What is In-Home PCS?
Medicaid Personal Care Services (PCS) covers the services of an in-home aide in the patient’s private residence to assist with the patient’s personal care needs which are directly linked to a medical condition. It is often an alternative to placement in an adult care home (rest home). All patient assessments for PCS and all in-home aide supervision must be conducted by a registered nurse who is employed by a home care agency licensed in the State of NC. In-home aide hours are limited to no more than 3 ½ hours per day and no more than 60 hours per month.

Patient Criteria
New PCS policies, approved by NC’s Physician Advisory Group, were effective 11/01/2005 implementing stricter criteria for program eligibility. Patients must have a minimum of two Activities of Daily Living (ADL) deficits identified through a mandated, standardized RN assessment that require hands on assistance from an in-home aide. Activities of Daily Living (ADLs) are Based on the KATZ Scale: These are: bathing; dressing; toileting; bowel/bladder incontinence; transferring/ambulation; and, feeding. Pregnant patients must meet additional conditions for coverage including agency prior approval from Medicaid. PCS for infants and children must not replace parental responsibilities or normal age appropriate tasks that a child would require – but rather be linked to a medical condition. PCS-Plus is for patients who have a qualifying medical condition and personal care needs that exceed the service limit for regular PCS. Up to an additional 20 hours of PCS a month are available through the PCS-Plus program (with Prior Approval) from DMA staff if the patient has 4 ADL impairments requiring extensive assistance or 3 ADL impairments and specified physical limitations.  

New Assessment and Authorization Form
PCS services must be authorized by the patient’s primary physician on the Physician Authorization for Certification and Treatment (PACT). The new PCS RN Assessment form (PACT) is mandatory - physicians should not sign the old DMA 3000 form – the new form says PACT at the top. Documentation on the PCS PACT form serves as the basis for determining whether or not the patient qualifies or continues to qualify for PCS. The RN assessor certifies by signature on the PCS PACT form that he/she completed the in-home assessment, determined the need for PCS, and developed the plan of care.  All RNs who complete a PCS assessment must be certified through State approved curriculum and testing. On the form, the Registered Nurse scores the patients ability to self-perform personal care tasks based on the Nursing Home MDS Definitions.

• INDEPENDENT:  No help needed or oversight needed. Does not meet in-home PCS Criteria
• SUPERVISION:  Oversight, encouragement, or cueing needed. Does not meet in-home PCS Criteria
• LIMITED ASSISTANCE:  Individual highly involved in activity; receives help in guided maneuvering of limbs or other non-weight bearing assistance. 
• EXTENSIVE ASSISTANCE:  While individual performs part of activity, help of the following is needed: weight-bearing support OR substantial or consistent hands-on assistance with eating, toileting, bathing, dressing, personal hygiene, or self-monitoring of meds.
• FULL DEPENDENCE:   Full performance of activity by another. 
  

Home Management Tasks Criteria
The only home management tasks allowed are listed on the covered tasks in the DMA policy. These tasks must be related and incidental to the patient’s personal care needs as indicated on the PCS assessment form. Home management tasks cannot be completed for others living in the household. Medicaid has developed standardized guidance that the RN will follow when assigning aide time to tasks on the PACT plan of care.

Physician Responsibilities

• Referral authorization- the physician must order the RN assessment for PCS services.
• After the assessment is completed, the physician authorizes the start of PCS services or continuation of services- with a verbal order or signed order. Faxed orders are acceptable when agencies follow licensure requirements.
• Physicians must sign the authorizations within 60 days of a verbal order in order to comply with home care licensure regulations.

Direct Patient Solicitation Prohibited in Policy
Direct solicitation by the PCS provider agencies or agency representatives to patients and/or their representatives for PCS services is prohibited. 

New State Utilization Review/Quality Assurance Program
In order to provide necessary oversight of the program, NC Medicaid will implement a new UR/QA program that provides a prospective review for PCS and sets compliance benchmarks for agencies to meet. DMA’s UR/QA program will be both agency record review and on-site review.

For More Information
DMA PCS Policy Link - http://www.dhhs.state.nc.us/dma/cc/ccsection6.htm
Or contact Kathie Smith, RN at the Association for Home & Hospice Care of NC
kathiesmith@homeandhospicecare.org