Overview of the PCA Program, People & Fraud

WHAT ARE PERSONAL CARE SERVICES (PCS)?

Personal Care Services (PCS) is a non-medical benefit that helps participants with everyday tasks. These tasks are called activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

Examples of ADLs

·        Bathing

·        Eating

·        Going to the toilet

·        Dressing

·        Walking

Examples of IADLs

·        Laundry

·        Light housework

·        Fixing meals

Personal care services provide specialized, non-medical assistance to seniors and disabled individuals. Caregivers assist with homemaking and personal activities, allowing care recipients to continue living comfortably and safely at home.

Personal care assistances (PCA) assist participants with activities of daily living, which may be difficult or dangerous for the client to perform on their own. Here is a brief overview of areas where personal care providers can help.

·        Dressing

·        Grooming

·        Hygiene

·        Bathing

·        Toileting

·        Mobility

·        Transference

·        Medication reminders

·        Meal planning

·        Meal preparation

·        Light housekeeping

·        Shopping

·        Errands

·        Monitoring

·        Companionship

In addition to caring for elderly adults, personal care assistants also work with disabled individuals and those recovering from illness, injury, or a hospital stay. Through personal care, day-to-day life can be made safer, more comfortable, and more livable for these individuals.

QUALIFICATIONS OF A PCA WORKER

To qualify as a PCA you must be at least 18 years of age, must demonstrate the ability to work well with the aged and disabled individuals, possess a valid state issued ID, must maintain current first aid and CPR certification, be physically able to perform the job tasks required, be free of communicable disease, have interest and empathy for people who are ill, elderly, or disabled, be emotionally mature and able to respond to participants and situations in a responsible manner, have good communication skills, must not have been convicted of a crime related to dependent population.

The responsibilities of the PCA include providing personal care, for example, mouth and denture care, shaving, finger and toe nail care, grooming hair, shampooing, combing, oiling, bathing or bed bath or shower, helps with dressing, help with toileting, reminds waiver participant to take medication, helps with eating, transferring or changing the participants position, helps in ambulation.

The PCA also provides housekeeping task such as, assures rooms are clean and in order, prepares shopping lists, purchases and stores groceries, prepares and serves meals, laundering, ironing, sweeping, mopping, and dusting, run errands, provide assistance during community outings, vacuum, clean stove, refrigerator, washer, dryer, and small appliances, changes linen and makes the bed, cleans the kitchen, including washing dishes, pots, and pans.

REQUIRED TRAINING

PCA must have CPR and First Aid certification. Additionally, PCA must successfully complete an annual curriculum training course covering Vulnerable Persons Act, Participant Rights and Dignity, Crisis prevention and intervention, how to deal with difficult participants, HIPPA Compliance, safety, professional documentation practices, emergency preparedness, universal precautions and infection control and person-centered thinking. All training shall be scored to ensure PCA has retained training information.

DELIVERY CHARACTERISTICS

The PCA worker must be available as needed and flexible to meet the participants needs. PCA’s must wear safety items such as gloves and partial facial masks when needed to prevent spread of infections or diseases. All PCA’s must wear uniforms that may consist of a smock top, a hospital scrub suit, lab jacket, apron, or other designated uniform. PCA must maintain a clean, neat appearance always. Nails must be clean, neat and short in length. PCA staff must wash their hands before and after encountering participants. The PCA staff must wear in plain view an identification badge or picture ID that contains their name, providers name and title. In the absence of regularly scheduled staff, the participant should be offered immediately replacement staff. PCS services cannot be provided by anyone who resides in the home with the participant regardless of relationship.

PROHIBITED SERVICE ACTIVITIES

The PCA may not:

·        Use the participants car or transport the participant

·        Consume the participants food, drink, or medication

·        Use the participants telephone for any reason other than an emergency or PCA related activities

·        Engage in the discussion of personal problems, religious or political beliefs with the participant/caregiver

·        Breach the participants confidentiality

·        Accept any gifts or tips

·        Bring friends, relatives, or other guests to the participants home

·        Engage in consumption of alcoholic beverages in the participants home or consumption of alcoholic beverages before or during service delivery to the participant

·        Smoking in the participants home

·        Soliciting money or goods from the participant/caregiver

·        Performing or engaging in yard maintenance

·        Performing or engaging in pet grooming

·        Performing or engaging in household repairs

·        Administering medication

·        Using illegal drugs

·        Using abusive language in the participant home

·        Engaging in sexual misconduct with the participants or others residing in the home of the participant

·        Performing PCS for individuals in the home other than the participant

·        Engaging in heavy cleaning such as, hanging or laundering curtains, waxing floors, or moving heavy furniture.

