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    __________________________________________________________________________




                                     FISCAL YEAR 2010

                               (July 1, 2009 – June 30, 2010)



   UNIFORM APPLICATION PROCEDURES AND STANDARDS:

                 LONG TERM CARE SERVICE PROVIDERS




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                                           TABLE OF CONTENTS

                                                                                             Page

I.        INTRODUCTORY MATERIAL                                                              8

          A.     PCA’s Mission Statement                                                     9

          B.     Letter from PCA’s President                                                 10

          C.     Providing Quality Care                                                      11

          D.     PCA’s Integrated LTC Program                                                12

II.       GENERAL INFORMATION FOR APPLICANTS                                                 14

          A.     Response to Applications                                                    15

          B.     Unit Prices                                                                 15

          C.     Areas of Service                                                            16

          D.     Agreement Period                                                            16

          E.     Quantity of Services                                                        16

          F.     Third Party Payor Reimbursable Service                                      16

          G.     Service Delivery                                                            17

          H.     Quality Improvement and Consumer Satisfaction                               17

          I.     Financial Stability                                                         17

          J.     Annual Financial Statements                                                 17

          K.     Transition to a New Provider                                                18

          L.     Personnel Policies                                                          18

          M.     Interrelationship of Providers                                              18

          N.     Insurance                                                                   18

III.      GENERAL OPERATIONAL PROCEDURES
          FOR ALL PROVIDERS                                                                  22

          A.     Intake                                                                      23


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         B.     Identification of Field Staff                                               23

         C.     Communication                                                               23

         D.     Emergencies                                                                 24

         E.     On Call Procedures                                                          24

         F.     Incidents                                                                   24

         G.     Service Orders                                                              25

         H.     Criminal History Reports                                                    25

         I.     Legal Residency Status                                                      25

         J.     Consumer Signatures                                                         26

         K.     Invoicing                                                                   27

         L.     Monitoring of Services                                                      28

         M.     Conflict of Interest Policy                                                 28

         N.     False Claims Act Policy                                                     29

         O.     Service Order Authorization Procedure                                       32

         P.     Provider Monitoring – Sanctions                                             35

IV.      SERVICE STANDARDS AND SERVICE SPECIFIC
         OPERATIONAL PROCEDURES                                                             43

         A.     Adult Day Care - Standards                                                  44

         B.     Adult Day Care – Service Specific Operational Procedures                    45

         C.     Attendant Care – Act 15 – Standards                                         49

         D.     Companion Service - Standards                                               55

         E.     Counseling - Standards                                                      57

         F.     Counseling - Service Specific Operational Procedures:                       60

         G.     Professional Evaluation - Service Specific Operational Procedures           62



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          1.     General Information                                                  62

          2.     Medical Physician Services                                           66

          3.     Psychiatric Physician Services                                       68

          4.     Psychological Evaluation                                             70

          5.     OBRA Psychological Evaluation                                        71

   H.     Home Health Care - Standards                                                72

   I.     Home Health Care - Service Specific Operational Procedures                  79

   J.     Home Support - Standards                                                    87

   K.     Home Support - Service Specific Operational Procedures                      91

   L.     Extermination - Service Specific Operational Procedures                     97

   M.     Financial Management – Service Specific Operational Procedures              104

   N.     Personal Care - Standards                                                   107

   O.     Personal Care, Respite, and Home Support - Service Specific
          Operational Procedures                                                      113

   P.     Personal Assistance Service (PAS) – Service Specifications                  123

   Q.     Personal Emergency Response System - Standards                              140

   R.     TeleCare Services                                                           146

          1.     General Information                                                  146

          2.     Health Status Measuring and Monitoring Service                       148

          3.     Activity and Sensor Monitoring Service                               152

          4.     Medication Dispenser and Monitoring Service                          156

   S.     Respite - Standards                                                         160

   T.     Temporary Shelter - Service Specific Operational Procedures                 162

   U.     Specialized Medical Equipment and Supplies - Standards                      166

   V.     Durable Medical Equipment (DME) - Service Specific Operational Procedures   167


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        W      Hearing Aids - Service Specific Operational Procedures                      172

        X.     Stair Elevator - Service Specific Operational Procedures                    176

        Y.     Transportation - Standards                                                  180

        Z.     Vision Care - Service Specific Operational Procedures                       182

V.      APPLICATION FORMAT AND FORMS                                                       185

        A.     Letter to Applicants                                                        186

        B.     Provider Application – Submission Format/Checklist                          187

        C.     Certification Form/Agency Profile                                           189

        D.     Assurances                                                                  192

        E.     Affirmation, Price Certification, and Service Profile Forms                 193

               1.     Adult Day Care Centers – Provider Affirmation                        194

               2.     Adult Day Care Centers – Price Certification Form                    196

               3.     Attendant Care – Act 15 – Price Certification Form                   197

               4.     Attendant Care / Personal Assistance Service (PAS) Profile           198

               5.     Counseling – Provider Affirmation                                    200

               6.     Counseling – Price Certification Form                                202

               7.     Professional Evaluation Services – Provider Affirmation              203

               8.     Professional Evaluation Services – Price Certification Form (1)      205

               9.     Professional Evaluation Services – Price Certification Form (2)      206

               10.    Home Health Care – Provider Affirmation                              207

               11.    Home Health Services – Price Certification Form                      209

               12.    Home Health Service Profile                                          210

               13.    Home Support – Provider Affirmation                                  211

               14.    Home Support – Price Certification Form                              213


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                15.    Home Support – Financial Management – Price Certification Form       214

                16.    Personal Care – Provider Affirmation                                 215

                17.    Respite Care – Provider Affirmation                                  217

                18.    Companion Services – Provider Affirmation                            219

                19.    Personal Care, Respite Care, Companion Services,
                       General Home Support Price Certification Form                        220

                20.    Personal Care Service Profile                                        221

                21.    Personal Assistance Service (PAS) – Provider Affirmation             223

                22.    Personal Assistance Service (PAS) – Price Certification Form         224

                23.    Personal Assistance Service (PAS) Profile                            225

                24.    Respite/Temporary Shelter – Price Certification Form                 227

                25.    Transportation – Provider Affirmation                                228

                26.    Transportation – Price Certification Form                            230

                27.    Personal Emergency Response – Provider Affirmation                   231

                28.    Personal Emergency Response – Price Certification Form               233

                29.    Health Status Measuring and Monitoring Service
                       Price Certification Form                                             234

                30.    Activity and Sensor Monitoring – Price Certification Form            235

                31.    DME – Hearing Aides – Price Certification Form                       236

                32.    DME – Stair Elevator – Price Certification Form                      237

                33.    Vision Service – Price Certification Form                            238

VI.      ATTACHMENTS                                                                        239

         A.     Procedure Codes for Aging Waiver Services                                   240

         B.     DME Supply List                                                             240

         C.     Sample Insurance Certificate                                                240


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   D.     Adult Day Care Congregate Meal Requirements                                 240




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                                  SECTION I.


                    INTRODUCTORY MATERIAL




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A.      PCA’s MISSION STATEMENT


        PCA’s mission is to improve the quality of life for older and disabled Philadelphians, assisting these

individuals in achieving maximum levels of health, independence, and productivity. Special consideration

is given to assuring services for those with the greatest social, economic and health needs. Based on the

principle that older persons have the ability and the right to plan and manage their own lives, PCA seeks

ongoing input from the elderly. PCA recognizes the dignity of all older people and respects their racial,

religious, sexual, and cultural differences.

        PCA’s mission is carried out through five major functions: planning, advocacy, program

development, service coordination and provision, and accountable administration of public and private

funds to purchase services. It works with organizations representing and serving older Philadelphians to

develop a comprehensive, coordinated, and accessible system of services responsive to the needs of the

aging population within community and institutional environments.

        PCA is the Area Agency on Aging for Philadelphia, as designated by the Commonwealth of

Pennsylvania in response to the 1973 amendments to the Older Americans Act of 1965. It operates under

the authority of the Pennsylvania Department of Aging.




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B.      LETTER FROM PCA’S PRESIDENT


         As a proud member of Philadelphia’s health care and human services communities, the Philadelphia
Corporation for Aging (PCA) faces the challenge of seeking workable solutions to basic human problems
within a rapidly changing environment. We are grateful for the expertise of the hundreds of agencies with
whom we partner to serve Philadelphia’s large and diverse elderly population a group whose proportional
size is unmatched by other major American cities.

