Provider agrees to have policies and procedures to adhere to the following:

1. Furnish DHS, the Secretary of the U.S. Department of Health and Human Services (DHHS), or the Minnesota
Medicaid Fraud Control Unit (MFCU) with such information as it may request regarding payments claimed for
services provided under these programs.

2. Comply with all federal and state statutes and rules relating to the delivery of services to individuals and to the
submission of claims for such services.

3. Provide to DHS its National Provider Identifier (NPI) and include its NPI on all claims, if Provider is eligible for an
NPI.

4. Comply with all provisions of Minnesota Statutes 62J.536, which requires electronic transmission of claims, eligibility
and other transactions, using DHS’ secure, HIPAA-compliant, automated transaction tool MN-ITS.

5. Accept as payment in full, amounts paid in accordance with schedules established by DHS, except where payment by
the recipient has been authorized by DHS.

6. Enroll in electronic funds transfer (EFT) if Provider is a pay-to provider and if requested by DHS.

7. Ensure, when required by law, that a health service program administered by DHS is the payer of last resort by
ascertaining the legal and financial liabilities of third parties to pay for covered services, and pursuing such third party
payments.

8. Assume full responsibility for the accuracy of claims submitted to DHS in accordance with the certification
requirements of 42 CFR 455.18 and Minnesota Statutes 256B.27, subd. 2.

9. Submit claims at no more than Provider’s usual and customary fee to the general public and only after the medical
care or service has been provided, in accordance with Minnesota Rules 9505.0450, subp. 1.

10. Except for claims for services under a waiver program, submit claims only for services, supplies, and equipment that
are medically necessary as defined at Minnesota Rules 9505.0175, subp. 25, and that meet professionally recognized
standards of health care, that Provider knows or has reason to know are properly reimbursable under federal and state
statutes and rules.

11. Make full disclosure of ownership and control information as required by 42 CFR 455.100 – 455.106, and upon
request, full disclosure of business transactions, as is required by 42 CFR 455.105.

12. Make full disclosure of persons convicted of program crimes as required by 42 CFR 455.106.

13. Ensure that Provider, all of its owners, managers, employees and contractors are not excluded from participation in
Medicare, Medicaid or other federal health care programs, by searching the Office of Inspector General List of
Excluded Individuals/Entities (LEIE) at the time of enrollment, before hiring new employees or entering into a
contract with a contractor, and monthly to see changes since the last search. Provider must immediately report any
exclusion information discovered to DHS.

14. Verify recipient eligibility before rendering services.

15. Comply with all federal statutes, implementing regulations and guidance prohibiting discrimination on the basis of
race, color, national origin, sex, age, religion and disability in any program or activity receiving federal financial
assistance from DHHS.

16. Render to recipients services of the same scope and quality as would be provided to the general public, within MHCP
guidelines, in accordance with Section 1902(a)(10)(B) – (E) of the Social Security Act.

17. Comply with the provisions of any fully executed addendum required by DHS, which is incorporated with the
provider agreement (that is, the addendum becomes part of the original provider agreement).

18. Ensure that its employees and contractors comply with all MHCP requirements, including any requirements added
post-enrollment.

19. Comply with the advance directive requirements if provider is a hospital, nursing facility, provider of home health
care, personal care assistance services, hospice, or managed care organization (MCO), as required by 42 CFR 489.102
and 417.436.

20. Maintain records that fully disclose the extent of services provided to MHCP recipients for a period of five years after
the initial date of billing DHS, in accordance with Minnesota Rules 9505.2160 – 9505.2245, or for the duration of
contested case proceedings, whichever is longer.

21. Ensure proper handling and safeguarding by provider employees, contractors, and authorized agents of protected
information collected, created, used, maintained, or disclosed on behalf of DHS. For the purposes of this Agreement,
“protected information” means data subject to any of the laws described below in 21.A. This responsibility includes:
A. Ensuring that employees and agents of the provider comply with and are properly trained about:

(1) The Minnesota Government Data Practices Act (MGDPA), Minnesota Statutes Chapter 13, in particular
13.46 Welfare Data;

(2) The Minnesota Medical Records Act, Minnesota Statutes 144.291 – 144.298;

(3) The federal Health Insurance Portability and Accountability Act (HIPAA), including but not limited to the
requirements of the Privacy Rule and Security Regulations, 45 CFR 160 and 164;

(4) Federal law and regulations that govern the use and disclosure of substance abuse treatment records, 42 USC
Sec.290dd-2 and 42 CFR 2.1 – 2.67; and

(5) Any other applicable state and federal statutes, rules, and regulations affecting the collection, storage, use and
dissemination of private or confidential information.