DOCUMENTATION

The PCA shall note on the record of contact all factual observations, contacts, or visits with the participant, and actions or behavior displayed by the participant. This documentation is essential in determining if changes should be made in the service plan. It is also essential to show that certain tasks were performed on certain dates and times.

MEDIKEY-ELECTRONIC VISIT VERFICIATION

Medikey is an electronic visit verification system. The system automates the manual processes associated with provider submission of claims. The system is utilized by the PCA to clock in an out by calling into an automated visit verification system via the beneficiary’s telephone land line. Beneficiaries without reliable land lines are assigned a one-time password (OTP) device that staff will use to clock in and out. The visit verification line will recognize if a device has been assigned and prompt the caller with instructions.

PCA is prohibited from removing the device from the home of the participant. Removal of the OTP device from the person’s home will result in the providers inability to be paid. A PCA guilty of removing the device is committing Medicaid fraud.

The PCA must obtain and document the OTP codes designating service start and end times while in the home of the participant, if not utilizing the person’s telephone land line to substantiate services billed including the units of service.

PCA shall never exceed hours assigned to them.

PCA Process

Services begin with the person. People who may receive PCA services include children, adults and elders. An assessor completes an assessment of the person's strengths and needs to identify what supports are needed. The assessor works with the person or responsible party to develop a service plan for the different supports the person may need.

A responsible party provides guidance when a person is not able to direct personal needs. The responsible party signs timesheets and assists with any decision-making daily. All persons under age 18 must have a responsible party. The assessor determines if a responsible party is needed at the time of the assessment.

Selecting an Agency

The person or responsible party chooses the agency that will provide the PCA services after the service plan is complete. A Personal Care Provider Organization (PCPO) is an agency that will assign a PCA to the person. A PCA Choice Agency gives the person or responsible party the option to hire and train the PCA. The PCA then becomes and employee of the PCA Choice Agency.

The agency provides training to the PCA on billing and agency rules. The PCA must follow the agency rules, policies and procedures.

Care Plan

The agency has a qualified professional (QP) to oversee the care plan of each person. The qualified professional works with the person or responsible party to develop a care plan that details each service that will be provided including:

·        How the services will be delivered.

·        When the services will be delivered.

·        Where the services will be delivered.

·        Who will deliver the services?

There are many people who are part of the team. Besides the assessor who provides the assessment, the PCA agency and a qualified professional (QP), have specific roles to play. The person may also have help from family and friends. Other services providers include:

·        Nurse

·        Social Worker

·        Personal Care Assistants

Most often, PCAs provide support to an individual in the person's home. PCAs may also provide services at the person's place of work or other places the person might go to be involved in community life.

Roles and Responsibilities

A PCA is a person who performs and assists with routine tasks of daily living for persons with disabilities and special health needs. These are tasks the person would perform if able. In general, you rule as the PCA, is to assist a person to be as independent as possible. PCA duties fall within four categories of services.

1.      Activities of daily living (ADLs).

2.      Health related procedures and tasks.

3.      Observation and redirection of behaviors.

4.      Instrumental activities of daily living (IADLs) for people 18 years and older.

1. Activities of daily living (ADLs) include the following:

·        Bathing

·        Dressing

·        Eating

·        Grooming

·        Mobility

·        Positioning

·        Toileting

·        Transfers

2. Health related procedures and tasks - Licensed health care professionals may assign PCAs to complete certain health related tasks for people under state law. The qualified professionals must be a registered nurse (RN) when the PCA is doing health-related procedures and tasks.

3. Observation and redirection of behaviors - PCAs may be required to observe and monitor the behavior of people. PCA may do verbal redirection.

4. Instrumental activities of daily living (IADLs) for people 18 years and older - PCA services may be used for assistance with IADLs if the person has been assigned help with ADLs in the care plan. IADLs include:

·        Accompany to medical appointments

·        Accompany to participate in the community

·        Assist with paying bills

·        Communicate by telephone and other media

·        Complete household tasks integral to the PCA services.

·        Plan and prepare meals

·        Shop for food, clothing and other essential items.

A PCA may accompany a person to a community activity if the activity is included in the care plan. Accompany means to "ride along" if the person uses public transportation and will need help upon reaching the location. PCA agencies must approve any other transportation prior to the event. There is no PCA reimbursement for mileage for transportation.