         During its many years of developing, funding, and implementing services and programs that
represent Philadelphia solutions to Philadelphia problems, PCA and its partners have produced a versatile
and unique “network of care”, now touching the lives of an estimated 70,000 people each year. For many,
our aging network offers a caring, helping hand providing guidance, reassurance, and reinforcement. For
some, we fill a definite gap in family support -- allowing them to resume normal family life despite
setbacks caused by functional ability or health. For others, who are without family or informal support, we
are a lifeline assuming essential day-to-day care giving responsibilities.

        As PCA coordinates a local “network of care”, it is a member of a national network that touches
seniors across the nation. We are one of 670 Area Agencies on Aging which derive authority from, the
Older Americans Act of 1965. This Act sets forth a unified set of goals and directions that broadly guide
our nation’s formal support of the aging. Its wisdom proven by the test of time, the Act remains relevant,
versatile, and adaptable in practical application. The 2005 White House Conference on Aging -- attended
by 1,200 delegates representing every state -- issued a resounding endorsement for the Older Americans
Acts, its reauthorization and funding. For those working within the aging network, and for the countless
individuals touched by its network, this is a true statement of success.

       PCA is proud to be linked to the Older Americans Act network and national counterparts through
common purpose and direction. We acknowledge and embrace our responsibility to provide proactive
leadership, as we tackle demographic challenges, which have yet to confront most cities and states.

        Our activities are guided by four central mandates set forth in the Older Americans Act: Facilitating
Independent Living, Empowering Older People Through Community Involvement, Advocating to Protect
Rights, and Targeting and Responding to Priority Needs. These practical themes formulate the core of
PCA’s mission and guide its progress each year. Thanks to our dedicated funding from the Pennsylvania
Lottery and the collaborations we have established with other agencies, we have reached beyond baseline
requirements of the Older Americans Act in developing programs for Philadelphia’s aging community and
non-elderly in need of long-term care services.

        We are proud that PCA’s programs serve as models for other Area Agencies on Aging who derive
benefit from our developmental work as they strive to fortify their own networks.

                                             Sincerely,
                                             Rodney D. Williams




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C.      PROVIDING QUALITY CARE


       PCA is charged with the responsibility for building and improving long-term care towards a goal of
providing a life-long “continuum of care." This goal is being accomplished through PCA’s visible
leadership role as a coordinator of long-term care, provider of information and referral services, and vocal
advocate of public policy that benefits the frail elderly and adults with disabilities.

       Together with its staff and community partners, PCA strives to remain accessible and responsive to
the needs of individuals in their communities. Central to these efforts is an emphasis on diversity -
designing a flexible array of programs that respond to individual and cultural preferences and needs.

       PCA’s perspective is that of an agency committed to consumer choice and to considering
individuals' diversity and personal preferences along with their medical needs.

       Faced with financial constraints, which is the hallmark of this era of health care cost containment,
PCA advocates full use of technological advances, along with thoughtful care decisions. It is hoped that the
influence of PCA’s home and community-based care philosophy will lead to innovative and improved
models of long-term care.

       But foremost on the agenda, as it has been since 1973, is cultivating the practical expertise and
common compassion that are needed to make quality of life a fact of life for older women and men across
the country.

        Chronically ill and disabled adults often need help to live safely and comfortably at home. Some
can afford to pay for services from the burgeoning home-care industry, but most rely on informal support
systems for daily assistance. Since Medicare and Medicaid provide limited care in the home, PCA fills the
service gap for them.

       Since the mid 1980s, PCA has dedicated an increasing percentage of its resources to funding long-
term care services and each year, thousands of Philadelphians (elderly and non-elderly) receive home-based
support services through PCA.




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D.      PCA’S INTEGRATED LONG TERM CARE (LTC) PROGRAM

        Since the inception of PCA’s Long Term Care Program (LTC) in 1976, the agency has maintained a
commitment to assuring quality consumer services. In support of its mission “to improve the quality of life
for older and disabled Philadelphians and to assist them in achieving optimum levels of good health,
independence and productivity”, PCA continues to make quality of life a fact of life through its integrated
LTC program.

       Through the use of centralized oversight, common procedures, consumer choice, and common
providers, PCA is able to provide an integrated and seamless service response. This integrated approach
reduces administrative overhead, increases program efficiency, and enhances communication with service
providers. Care management staff carry a programmatically mixed caseload so that as consumers’ needs
change over time, there is minimal disruption in care management and service delivery.

1.      PCA’S LTC DEPARTMENTS

        The Long Term Care (LTC) Program consists of three primary Departments:

        The Long Term Care Assessment (LTCA) Department is responsible for determining, through
performing and assessment, an applicant’s appropriateness for level and locus of care, and makes a referral
to the appropriate program.

        The Long Term Care Options (LTCO) Department is responsible for developing and arranging a
care plan, authorizing services, and providing ongoing care management for those consumers determined
appropriate for home and community based services by LTCA.

        The Community Living Options Department is responsible for two programs. The Domiciliary
Care (Dom Care) Program provides eligible consumers residential and supportive services in a homelike
setting. The Nursing Home Transition Program assists persons residing in nursing homes who are capable
of living independently to move back into the community.




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2.      LONG TERM CARE SERVICES

       PCA’s LTC Program includes a wide range of services so that older and disabled adults may live in
the community rather than in a nursing home.

       To receive services, individuals must be 60 years of age or older and, when clinically eligible for
nursing home care (NFCE), they must be in need of assistance with multiple activities of daily living. A
consumer’s care needs are met through care plans developed jointly with a PCA Care Manager. Consumers
choose the providers they wish to use for services from a list provided by the Care Manager. Over 8,000
individuals receive services at any one time. The range of services offered includes:

Adult Day Care                                      Major Cleaning and Extermination
Personal Care                                       Housing Services and Home Modifications
Counseling                                          In-home or Institutional Respite
Home Delivered Meals                                Medical Equipment and Supplies
Hearing Aids                                        Stair Elevators
Specialized Evaluations                             TeleCare Services
Nursing                                             Transportation
Physical, Occupational and Speech Therapy           Emergency Response Systems

        The primary sources of funding for LTC services are Medical Assistance dollars from the
Pennsylvania Department of Public Welfare (DPW) and Pennsylvania Lottery dollars through the
Pennsylvania Department of Aging (PDA). It is PCA’s goal to use the same providers to deliver services
under both funding sources. The same Service Standards, Service Specific Operational Procedures, unit
costs, reporting requirements, consumer selection options, and other operational aspects apply to all
services and providers, regardless of the source of funding.

3.      COMMUNITY CHOICE PROCESS/AGING WAIVER PROGRAM – MEDICAL
        ASSISTANCE FUNDS

        DPW received a waiver from the Centers for Medicare and Medicaid Serivces (CMS) to use
Medical Assistance funds to pay for consumer services. There currently is an aggregate cost cap of 80% of
the average nursing home rate and consumers must be financially eligible for Medical Assistance and
clinically eligible for nursing home care. PCA certifies all Aging Waiver Program service providers for
participation in the Medical Assistance Program and Aging Waiver Program providers are paid directly by
the Department of Public Welfare through the PROMISe system for services authorized by the PCA staff.

4.      OPTIONS PROGRAM - LOTTERY DOLLARS

         Care plans with an individual cap of up to 80% of the average nursing home rate in Philadelphia are
paid for with Pennsylvania Lottery dollars for those consumers with incomes and/or resources above
Medical Assistance allowable limits, or who, although requiring assistance with ADLs, are nursing facility
clinically eligible (NFI). The provision of Options services is through a contract with PCA, which pays
providers directly. Services provided under the Options Program are identical to those provided under the
Aging Waiver Program. Persons with income above 125% of poverty are required to participate in the cost
of all services paid for with Lottery dollars and are billed directly by PCA.




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                                     SECTION II.




            GENERAL INFORMATION FOR APPLICANTS




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                           GENERAL INFORMATION FOR APPLICANTS

       This application packet provides interested service providers with information to prepare and submit
applications for consideration by the Philadelphia Corporation for Aging’s (PCA) Business Administration
Department, to provide services to homebound elderly residents of Philadelphia participating in PCA’s
Long Term Care programs.

A.      Response to Applications

       Applications may be submitted to PCA at any time, however the required information must be
submitted in the order and format detailed in the forms packet.

        Though applicants may choose to apply to be an Aging Waiver Provider only, in order to assure
consistency and continuity in service delivery, they are strongly encouraged to apply to be a provider for
both programs, the Options Program and the Aging Waiver Program. Providers wishing to be an Options
Program provider must be willing to participate in the Aging Waiver Program as well.

         NOTE: Applications to be an Options Program provider will be processed twice yearly, at the
start of the fiscal year – July 1, 2009 - and at mid-year – January 1, 2010. Applications to be an
Aging Waiver Provider will be processed at any time during the fiscal year.