 

B. Ensuring, consistent with the laws stated in 21.A, that the provider’s employees, contractors, and authorized agents:

(1) Do not use or further disclose protected information created, collected, received, stored, used, maintained or
disseminated in the course or performance of this Agreement other than as necessary to perform their
obligations under this Agreement, or as required by law, either during the period of this Agreement or
thereafter (respectively, 45 CFR 164.502(b) and 164.514(d), and Minnesota Statutes 13.05, subd. 3).

(2) Use appropriate administrative, physical, and technical safeguards to prevent use or disclosure of the
protected information other than as provided for by this Agreement and to ensure the confidentiality,
integrity, and availability of any protected health information that it creates, receives, maintains, or transmits
on behalf of DHS.

(3) Do not transmit PHI over the internet or any other unsecure or open communication channel unless such
information is encrypted or otherwise safeguarded using procedures no less stringent than those described in
45 CFR 164.312. If the provider stores or maintains PHI in encrypted form, provider shall, at DHS’ request promptly provide DHS with the key or keys to decrypt such information. Provider shall not forward previously encrypted data to any other party, unless otherwise required by this Agreement.

(4) Mitigate, to the extent practicable, any harmful effects known to provider of a use, disclosure, or breach of
security with respect to protected information by provider in violation of this Agreement.

(5) Make the required notifications upon discovery of a breach, as defined in 45 CFR 164.402, of unsecured PHI
to DHS, to each individual whose unsecured PHI has been breached, and, when the breach involves the
unsecured PHI of more than 500 people, to the media of a state or jurisdiction. See 45 CFR 164.400 – 414. 

22. Accept and be bound by the terms and conditions of DHS’ EDI Trading Partner Agreement when billing
electronically. Provider acknowledges that any organization or individual that submits claims on its behalf will abide
by the EDI Trading Partner Agreement as an agent of provider. Provider authorizes the agent to bind provider to the
terms of the EDI Trading Partner Agreement. Provider will give each EDI trading partner an individual login ID and
password.

23. For provider entities receiving or making Medicaid payments totaling at least $5 million annually, establish written
policies and procedures for the education of all employees, contractors and agents, that includes information about the
False Claims Act and other provisions named in Section 1902(a)(68)(A) of the Social Security Act.

24. Determine the applicability to provider of any other state or federal laws and ensure compliance with those laws.

25. Cooperate with DHS audit procedures.

26. Execute any required Assurance Statements and provide certification or licensure information if required by DHS for
a particular provider type. Provider also agrees to notify DHS of any changes to its certification or licensure status.

27. Comply with Minnesota Statutes 256B.0644 as a requirement of participation in other state health care programs.
Provider agrees to provide active caseload data upon DHS’ request and at least 10 days before limiting acceptance of
new MHCP recipients.

28. Refund any overpayments made to provider by DHS, including those resulting from payments made by Medicare,
third party payers, billing errors, fraudulent billing, and from increased interim payments made pursuant to DHS’ plan
for continuity of operations during times of pandemic and crisis.

29. Notify DHS no later than 30 days before the effective dater of a sale, merger, or transfer of an enrolled entity, in
accordance with Minnesota Rules 9505.0195, subp. 8. Failure to notify DHS may result in the sale or transfer not
becoming effective with DHS for any purpose, including claims processing, payment of claims and claims
adjustments. Provider also agrees to notify DHS whether it intends to transfer its National Provider Identifier (NPI) or
its Federal Employer Identification Number (FEIN) to the new owner and to complete any documentation or addenda
DHS requires, including a Provider Entity Sale or Transfer Addendum. Provider acknowledges that upon sale, merger
or transfer of the enrolled entity, DHS will recognize the effective date of the sale or transfer as the date from which all
claims payments or adjustments will be assigned to the new owner, without regard to date of service, date of
submission to DHS, or adjudication date, including those resulting from a later audit or reprocessed claims. Any
intent on the part of the provider or purchaser to the contrary must be addressed in the purchase agreement and
transfer documents and is the responsibility of provider and purchaser to enforce. DHS retains the right to pursue
monetary recovery, or civil or criminal actions against the seller or transferor. Nothing in this Agreement negates the
obligation of the new owner to contact DHS by the effective date of sale, merger or transfer.

 

These are just a highlight of the polices and procedures required to start a PCA agency. Holt Law provides representation in this area for a reasonable flat fee.

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