Role of the Qualified Professional (QP)

PCA Agencies employ qualified professionals (QP) to supervise the delivery of PCA services. The agency matches a person's needs to a qualified professional who has experience in that area. For example, the qualified professional might be a nurse, social worker or a person trained to work with people who have developmental disabilities.

The qualified professional works with the person or responsible party to detail the tasks of the PCA. The PCA should assist only when the person requests or needs help to perform the task. The person should do as many tasks personally as possible.

The qualified professional answers PCA questions about the care plan and offers methods for completing tasks. The qualified professional also helps the PCA to work with others who provide services and supports for the person. Additional responsibilities of the qualified professional include:

·        Communication with doctors, assessors and the PCA Agency

·        Observation and supervision of the PCA

·        Providing additional training and guidance to the PCA when needed

·        Monitoring of the person's care plan and determining if changes are needed.

Qualified Professional (QP) is a skilled person who provides oversight of PCA services and PCAs. The QP supervises the PCA in the delivery of these services based on the care plan.

Role of family members and friends

Family and friends may play important roles in the care of a person you are supporting. PCA can expect to work cooperatively with family and friends when this type of "circle of support" exists.

The PCA is a family member

If you are providing PCA services to a family member, you may realize that it is difficult to tell where one role starts, and the other role stops. Other family members may also be confused about these dual roles.

Talk the situation over with the person you are assisting. Work together to establish clear boundaries for when you are working as a PCA and when you are "off duty" and are responsible for your role as a family member.

Being clear about the expectations for each role will save on confusion, frustration and even conflict. When problems occur, talk through and resolve the issues. Ignoring problems and hoping for improvement causes more problems in the long run.

Responsible Party (RP) is a person who can make choices for a person getting PCA services. The RP is the decision- maker when the person is unable to direct his or her own care. An RP helps a person to live in the community rather than a facility.

Importance of choice and independence

Individual choice and independence is critical to the health and well-being of each of us. Each person you work with should be encouraged to do daily tasks as much as each person can. Personal choices include:

·        How personal cares are done

·        How time is spent each day

·        When personal cares are done

Independence helps an individual to:

·        Oversee daily life

·        Feel good about daily accomplishments

·        Stay active both mentally and physically

Do not assume the person needs your help. Practice patience. Many times, a task will take longer if the person does it alone. Offer your assistance when necessary but allow the person to make the decision to accept your help. Using the word "assistance" instead of "help" encourages independence and a sense of accomplishment when the task is completed.

Consumer Role - A consumer is a person who needs and uses PCA services.

Recipient is a person who uses the products, goods or services.

Assessor Role

Once these are identified for the person, we can provide or develop needed supports and services. The Assessor is a skilled person from the lead agency who has the training to assess a person's need for services, such as PCA. The assessor identifies:

·        A person's strengths, preferences, functional skills and need for support and services.

·        The extent to which natural supports and informal providers can meet the person's need for support and services.

·        The extent to which human services agencies and providers can provide or develop needed support or services.

Communications

Communication is one of the most basic skills we learn in our lifetime. However, learning to communicate effectively takes a bit of time and effort. Communicating well gives you an opening to learn about a person and build trust. You gain knowledge of the person's personality, needs, likes and dislikes.

To communicate well, you need these skills:

·        Listening

·        Asking good questions

·        Observing non-verbal communication

·        Speaking openly and honestly to solve problems

·        Accepting feedback

Listening - You may be hearing what the other person is saying, but are you really listening? Listening involves not only hearing but doing your best to understand what the person means. You can practice being a good listener by using these techniques:

·        Ask questions to clarify

·        Be patient and avoid interrupting the speaker

·        Focus on the speaker with your full attention

·        Pay attention to non-verbal communication

·        Show that you are listening by nodding in agreement, asking questions and repeating key ideas

Asking good questions - Some questions you ask seeking a quick response such as "Shall I shut the door?". This type of question gets you a yes or no but does not encourage communication. When you want to learn more about a person's needs, you ask open-ended questions. Questions such as "How do you like to get ready in the morning?" are important so you learn the person's preferences and needs rather than doing things as you would in your own home.

Observing non-verbal communication - You use non-verbal communication whenever you smile at someone, wave your hand or use your finger to point at something. We also communicate non-verbally by choices in our clothing; how we open and shut the door; or by slumped shoulders or a raised eyebrow. Often, we do not realize we may be sending a message to another person.

Look for non-verbal cues in others, especially the people for whom you provide PCA services. Be aware of the person's facial expressions and body language. Watching expressions and body language is vital if the person is reserved or speech problems exist.