        If any of the required information and forms are missing or are incomplete, the applicant will be
given 30 days to provide the additional material. Additional time may be granted in special circumstances.
All “Assurance” forms must be signed in the affirmative by an official authorized to commit the applicant
to the requirements stated therein. If an application cannot be processed in a reasonable period of time, as
determined by PCA, the provider may resubmit all material at a later date.

       PCA reserves the right to verify any information that appears inconsistent, unclear, or erroneous.
Any applicant that willfully provides false information, as verified by PCA, shall be immediately
disqualified from consideration for a period of up to one year. However, PCA reserves the right to waive
minor errors or irregularities. PCA reserves the right to request best and final price quotes from applicants
and acceptance of a final price quote rests solely with PCA.

        NOTE: Because of PCA’s on-site monitoring and audit requirements, PCA will only consider
applicants that have a local office (i.e., an office located within a reasonable distance of Philadelphia),
so as to facilitate access to all required provider records. While it is recognized that certain services
can be delivered through electronic and/or mail service, PCA must still be able to access provider
records and documentation related to both the due diligence process for provider certification, as
well as the delivery of authorized service.

B.      Unit Prices

        Reimbursement for services provided will be based on unit prices. The unit prices stated on the
Price Certification Forms shall apply to both the Options Program and the Aging Waiver Program. The
unit prices will remain firm for the fiscal year.



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       NOTE: It is requested that providers offer the same unit price(s) to PCA consumers who wish
to purchase additional service on their own.

C.      Areas of Service

        All applicants must have the capacity to deliver service to one or more PCA defined geographic
areas of Philadelphia. Identification of areas to be served shall be made as part of the application process
and the areas identified will determine on which Consumer Selections List(s) the provider is included.
Given consumer choice, applicants should select only those areas they are confident they can comfortably
serve.

      NOTE: In order to provide service in another county in Pennsylvania, an application must be
submitted to that county.

D.      Agreement Period

        Subject to the availability of funds, PCA intends, through this process, to certify and contract with
providers to provide service for the fiscal year period, July 1, 2009 through June 30, 20010. New applicants
for a PCA contract will only be processed at the start of fiscal year – July 1, 2009, and again in mid-year –
January 1, 2010. Applications for certification in the Aging Waiver program will be accepted on a rolling
basis.

E.      Quantity of Service

       PCA does not guarantee any minimum or maximum volume of service for the fiscal year. PCA
assures providers that the availability of all providers will be made known on PCA’s Consumer Selection
Lists.

        The dollar amount of any contract does not represent intent, either expressed or implied, to purchase
service at any level, and shall not be construed as a guarantee of payment beyond service specifically
ordered through an official PCA Service Order form and delivered by the provider.

F.      Third Party Payor Reimbursable Service

The LTC Program is mandated by the Pennsylvania Department of Aging to pursue reimbursement through
other sources, such as Medical Assistance and Medicare and other third party payors. Any provider
offering a service covered by Medicare or Medical Assistance must be enrolled to provide that service
before certification or contracting through this application process. Any consumer who is eligible and
meets the requirements for Medical Assistance or Medicare must receive service paid for by the third party
source. For such a consumer, service will be ordered and paid for by PCA only if it cannot be provided by
Medical Assistance or Medicare or other third party payor. PCA expects each applicant to be
knowledgeable about third party reimbursement; therefore, PCA will not retroactively reimburse a provider
if the claim is rejected by Medical Assistance, Medicare, or other third party payor. A large number of PCA
consumers meet the requirements for billing to Medical Assistance and Medicare.

       Concerning Medicare billable services, PCA requires that services be billed directly to Medicare
and not to PCA or the consumer.



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       The applicant must be knowledgeable about the billing requirements for Medicare and Medical
Assistance in Pennsylvania, and must process all required forms, including having the forms completed by
the consumer’s physician. NOTE: The provider must inform the PCA Care Manager every time a
service can be billed to Medical Assistance or Medicare. PCA will provide the necessary insurance
information and the name and telephone number of the consumer’s physician at the time the service is
ordered. The Care Manager will assist the provider in contacting the physician and in facilitating the
completion of forms only in exceptional situations (e.g., when the provider’s repeated attempts to contact
the physician have been unsuccessful).

G.      Service Delivery

        The provider must have the capacity to start service within 3 business days after receiving the
service order, or within the times frames defined in the individual Service Specific Operational Procedures.
There may be instances where a PCA Care Manager requests next day delivery in order to meet a
consumer’s urgent needs.

        PCA requires that providers obtain consumer signatures for all services provided to PCA
consumers. No request for payment shall be made without a signed receipt for each unit of service. Any
Options service billed based on unsigned or forged verification forms will be deducted from the provider’s
next payment. Similarly, any Aging Waiver service billed without proper consumer verification will
require that the provider submit a claim adjustment to reimburse DPW. NOTE: Falsification of invoices
will result in the immediate termination of the provider’s contract and the possible termination or
suspension from the Medical Assistance Program.

       PCA requires that providers deliver service on the days and at the time(s) requested. If PCA’s
request cannot be met or an exception occurs once service has started, the consumer and the consumer’s
Care Manager must be notified. Any alternate plan must be approved by the consumer and the PCA Care
Manager.

H.      Quality Improvement and Consumer Satisfaction

      PCA recommends that providers periodically review and analyze their services focusing on quality
improvement and the identification of problems. It is also recommended that providers periodically survey
consumers to gauge their satisfaction.

I.      Financial Stability

       Providers making application to PCA must be financially solvent and able to demonstrate an ability
to meet daily operational and payroll expenses. Should a provider enter into bankruptcy proceedings, the
PCA Contract Manager must be notified immediately.

J.      Annual Financial Statements

        All providers are required to submit a copy of their annual financial statements to their PCA
Contract Managers. These annual financial reports will be due no later than ninety (90) days after the end
of the provider’s fiscal year.




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K.      Transition to a New Provider

       In the event that a consumer selects a new service provider or the current provider terminates
services, the current provider must participate in any plan to transition services. Participation shall include
providing a copy of the consumer’s record including a service summary, and attending an orientation
meeting with the new provider and any additional meetings needed to successfully transfer the consumer.

L.      Personnel Policies

         The provider is required to submit a copy of their personnel policies as part of their application.
The policies must cover hiring practices, employee benefits, supervision procedures, and employee training
as it relates to the services covered by the application.

M.      Interrelationship of Providers (Excerpted and modified from the “Medical Assistance
        Handbook, Chapter 1101, Responsibilities")

        Providers are prohibited from making the following arrangements with other providers:

        1.     The referral of consumers directly or indirectly to other practitioners or providers for
               financial consideration or the solicitation of consumers from other providers.

        2.     The offering of, or paying of, or the acceptance of, remuneration to, or from, other providers
               for the referral of consumers for services or supplies.

N.      Insurance

        Providers must provide evidence that they meet PCA’s insurance requirements in order to be
certified for the Aging Waiver Program and in order to participate in the Options Program.

       It is advised that before completing an application, providers verify with their insurance
carriers that they are able to meet PCA’s insurance requirements.

        The insurance requirements are provided below.




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                               PCA’s INSURANCE REQUIREMENTS


Provider shall, at its sole cost and expense, procure and maintain in full force and effect, throughout the
term of the Agreement, the following insurance from companies licensed or approved to do business in the
Commonwealth of Pennsylvania, or through a qualified self-insurance program approved or registered by or
with the Commonwealth and acceptable to PCA, in the forms and on the terms and conditions specified
herein. All insurance companies must maintain a Best’s Insurance Guide rating of at least “A-” and a
financial size of at least Class VII for companies licensed in the Commonwealth or Class X for companies
approved but unlicensed in the Commonwealth. Except as specifically provided herein, all such insurance
shall be written on an occurrence basis.

       1.     General liability insurance (including coverage for physical abuse and sexual molestation
              with sublimits of at least $500,000 per occurrence and 2,000,000 per annual aggregate) with
              no self-insured retention, and with no endorsements excluding or limiting coverage,
              including, but not limited to, contractual liability coverage, naming PCA and the
              Commonwealth of Pennsylvania and their directors, officers, employees and agents as
              additional insureds, with an endorsement stating that the coverage afforded the additional
              insureds shall be primary and non-contributory to any other coverage available. Such
              coverage shall have limits of coverage, on a stand-alone basis or in combination with excess
              or umbrella coverage, of not less than $1,000,000 combined bodily injury and property
              damage per occurrence and $3,000,000 per annual aggregate.

       2.     Automobile liability insurance written on the current Insurance Services Office’s
              commercial auto form or its equivalent, with no self-insured retention, naming PCA and the
              Commonwealth of Pennsylvania and their directors, officers, employees and agents as
              additional insureds, with an endorsement stating that the coverage afforded the additional
              insureds shall be primary and non-contributory to any other coverage available, and with
              limits of coverage, on a stand-alone basis or in combination with excess or umbrella
              coverage, of not less than $1,000,000 per occurrence combined single limit for bodily injury
              and property damage, covering owned, non-owned and hired vehicles;

       3.     Workers compensation insurance (with statutory limits of coverage and no deductible) and
              employers liability insurance (with limits of coverage of not less than $100,000 per accident,
              $100,000 per employee by disease and $500,000 policy limit by disease and no deductible)
              endorsed for all states in which work is to be performed under the Agreement (including,
              without limitation, Pennsylvania).

       4.     Professional liability insurance naming PCA and the Commonwealth of Pennsylvania and
              their directors, officers, employees and agents as additional insureds (except with respect to
              Health Care Providers under the Medical Care Availability and Reduction of Error
              (MCARE) Act), with an endorsement stating that the coverage afforded the additional
              insureds shall be primary and non-contributory to any other coverage available, and with no
              endorsements excluding or limiting coverage, as follows:

              a.      “Participating Health Care Providers” under the MCARE Act must have statutory
                      limits and must participate in the MCARE Fund;



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          b.     “Non-participating Health Care Providers” under the MCARE Act and other
                 providers of professional services (including, but not limited to, social and legal
                 services providers and those health care providers who are not “Health Care
                 Providers” under the MCARE Act) must have limits of coverage of not less than
                 $1,000,000 per occurrence and $2,000,000 per annual aggregate and no-self insured
                 retention.

          c.     Professional liability insurance may be written on a claims-made basis, provided,
                 however, that the policy permits Provider to purchase extended reporting period
                 coverage (“Tail Coverage”) upon termination of the policy.

                 (1.)   In the event that insurance is written on a claims-made basis, Provider hereby
                        agrees to maintain, following termination of such coverage or of the
                        Agreement (whichever is earlier), professional liability insurance, covering
                        claims arising out of occurrences during the term of the Agreement, whether
                        by (i) purchasing additional policies of insurance with no exclusion for prior
                        occurrences and the option of purchasing appropriate Tail Coverage, or (ii)
                        purchasing the appropriate Tail Coverage. Tail Coverage for medical
                        professional liability coverage shall be of unlimited duration. All other Tail
                        Coverage shall be maintained for a period of not less than the greater of six
                        years or as required by law, following termination of the Agreement or of such
                        claims-made coverage (whichever is earlier). In no event shall any such Tail
                        Coverage provide limits of coverage lower than the limits of coverage required
                        herein for professional liability.

                 (2.)    In the event that Provider elects to maintain insurance written on a claims-
                         made basis, these undertakings (and the provision of certificates or policies of
                         insurance evidencing compliance with same, as further specified below) shall
                         survive termination of the Agreement.

   5.     All-risk or special form property damage insurance, naming PCA and the Commonwealth of
          Pennsylvania as additional insureds and loss payees, insuring as they may appear the
          interests of Provider, PCA and the Commonwealth of Pennsylvania in all personal property,
          fixtures and improvements to real estate funded or supplied by PCA, whether titled to
          Provider or to PCA. Such coverage shall be written for the full replacement value of the
          property in question without penalty or deduction for coinsurance or deductible greater than
          $500.00, and shall be amended as necessary to reflect changes in inventory.

          If Provider has contracted with PCA for any prior period(s) and has in force general liability
          or, if applicable, excess insurance, written on a claims-made basis, covering claims arising in
          connection with its performance under contract with PCA during such period(s), Provider
          shall maintain said insurance during and for a period of not less than the greater of six years
          or as required by law, following the term of the Agreement (whether by (i) purchasing
          additional policies of insurance with no exclusion for prior occurrences and the option of
          purchasing Tail Coverage, or (ii) purchasing the appropriate Tail Coverage); provided,
          however, that all other terms and conditions contained in this Exhibit “C” are otherwise met.
           In the event that Provider elects to maintain insurance written on a claims-made basis, as


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          provided in this paragraph, this undertaking (and the provision of certificates or policies of
          insurance evidencing compliance with same, as further specified below) shall survive
          termination of the Agreement.

          Provider shall provide PCA with certificates of insurance evidencing compliance with the
          requirements of this Exhibit “C” prior to performance under the Agreement in substantially
          the form attached hereto as Appendix 1 to this Exhibit “C”. All certificates shall evidence
          the agreement on the part of the insurer to provide PCA with 30 days prior written notice of
          any non-renewal, cancellation or modification of coverage, or of any impairment of the
          aggregate insurance exceeding $100,000, except in the case of coverage for physical abuse
          and sexual molestation where written notice shall evidence any impairment of the aggregate
          insurance available as a result of loss. Any language on the certificate which states that the
          insurer will “endeavor to” mail such notice and any language stating “but failure to do so
          shall impose no obligation or liability of any kind upon the insurer affording coverage, its
          agents or representatives, or the issuer of this certificate” shall be deleted. PCA shall have
          the right, in its sole discretion, to pay any premium necessary to maintain in force the
          coverages required hereunder, and to recover the amount of such payment, whether by set-
          off against amounts due to Provider under the Agreement, or otherwise. PCA shall have the
          right to require Provider to submit certified copies of policies of insurance required
          hereunder upon reasonable notice.

          The insurance requirements set forth, and shall not be construed, to limit or reduce (or be
          limited or reduced by) any other insurance obligation of Provider under the Agreement; nor
          to limit Provider’s liability under the Agreement to the limits of coverage required or
          procured.




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                                    SECTION III.



 GENERAL OPERATIONAL PROCEDURES FOR ALL SERVICE

                                    PROVIDERS




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GENERAL OPERATIONAL PROCEDURES FOR ALL SERVICE PROVIDERS

This document is a supplement to the Options and Aging Waiver Standards and Service Specific
Operational Procedures. It sets forth the operational procedures that ALL Providers offering care to
PCA consumers of the LTC Department programs, must follow, regardless of the payment source for
service provision.

A.      INTAKE

        The LTC Assessor or LTCO Care Manager develops a care plan in conjunction with the consumer
        and/or caregiver. In cases where a need for specialized services exists, the Assessor or Care
        Manager contacts the provider selected by the consumer to make the initial referral.

        The provider agency will be given information necessary to authorize service by way of a Service
        Order from the Assessor or Care Manager. The type of service and time frame in which the service
        is to be provided will be specified. If the provider is not able to meet the request, the Assessor or
        Care Manager will refer the consumer to another agency of his/her choice. Note: for Aging Waiver
        consumers, DPW regulations require providers confirm consumer eligibility prior to the
        delivery of service. Eligibility can be confirmed via DPW’s Eligibility Verification System
        (EVS) and/or through DPW’s Provider Reimbursement and Operations Management Information
        System (PROMISe).

        Even if a service order is based on payment by PCA or Aging Waiver funds, the State of
        Pennsylvania mandates that all other third party payers be billed before PCA or Aging
        Waiver funds are invoiced.

B.      IDENTIFICATION OF FIELD STAFF

        All staff persons in contact with LTC consumers are required to wear attire appropriate to the
        industry and function being carried out. All field staff shall be given provider issued photo
        identification cards.

C.      COMMUNICATION

        Communication by phone, voice mail, fax, and e-mail, as well as face-to-face meetings, when
        necessary, between the LTC staff and the Provider, and between Providers, are at the core of
        responsive service to consumers. The points in time when communication is necessary between the
        Provider and PCA, fall into seven primary categories:

        1.     If required, or if concerns arise, following initiation of service;
        2.     When a change in the consumer’s functioning is observed;
        3.     When collaboration between Providers is necessary;
        4.     When there are changes in the plan of treatment;
        5.     When there are consumer complaints;
        6.     When emergencies occur;
        7.     At the time of discharge or suspension of service.



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D.      EMERGENCIES

        1.     CONSUMER - All Providers for all services shall develop and follow written
               policies and procedures regarding the handling of medical emergencies that
               consumers may experience during service provision. The written policies and
               procedures will be reviewed as part of regular monitoring.

        2.     PCA STAFF - Providers shall notify designated staff immediately in the
               event an emergency occurs while providing service, and shall submit an
               incident report (see Item F below) to PCA.