Misreading body language is easy so be sure to ask questions to clarify. For example, if a person looks in pain, ask "Is something hurting you? Where does it hurt?" Be clear about your own body language. Use words as well as facial expressions to communicate feelings and emotions if you feel someone is misunderstanding you.

Speaking openly and honestly to solve problems - The easiest way to manage conflict is to avoid creating misunderstandings in the first place. Think ahead to possible issues that may cause difficulties and address those issues before problems occur.

Discuss routines and schedules. Communicate your own needs and expectations. Learn the person's preferences. For example, agree on how much notice you should give for time off so others can cover the time you would otherwise be available.

If you are uncomfortable about a situation, let the person know in an open and non-confrontational manner. For example, the person asks you to perform a task that is not part of the care plan. Explain why you are unable to do the task in a factual and calm way.

Accepting feedback - Misunderstandings and conflict can happen between two people. Having different ideas about how to solve a problem or what to do in a situation is part of what makes each of us unique as a person. Those differences may create conflict.

When a conflict arises, talk it over with the individual. You may both learn and grow from working together to resolve a conflict. You may be able to improve your relationship and gain increased respect and trust for one another. How you choose to talk with the other person can make a big difference. Here are some tips:

1.      Choose an appropriate time for the discussion - When you are in the middle of an emotional situation may not be the best time. Choose a time when both of you are calm and not under stress. Complete tasks that need immediate attention and talk afterwards.

2.      Be clear about what you want to accomplish - Do you need to make a request, express feelings and clear up a misunderstanding or find out why the person reacted a certain way to something you did? Explain what you want early in the discussion to keep the other person from having to guess about the purpose. Mistaken assumptions can make the situation worse.

3.      Use "I" statements when talking about feelings - Own up to your feelings. Rather than saying "You made me upset when you forgot to leave the key out for me," say "I got upset when you forgot to leave the key out." Speaking in a manner that takes ownership for your own feelings is a more neutral way to point out a problem. Accepting ownership also offers more opportunity to resolve a situation rather than placing blame on the other person.

4.      Begin with something positive to show your goodwill toward the person - If you say, "I really enjoy working with you, and I'm sure we can clear up this problem if we talk it over," you set a positive tone for the rest of the conversation. Be honest – try to find something positive that you can say honestly and from your heart. An insincere compliment may make the situation worse.

5.      Speak to the other person with respect - Do not speak in a tine that sounds like you feel superior. Be clear that you are expressing an opinion rather than telling the person what and how to think.

If you find that you are unable to resolve a conflict with the person on your own, you may need to get some help with the situation. You can ask for assistance from the qualified professional assigned to work with you and the individual.

PROFESSIONAL CONDUCT

Introduction - The people you serve are relying on you for basic needs to function in everyday life. Responsible work habits are a requirement of the job which means working the hours you are scheduled and being on time for your work. You must give notice as soon as possible if you are unable to work due to an unplanned problem such as illness.

Do you often have emergencies or crisis situations you need to deal with in your personal life? Think carefully when answering this question. If the answer is "yes," is there a way to organize your time or commitments to lessen the impact on your ability to do the work you have promised to do?

Code of Ethics - The National Alliance for Direct Support Workers has written a Code of Ethics for professional behavior. This guide may help you learn more about ethical behavior. Behaviors important for a PCA include:

·        Honesty in what you say and how you behave.

·        Pride in your work. If a job is worth doing, then it is worth doing it correctly to the best of your ability.

·        Respect for other people including the people you assist, your agency, supervisor or qualified professional, and co- workers as well as those whose religions and cultures are different from you.

Do's and Don’ts

·        Do dress and behave according to professional standards.

·        Do show patience: Allow a person to take extra time to complete a task independently.

·        Don't make promises or commitments you know you cannot keep.

Home Care Bill of Rights - All PCAs should be aware of specific rights set out in law for people who receive home care services. These

·        Know your agency's grievance policy and assist the person in the steps of the grievance process.

·        Assist the person in contacting the local Ombudsman by telephone.

·        Assist the person in contacting the Ombudsman by mail.

Ombudsman Services - The State of Mississippi’s Office of the Ombudsman for Long-Term Care is a resource available to people receiving PCA services. An ombudsman is an independent person advocate who:

·        Identifies problems and advocates for changes to address problems at no charge to the person.

·        Investigates complaints concerning the health, safety, welfare and rights of persons in long-term care.

·        Works to resolve personal concerns.