        3.     WEATHER EMERGENCIES/DISASTERS - Providers shall have written policies and
               procedures describing the actions to be taken to ensure continued service to LTC consumers
               in the event of a weather emergency or a disaster. The policies and procedures must
               especially note the actions to be taken to ensure continued service to those consumers
               identified by the Provider and/or LTC staff as most at risk. The written policies and
               procedures will be reviewed as part of regular monitoring.

E.      ON CALL PROCEDURES

        1.     The Provider shall provide PCA consumers with written procedures for how to contact a
               staff person to discuss problems or concerns that require attention during non-business hours
               (weekdays after 5:00 PM and week-ends).

        2.     If the provider agrees to accept referrals for service to start within 24 to 72 hours, staff shall
               be available after normal business hours and on the weekends to receive referrals. In
               addition, the provider shall have the capacity to commit over the telephone when called to
               start service. It is anticipated that this need for extended-hours of coverage will apply
               primarily to home health and personal care service providers. Providers of other types of
               services who may utilize answering machines or answering services, are expected to respond
               to such referrals on the next business day.

        3.     The On Call Procedures will be reviewed as part of regular monitoring.

F.      INCIDENTS

        1.     Incidents of injury or threat to the consumer, an unsafe environment, alleged theft and
               damage to the consumer’s property.

               a.     All incidents must be reported immediately to the Care Manager (or the Care
                      Manager Supervisor or the Nurse Consultant) and be followed by submission of a
                      written Incident Report within 24 hours to the LTC Care Manager and the Contract
                      Manager in the Business Administration Department

               b.     A representative of the Provider shall visit the consumer to discuss the incident,
                      prepare a written statement that describes the incident from the consumer’s
                      perspective, ask the consumer to sign the statement, and submit the statement along



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                      with the Incident Report. The consumer should be encouraged to file a police report
                      if appropriate.

               c.     Irrespective of the willingness of a consumer to sign a statement and/or file a police
                      report, the Provider must resolve the situation consistent with industry standards and
                      consistent with consumer preferences. The Provider shall advise the PCA Care
                      Manager and Contract Manager of the results of these efforts.

G.      SERVICE ORDERS

        1.     All service orders will be sent by Philadelphia Corporation for Aging personnel only.

LTC Care Management staff (Assessors, Care Managers, Care Manager Supervisors, Nurse Consultants, or
PCA administrative staff) are the only staff authorized to place service orders. The Provider must receive
the service order before service delivery can begin.



        3.     If the service order is unclear or erroneous, the PCA Care Manager or Care Manager
               Supervisor must be contacted immediately to discuss the concern. A corrected service order
               must be received before initiating or continuing service. The PCA Care Manager or Care
               Manager Supervisor will make any needed corrections in the care plan and forward a new
               service order, as indicated.

        4.     Please see the Service Order Procedures in Section IV, noting especially PCA’s
               requirements for Web based accessing of referrals by providers.

H.      CRIMINAL HISTORY REPORTS

        Without in any way limiting providers’ duties under any other term or condition of any agreement
        between providers and Philadelphia Corporation for Aging and/or providers and the Commonwealth
        of Pennsylvania Department of Public Welfare, providers shall comply with any federal, state, or
        local law pertaining to mandatory use of criminal history record information, including but not
        limited to the Older Adults Protective Services Act, 35 P.S. Section 10225.101 et seq., and the
        regulations promulgated pursuant thereto, 6 Pa. Code Chapter 15 (commonly referred to as “Act
        13”). In the event that Provider is not otherwise required by applicable law to review criminal
        history record information, Provider shall obtain criminal history record information for all
        employees having contact with PCA consumers and shall exercise discretion in making employment
        decisions based thereon.

I.      LEGAL RESIDENCY STATUS

        Without in any way limiting a provider’s duties under any other term or condition of any agreement
        between providers and Philadelphia Corporation for Aging and/or providers and the Commonwealth
        of Pennsylvania Department of Public Welfare, providers shall comply with the Immigration
        Reform and Control Act of 1986, 29 U.S.C. Section 1802 et seq.




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J.      CONSUMER SIGNATURES

        1.     The Provider shall obtain the consumer’s signature, or the signature of an authorized
               representative, on a standardized form or time-slip, each time a service is delivered to a PCA
               consumer. Use of an authorized representative is permissible when the consumer is unable to
               sign due to either physical and/or cognitive limitations. The consumer’s PCA Care Manager
               must confirm the approval and designation of an authorized representative. Providers must
               maintain proof of that designation in their consumer records.

               NOTE: The Provider’s use of electronic / telephony systems in place of the consumer
               signature process, described throughout this section, is possible only with PCA’s prior
               written approval.

        2.     The consumer or the consumer’s authorized representative must be given a copy of the
               signed time-slip or comparable form as a confirmation of delivery of service. It is
               recommended that providers utilize multi-part forms to facilitate this acknowledgement of
               the receipt of service on the given day.

        3.     For those services authorized and ordered in time increments (e.g. ¼ hour), the service
               verification form or time-slip must clearly identify the consumer served, the worker
               providing service, the time service started and ended, including whether A.M. or P.M., for
               each date of service, and must be signed by the consumer and the worker for each day and/or
               instance of service in a given day (e.g. split shift of personal care service, etc.).

               When service is delivered at an adult day service center, the verification of attendance by a
               single consumer signature must indicate the arrival and departure time. In those instances
               where a consumer is unable to sign on a given day because of an acute health condition or
               episode, the signature of a designated center representative will be acceptable, but the event
               must be documented in the consumer’s record.

               For those services where the unit of service is defined as either a visit, an installation, the
               delivery of an item(s), a one way ride, or a repair, the service verification form or time-slip
               must identify the consumer served, and the date of service, and must be signed by the
               provider of the service (e.g. nurse, counselor, driver, etc.) and the consumer, or the
               consumer’s authorized representative.

               The Service Specific Operational Procedures for each service need to be referenced for
               further guidance related to service delivery or time-slip requirements.

        4.     For those services that are to be delivered on a recurrent basis within the consumer’s care
               plan (e.g. personal care, companion services, adult day service, etc.) the Provider must
               obtain a sample of the consumer’s signature at the time service is initiated, for verification
               purposes, using a staff member other than the person providing the service. If the consumer
               cannot sign, the signature of a person authorized to sign is to be obtained. The authorized
               person must sign their own name each time and indicate they are signing for the consumer


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               Exceptions to obtaining the sample signature include services that are provided on a one-
               time basis and/or entail a monthly rental cost for equipment. In such instances, the signature
               of the consumer or the consumer’s authorized representative at the point of service or the
               time of installation will suffice.

        5.     The signed service verifications or time slips are to be cross-checked with the sample
               signature and be kept in the consumer’s files or with the billing documents at the Provider’s
               office. The documentation shall be made available, as needed, for PCA’s monitoring or
               audits.

               No payment claim is to be submitted to PCA or MA without a signed receipt for each
               individual item or service. Any questionable or missing signatures during an audit by PCA
               or other authorized agent will result in a deduction of the amount billed from the next
               invoicing period. The mailing of copies of signed time slips to PCA is NOT required, unless
               specified by PCA. Documentation verifying service provision, as invoiced and reimbursed,
               must be made available for purposes of PCA monitoring and auditing.

        6.     NOTE: Personal Care providers are required to use a scheduling system for each field
               worker visiting PCA consumers. That schedule shall identify the worker’s name, each
               consumer to be visited, the date, starting and ending time, travel time between visits,
               and break time. Each worker’s schedule, combined with the daily time slips, must
               back-up that worker’s payroll records and the hours billed to PCA and/or MA.

               Just as careful scheduling of times of service is important to assure the most responsive and
               efficient level of service to our consumers, PCA expects that the scheduling of visits for
               workers be done with an eye to a reasonable visit pattern, including the overall work-load,
               breaks, and travel time. PCA’s monitoring, in consumers’ homes and in the Provider’s
               office, includes an evaluation of worker visit patterns and the number of hours per week
               scheduled, with an eye to: allowing travel time, no overlapping schedules (including staff
               working for more than one provider), realistic working hours, and rate of pay. Rescheduling
               of service shall occur only with consideration of the consumer’s needs, the plan of care, and
               with LTC Care Management approval.

K.      INVOICING

        1.     Invoices to PCA or MA are to be submitted on a monthly basis, based on prices agreed
               upon through the provider application process and the presence of consumer signatures on
               time slips. For the Options Program, invoices are to be submitted according to the schedule
               of dates provided by PCA and via the web-based Automated Billing System (ABS)
               procedures. For the Aging Waiver Program, PCA recommends the submission of claims to
               MA (via the PROMISe system) on a monthly basis, but recognizes that MA allows providers
               to submit claims on a more frequent basis.

               Questions regarding billing are to be directed to the Provider’s PCA Contract Manager.




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        2.     For Options, all services must be billed for the month that they are delivered to a LTC
               consumer. PCA does not allow any back billing for an individual consumer once an Options
               invoice has been submitted for a month.

               Care managers must be notified of any service that is not delivered in the month it was
               ordered, so that corrections can be made to care plans.

        3.     Travel time – providers may not invoice for staff travel time to and from a consumer’s
               home.

L.      MONITORING OF SERVICES

        1.     Each consumer is given the opportunity to monitor the quality of the services they receive, to
               select their service provider(s), and to approve the staff serving him or her. In order to
               measure the quality of care consumers receive, PCA tracks changes in providers and requests
               that consumers answer a Consumer Satisfaction Survey for each service they receive each
               year.

        2.     As a second method of tracking the quality of services consumers receive, Care Managers
               and administrative staff record based on telephone, in the office, and in the home contacts,
               their observations regarding the level and quality of communication with providers and the
               quality of the services that consumers receive.

        3.     PCA’s Business Administration Department audits the Provider’s records, files, and reports,
               in order to evaluate the quality, completeness, accuracy, and appropriateness of the
               Provider’s record keeping and various procedures, as well as to assess the type, amount,
               scope, and duration of the services provided. The audits pay particular attention to the
               interventions used and the subsequent outcomes in addressing the chronic problems of the
               consumer population.

M.      CONFLICT OF INTEREST POLICY

        1.     It is PCA’s expectation that providers will develop and maintain a Conflict of Interest Policy
               as part of their operating procedures. The policy must be in effect as a condition of
               certification, and will be reviewed during PCA’s monitoring. The policy shall include
               language addressing conflict of interest in the recruitment of staff and consumers, the
               provision of services, the marketing of services, and consumer confidentiality. Specifically,
               in order to minimize risk to the Provider, PCA, and consumers, the policy shall include
               references to:

               a.     Not engaging in any practices that are deemed improper as per DPW Medical
                      Assistance Regulations – Chapter 1101;

               b.     Recruiting staff in a proper and professional manner;

               c.     Respecting the right of all consumers to make a free choice in the selection of
                      providers, without encouragement to change providers through the offering of
                      financial or other enticements, pressure, or threats. This applies to consumers


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                      receiving services from another provider and when an employee leaves the
                      Provider’s employment;

               d.     Receiving prior written approval from PCA before using PCA’s proprietary material
                      and marketing services in a way that respects the right of all consumers to make a
                      free choice in their selection of providers, without encouragement to change
                      providers through the offering of financial or other enticements, pressure, or threats;

               e.     Protecting consumer confidentiality, including not revealing that a PCA consumer is
                      known to the Provider or revealing any information about any PCA consumer,
                      assuring that employees during and after employment will never reveal the names of
                      consumers served by the provider or any other information about the consumers.
                      Providers are encouraged to have employees sign a form, as a condition of
                      employment, assuring that no consumer information will ever be revealed.

               f.     Not engaging in any activity or conduct that conflicts with, or appears to conflict
                      with, the interests of PCA or its consumers.

N.      FALSE CLAIMS ACT POLICY

              Introduction: On February 8, 2006, President George W. Bush signed into law the Deficit
Reduction Act of 2005 (“DRA”). The DRA reduces federal Medicare and Medicaid spending; funds
programs benefiting certain individuals and families; and, significantly, addresses Medicaid fraud and
abuse.

               Specifically, Section 6032 of the DRA, entitled “Employee Education About False Claims
Recovery,” mandates the amendment of Medicaid State Plans to require certain entities, including PCA, to
implement written policies that describe: (1) the prevention and detection of fraud, waste and abuse; (2)
false claims laws; and (3) whistleblower protection. Accordingly, without in any way limiting any other
policy, procedure or other requirement, including any requirement dealing with related matters, the
following shall apply:

               Policy: The purpose of this policy is to comply with requirements set forth in Section 6032
of the DRA regarding federal and state false claims laws. Entities covered under this provision of the DRA
must ensure that all employees, including management, and their contractors and agents, are educated
regarding federal and state false claims laws and the role of these laws in preventing and detecting fraud,
waste, and abuse in federal health care programs, including Medicaid.

                Because PCA arranges for health care services and provides social services funded by
federal health care programs, it is important to assure that the PCA Workforce understands and complies
with the compliance requirements for such programs.

               False Claims Laws: False claims laws are intended to combat fraud and abuse against the
government, including fraud and abuse in federal health care programs. The laws allow the government,
and in some cases, private individuals, to bring civil actions against healthcare providers to recover
damages and penalties when providers submit fraudulent or false claims to the government. There are
many different types of false claims. Examples include:

                     overcharging the government program


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                      charging for services that were never performed
                      providing less than what was promised
                      providing unnecessary services
                      misrepresenting the services provided
                      billing for services provided by an unlicensed or unqualified provider

                Federal Laws: There are both federal laws and Pennsylvania laws that address false claims
and protections for individuals who report fraud and waste to the government (commonly referred to as
“whistleblowers”). The Federal False Claims Act prohibits any person or entity from knowingly submitting
or causing the submission of a false or fraudulent claim for payment to the federal government. For
purposes of the Act, the term “knowingly” means having actual knowledge or acting in reckless disregard
or deliberate ignorance of the truth or falsity of the information. Violators of the Act may be liable for up to
three times the amount of the fraud, plus a civil penalty of not less than $5,500 and not more than $11,000
for each claim. The Federal False Claims Act authorizes private individuals to bring false claims actions on
behalf of the government, for which the individual may receive between 15 and 30 percent of any recovery
depending in part upon whether the government intervenes in the action. The Act applies to federally
funded programs, including Medicare and Medicaid.

                 The Federal False Claims Act also prohibits an employer from retaliating against an
employee for attempting to uncover or report fraud on the federal government. Any employee who is
discharged, demoted, suspended, threatened, harassed or in any other way discriminated against in his or
her employment as a result of the employee’s lawful acts in furtherance of a false claims suit may bring an
action against the employer in federal district court. An employee who is retaliated against as set forth in
the Act is entitled to reinstatement at the same level, two times the amount of back pay plus interest, and
compensation for any special damages sustained as a result of the discrimination, such as litigation costs
and reasonable attorneys’ fees.

               The Program Fraud Civil Remedies Act of 1986 (“PFCRA”) is another federal law that
provides administrative remedies for the knowing submission of false claims and false statements. For
purposes of the PFCRA, a false claim or false statement includes a claim or written statement submitted to
the federal government which asserts a material fact that is false, omits a material fact, or is for services that
were not provided. Penalties for a violation of the PFCRA include a civil penalty of up to $5,000 per claim,
plus an assessment of up to twice the amount of each false claim.

                Pennsylvania Laws: The Commonwealth of Pennsylvania has not yet enacted a false
claims statute like the Federal False Claims Act. However, it does have anti-fraud laws that impose
criminal and civil penalties for false claims and false statements. The law applicable to Medicaid providers
prohibits the submission of false or fraudulent claims to Pennsylvania’s medical assistance programs as
well as the payment of kickbacks in connection with services paid in whole or in part by a medical
assistance program. A violation of the law is a criminal felony offense that carries with it penalties of
imprisonment of up to 7 years, fines, and mandatory exclusion from Pennsylvania’s medical assistance
programs for five years. Beyond criminal penalties, the law authorizes the Pennsylvania Department of
Public Welfare to institute a civil action against a provider for two times the amount of excess benefits or
payments paid plus interest.

               Pennsylvania has another anti-fraud law that prohibits beneficiaries of medical assistance
programs from making false claims or false statements in connection with an application for medical
assistance benefits or payments. Depending upon the nature of the violation, criminal penalties range from



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felony to misdemeanor offenses. In addition, the Department of Public Welfare may institute a civil action
against a beneficiary.

                Pennsylvania also has a Whistleblower Law that prohibits an employer from discharging,
threatening or otherwise discriminating or retaliating against an employee of a public body because the
employee in good faith reports or is about to report wrongdoing or waste to the employer or appropriate
authority. While the Law applies only to employees of a “public body,” Pennsylvania courts have
interpreted the phrase “public body” to refer to entities that receive money from the Commonwealth. This
includes Medicaid providers.