Find your local Ombudsman here http://www.mdhs.ms.gov/adults-seniors/services-for-seniors/

FRAUD

You are breaking federal law if you:

·        Provide false information by claiming hours that you did not actually work.

·        Sign the name of someone else such as the person receiving services.

·        Complete and sign a timesheet for another PCA.

Some examples of fraud investigated include the following:

1.      A person complained that she had not received services from her PCA agency for three months. However, the PCA agency received payment for more than 700 hours of service for those same three months. The individual stated that she signed blank timesheets on some occasions.

2.      A mother had a child receiving PCA services. The mother admitted to the Division of Medicaid that she proposed an arrangement where she and the PCA shared the state's payment for services. The mother signed the timesheets even when the PCA did not provide services. DHS recovered over $4,500 in fraudulent payments.

3.      A PCA agency claimed hours for services to seven people on dates when all seven people were in the hospital. People receiving services are not eligible for PCA services during a hospital stay.

Under Mississippi law, theft of any amount of public funds is a felony. PCA service is paid with public funds through the state's Medical Assistance program.

You are breaking the law if you claim even one hour of PCA services on your timesheet that you did not provide. This means you must be accurate in the hours of service you report on your timesheet.

To avoid fraudulent behavior, only document hours of work:

·        When you are present in your role as a PCA.

·        When you engage in PCA work activity based on the care plan:

Do not:

·        Accept money when you have not done the work.

·        Add hours of PCA service after the person has signed the timesheet.

·        Ask the person to sign a partially completed timesheet so the person is unable to verify the hours worked before the timesheet is submitted.

·        Claim more hours of work with the understanding that the hours will be made up later.

·        Fill out a timesheet for days you do not provide any PCA services (for example, the person receiving services is in the hospital or a nursing home).

A PCA cannot claim hours for work if the person receiving services is at the PCA's home. If the person chooses to visit the PCA in the PCA's home, the visit must occur outside of the PCA's hours of work for that person. The PCA cannot claim hours worked if the PCA is in the person's home but taking care of the person's or PCA's children.

There are severe penalties for falsely claiming hours worked. You may be:

·        Disqualified from working at a job that receives Medicare and Medicaid funding which includes Mississippi Medical Assistance for five (5) years.

·        Fired by your employer.

·        Prosecuted and convicted of fraud which may affect other jobs in the future.

·        Required to repay the money.

·        Sent to jail.

·        Unable to apply for and receive low-income housing assistance.

The Mississippi Division of Medicaid has an area responsible to look for and investigate suspected fraud. Mississippi State Medicaid Fraud Control Unit:

·        Conducts post-payment review of claims to determine the accuracy of the payment.

·        Investigates reports received on the Hotline.

·        Measures performance and quality of services provided by DOM.

When you enroll as a PCA, you must sign a Provider Agreement for Individual Personal Care Assistant form. Your signature indicates you are agreeing to help the Medicaid Fraud Control Unit and to give details on payments claimed for services under the Medical Assistance program.

You should always report any suspected improper billing practices to the DOM Hotline. DOM does not share the names of callers.

·        Toll-free: 800-880-5920

·        Phone: 601-576-4162

·        Fax: 601-576-4161

·        Mailing address: 550 High Street, Suite 1000, Jackson, MS 39201

Lesson Summary

The text discusses the roles and responsibilities of Assessors and Personal Care Assistants (PCAs) in providing support for individuals in need. Here are the key points covered:

• Assessors play an important role in identifying the necessary supports for individuals.
• Effective communication techniques such as listening, asking questions, and observing non-verbal cues are essential in providing care.
• Professional conduct guidelines for PCAs highlight honesty, respect, and adherence to ethical standards as crucial.
• Avoiding fraudulent behavior in Personal Care Services (PCS) is emphasized, with outlined consequences and reporting mechanisms for fraud.

Personal Care Services (PCS) involve non-medical assistance with daily activities for seniors and disabled individuals. The roles and requirements of PCAs include:

• Assisting with tasks like dressing, grooming, hygiene, bathing, and meal preparation.
• Meeting specific qualifications, undergoing training, and handling personal care and housekeeping responsibilities.
• Creating individualized care plans tailored to the client's needs, potentially utilizing electronic visit verification for accurate billing.
• Collaborating with clients, families, and professionals to ensure effective care plans and promote independence.

The responsibilities of a PCA encompass assisting with daily living tasks, health-related procedures, behavior monitoring, and instrumental activities of daily living. Key considerations for PCAs include:

• Maintaining clear boundaries and effective communication, especially when caring for family members.
• Encouraging independence and respecting individual choices are vital for providing quality care.