                How to Report Concerns Regarding Fraud, Abuse, and False Claims: PCA is
committed to conducting its business in a lawful and ethical manner. The PCA Workforce must comply
with all applicable laws, regulations, policies, procedures, and other requirements. PCA requires all PCA
Workforce members to identify and report immediately any issues regarding fraud, waste, abuse and false
claims, including any suspected issues or concerns, to PCA’s Manager of Auditing Services or Vice
President of Business and Finance. Any questions about this policy should be directed to PCA’s
Compliance Officer, the Vice President of Business and Finance.

                Reports may be made on an anonymous basis. Any reported matters that suggest substantial
violations of applicable laws, regulations, policies, procedures and other requirements shall be documented
and investigated promptly.

References:    Deficit Reduction Act of 2005, §§ 6031 and 6032
               Federal False Claims Act, 31 U.S.C. §§ 3729-3733
               Program Fraud Civil Remedies Act of 1986, 31 U.S.C. §§ 3801-3812
               Pennsylvania Whistleblower Law, 43 P.S. §§ 1422-23
               Pennsylvania Public Welfare Fraud and Abuse Control Laws, 62 P.S. § 1407, § 1408




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O.      SERVICE ORDER AUTHORIZATION PROCEDURE


        1.     No service is to be initiated, changed, or terminated prior to care plan expiration, or included
               on an invoice without receipt of a service order. Providing service without a service order is
               not allowed and will not be reimbursed.

        2.     Upon development of the PCA care plan, a service order will be forwarded to the provider.
               If the provider identifies an error on the service order, or has a question, they are to call the
               LTC staff person immediately to clarify any concerns.

        3.     Only the lesser of the amount of service ordered or the service amount that is delivered will
               be paid. The amount invoiced for each consumer is not to exceed the authorized amount in
               the care plan. Any amounts invoiced by the provider that exceed PCA authorized amounts
               will not be paid and reported back to the provider as discrepancies.

        4.     With the implementation of web-based service orders, it is absolutely essential that providers
               log in to the PCA site and download service orders daily.

        5.     If a provider is expecting a service order to start service and the service order is not received
               in sufficient time to initiate service, the provider must contact the Care Manager (or his/her
               direct Supervisor or RN Consultant, if unavailable) to verify the current status of the request.
               6.      Service orders are labeled (I) Initial, for all new consumers and those care plans that
               are renewed six month care plans; (M) Modified, for changes to a service during the six-
               month care plan period; or (T) Terminated, to terminate specific services. Services put on
               hold are reflected on a Modified service order, (refer to attached codes). All service types,
               which are re-ordered, will show as Duplicates.

        7.     It is important that particular attention be paid to the dates on the service order and the
               monthly totals. If a provider is not able to start a service as specified, the provider must
               notify the Care Manager (or his/her direct Supervisor) to assure the service is still needed
               and remains appropriate and to assure it is re-entered for the next month. All rescheduled
               service or additional months or units must be authorized through a service order.

        8.     If the days of the week that service is provided differ from those indicated on the service
               order, the total amount of service projected for the month in PCA’s system may be less. If
               this happens, the excess service during the month delivered by the provider will not be paid
               and the full amount reflected on the provider invoice will not be reimbursed. Each service
               order specifies the total units and/or cost for each month. It is each provider’s responsibility
               to assure the service being billed is equal to, or less than that specified on the service order.
               It is important that providers notify the Care Manager of all delivery patterns, especially if
               there is a change, so that PCA and provider records are identical.

        9.     Please note that although the LTC Program may authorize provision of service by a service
               order, payment remains contingent upon fulfilling any related reporting requirements, as
               delineated by PCA for the Options consumers and DPW for the Aging Waiver program. For
               the Aging Waiver program, providers must confirm consumer eligibility utilizing the
               Eligibility Verification System (EVS) and/or PROMISE system, prior to the delivery of


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          service, as stipulated by DPW regulations.

   10.    Care plans typically are ordered for a six-month or one year period. It is suggested each
          provider set controls to track all consumer care plans to assure service orders are received
          prior to expiration of the previous care plans. If a new service order is not received in a
          timely manner (received before the next period begins), the provider must contact the Care
          Manager or his/her direct Supervisor and obtain a copy before continuing service. Providers
          must not continue to provide service without an updated service order.

   11.    The reason codes that follow are used to explain the basis for revising care plans.




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  CODE                                      TERMINATIONS

     01     Consumer deceased.

     04     Nursing Home placement.

     05     Closure - (moved out of area, withdrew, situation resolved, etc.).

     15     Internal transfer. Service/case transferred to another PCA Department.

     19     Consumer is clinically ineligible.

     29     Consumer is financially ineligible.

  CODE                                   HOLDS / EXCEPTIONS

     16     Temporary hold -( Hospitalized, vacation, etc.)

     30     Provider no show. Worker did not show up or call to cancel visit.

     36     Temporary hold - skilled care/ Medicare. Consumer receiving third party
            reimbursed services.

     66     Temporary hold - Housing service not performed yet.




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P.      PROVIDER MONITORING: SANCTIONS

        A provider’s PCA contract for Long Term Care (LTC) and/or enrollment in the Aging Waiver
        Program is contingent on a provider meeting the appropriate Long Term Care (LTC) service and
        clinical care standards, program requirements, and applicable State licensing standards. Provider
        compliance to such standards is measured by PCA on an ongoing basis through formal monitoring
        procedures, as well as the day-to-day experiences of consumers and care managers.

        The purpose of this procedure is to set forth a system for addressing compliance issues or
        documented deficiencies in a provider’s performance and to delineate the subsequent actions
        leading to suspension of referrals, removal of consumers, contract termination, or decertification
        recommendation.

        1.     Findings of non-compliance to program standards, service delivery problems, and/or
               deficiencies may be identified by PCA in one of the following methods:

               a.      Results of formal monitoring site visits, such as the Administrative, Clinical, and or
                       fiscal audits. Where applicable, the Clinical audit will also measure compliance with
                       Clinical Audit Guidelines issued to providers.

               b.      The experiences and/or observations of LTC Department staff -care managers, nurse
                       consultants, etc., documented through Problem or Contact Logs, incident reports, or
                       care managers provider performance evaluations.

               c.      Consumer or caregiver complaints made directly to the care managers of LTC, the
                       Business Administration Department, through community ombudsman, and/or
                       concerns identified in consumer satisfaction surveys.

        2.     Requests for corrective actions to address deficiencies, with a time frame for
               implementation, are communicated to the provider in one of the following ways:

                       -      As a result of clinical care discussions or incidents reports;
                       -      Documented discussions of case conferences;
                       -      At an exit interview following all monitoring visits and in writing via the
                              monitoring/audit reports;
                       -      Monitoring follow-up meetings.

               a.      Plans of correction, in response to monitoring/audit findings, are required to be
                       submitted to PCA within 30 days of the date the monitoring report is mailed to the
                       provider. The acceptance of the plans of corrections will be confirmed to the
                       provider, in writing. The provider will be required to submit, within a reasonable
                       period of time, any revisions/corrections to plans of corrections deemed
                       unacceptable, in whole or part. Proof of implementation will be verified through
                       follow-up site visits, as needed.

               b.      Requests for immediate corrective actions may be made based on the severity of the
                       identified problems, e.g. clinical care issues- (see clinical audit section D.), incident
                       reports, direct care manager observations, unacceptable plans of corrections, etc.


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          c.     Provider meetings are scheduled periodically, and as needed, to provide a forum for
                 mutual discussions related to service issues, problem solving activities, and/or
                 monitoring results.

          d.     Notification of all adverse actions will be confirmed to the Providers, in writing.
                 Providers will be afforded the right to appeal adverse actions to terminate contracts,
                 certification, and decertification actions - see PCA Appeal Procedures.

   3.     Administrative Audits

          Providers’ compliance with PCA service standards are initially determined through a formal
          evaluation in a competitive bidding process (RFP) and/or certification process. An on-site
          Administrative audit is intended to gauge/verify a provider’s continued compliance with
          service standards as delineated in the contract or provider agreement. Those areas reviewed
          include:

                 -      Appropriate licenses, e.g. Medicare, MA, PDA, etc.;
                 -      Insurance coverage;
                 -      Verification of usual and customary rates;
                 -      Agency’s administrative procedures, including: record keeping, billing,
                        personnel records, training, etc.;
                 -      Time slip audit.

          a.     Verification of loss of appropriate licenses or a change in status of ownership,
                 provider name, or affiliation can affect the contract or certification status of a
                 provider.

                 (1.)   A provider’s loss of licensure - Medicare, MA, or PDA (adult day care) will,
                        in turn, result in contract termination or decertification action. Note: in
                        instances where a provisional license is issued, the provider will be placed on
                        “hold for new referrals” pending full licensure. The following actions will be
                        taken for a provider’s loss of license:

                        (a.)      Consumers served by that provider will be asked to select another
                                  provider.

                        (b.)      The PCA contract will be terminated and decertification action will be
                                  initiated - (see Aging Waiver Decertification Procedures).

                 (2.)   Merger with or acquisition of another provider may/will require a change in
                        the contract. Such changes may also result in new Medicare and MA
                        numbers being assigned to the new or changed entity. In such instances PCA
                        will assign a new provider number to be used in building consumer care
                        plans.

                        (a.)      Depending on the type of change, PCA may place a temporary “hold”
                                  on new consumer referrals, pending the assignment of new Medicare


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                               or MA numbers, as well as new PCA number.

                       (b.)    If such action results in structural and/or operational changes, which
                               adversely impact on the quality of service delivered by the provider,
                               consumers will be removed and asked to select another provider. The
                               provider will remain on hold pending the implementation of
                               appropriate corrective actions.

          b.    Providers must demonstrate proof of the types of and amount of insurances required
                by PCA as a condition for contract or certification.

                (1.)   Providers are required to submit updated certificates of insurance as needed.
                       Failure of a provider to submit updated certificates within a reasonable period
                       of time after it is identified as a deficiency, either as a result of an on-site
                       audit or through tracking of expiration dates, may result in PCA withholding
                       payment for current invoices, pending the corrective action.

                (2.)   Refusal or failure to comply with insurance requirements, unless given a
                       waiver, can result in a provider’s contract termination or decertification
                       action. In such instances, the following steps will be implemented:

                       (a.)    Consumers will be asked to select another provider.

                       (b.)    PCA contract will be terminated and decertification action initiated.

          c.    Providers must have in place the appropriate administrative procedures and
                organizational structure to meet LTC service standards relative to: staffing, training,
                record keeping, billing, and care manager communication.

                (1.)   Staffing must meet the specified levels of education, training, experience
                       indicated in the service standards and be approved by PCA; e.g. skilled
                       services, supervisory positions, etc. Only approved staff will be allowed to
                       provide service to PCA consumers. Failure to utilize approved qualified staff
                       can result in the provider being placed on “hold” for new referrals. (See
                       Clinical Audit, section D.)

                (2.)   Failure to have in place or follow required training curriculum can result in a
                       provider being placed on “hold” for new referrals, pending corrective actions.

                (3.)   Record keeping procedures, inclusive of personnel and consumer records,
                       must comply with all service and contract requirements.

                (4.)   The provider is expected to maintain consistent, ongoing communication with
                       the appropriate PCA staff and comply with all service reporting requirements.

                (5.)   The following corrective actions will be required when deficiencies are
                       identified in those provider service requirements identified in a. through d.,
                       above:


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                       (a.)   A hold for new referrals to the provider will be initiated, pending the
                              receipt and approval of a plan of correction.

                       (b.)   In instances where the identified deficiency(s), through its impact on
                              the quality of services delivered, presents a risk to consumers, those
                              consumers will be immediately removed and will be asked to select
                              another provider; see Clinical Audit section for additional
                              clarification.

                       (c.)   Implementation of corrective actions will be verified as needed,
                              including through an on-site “retest”. Failure to implement corrective
                              actions, as verified through this retest, will result in consumers being
                              removed and asked to select another provider.

                       (d.)   Failure to implement corrective actions may also result in contract
                              termination and initiation of decertification action.

          d.    Time-Slip Audit

                (1.)   Service providers are required to maintain fiscal records and procedures that
                       fully disclose the nature and extent of services rendered to consumers, as
                       authorized by Care Managers. These procedures must include provisions for
                       obtaining a consumer’s or family/caregiver’s signature that confirm delivery
                       of service using time-slips, encounter forms - (e.g., MA 91), or a comparable
                       format.

                       Providers may only invoice for delivered services confirmed by such
                       signatures. PCA auditors must be able to trace a clear audit trail from
                       workers’ field schedules, visits, signed documents and specified reports, PCA
                       Service Orders, to billed units related to a consumer file.

                       There may be some limited situations when a consumer is unable to sign due
                       to physical and/or cognitive limitations. This may be evident in Adult Day
                       Care centers, where obtaining a consumer’s signature may not be possible, in
                       some instances, due to clinical reasons. In those instances, the center can
                       utilize daily attendance logs, which are signed by a designated staff person.
                       The attendance log must document date of service, time of arrival and
                       departure, and that the consumer is unable to sign.

                (2.)   Time-slip audits will be conducted, at a minimum, yearly by the Contract
                       Managers and/or designated auditor(s) from PCA. This review will verify
                       invoiced units of service through documentation of signatures on time-slips
                       or attendance logs for a designated invoice/reporting period(s).

                (3.)   Over-billing (for service not delivered) or invoiced units of service that are
                       not verified by an acceptable consumer or other PCA approved signature (on
                       time slips, or other comparable formats) will be disallowed and the provider


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                              will be denied payment for those units of service:

                              (a.)   Disallowed units of service for the LTC Options program will be
                                     adjusted in the provider’s next payment.

                              (b.)   Disallowed units of service for the Aging Waiver Program will
                                     require the provider to submit an invoice adjustment to MA, giving
                                     back any overpayment. A copy of the invoice adjustment must be
                                     submitted to PCA.

                              (c.)   The degree of such billing errors may also require a more detailed
                                     review and testing by auditors from the Fiscal Department.

                              (d.)   A “hold” for new referrals will be initiated when the billing
                                     discrepancies are extensive, as confirmed by either the routine or
                                     special audits.

                              (e.)   Billing of a fraudulent nature may result in contract termination,
                                     initiation of decertification, and other legal actions.

                      (4.)    Providers will be expected to implement appropriate and timely corrective
                              actions for all discrepancies, including those attributable to entry errors,
                              incorrect filing, etc.

4.      Nursing Quality Assurance

        Provider compliance with PCA clinical standards initially is determined through a confirmation of
        Medicare and Medical Assistance licensure/certification and review of formal procedures and record
        keeping. Two primary activities are employed to ascertain ongoing compliance: clinical audits and
        internal reporting mechanisms by PCA staff.

        a.     Clinical audits are performed in order to gauge/verify a provider’s actual nursing/clinical
               practice and record keeping procedures to identify any potential situations of consumer risk.
               From the broader perspective, PCA staff looks for continued compliance with professional
               clinical standards related to the Nurse Practice Act, CMS regulations, State licensure, and/or
               PCA standards. Those areas reviewed include:

               -      Referral forms (for timeliness of response);
               -      Initial assessments (including CMS 485 and OASIS);
               -      Interventions;
               -      Documentation of agency case management compliance.

               The results of the audit are formally communicated to the provider, as follows:

               -      Clinical audit results, including those that demonstrate inappropriate clinical practice,
                      are verbally presented and discussed at an exit interview;
               -      Audit results, including those that demonstrate inappropriate clinical practice, are
                      spelled out by PCA in a written report to the provider,


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          -      Corrective actions, delineated in a Plan of Correction accepted and approved by
                 PCA, are required from the provider in response to PCA audit results that
                 demonstrate inappropriate clinical practice either in one or more “at risk” situations
                 or one or more clinical audit scores below 70%. Response is required whether the
                 results relate to one nurse or involve the entire agency.
          -      Based on PCA findings, the provider may be required to complete a new assessment
                 of the consumer, which may involve a joint visit with PCA staff.

          Serious “at risk” violation(s), flagrant disregard for PCA expectations, failure to submit a
          Plan of Correction within the acceptable time frame established by PCA, failure to act on a
          Plan of Correction, multiple audit scores substantially below 70%, or repeated scores below
          70% without signs that activity is being taken to correct, will result in one or more of the
          PCA actions, that follow. The specific action initiated will depend on the severity of the
          situation.

                 (1.)    The Program Review Nurse(s), in collaboration with the Contract Manager,
                         will immediately place the agency on hold for referrals. Depending on the
                         severity of the practice issues, the provider will be required to demonstrate
                         appropriate changes in practice before reinstatement.

                 (2.)    Program Review Nurses will re-orient the agency and all staff to PCA
                         philosophy, care management principles, and expected nursing practices, if
                         determined that a lack of understanding is the cause of the deficit.

                 (3.)    Where indicated, consumer(s) will be asked to select another provider.
                         Depending on the severity of the practice issues, the provider will be required
                         to demonstrate appropriate changes in practice before reinstatement.

                 (4.)    The PCA contract will be terminated and decertification action initiated.

   b.     Specific actions, based on substantiation that there is an inability on the provider’s part to
          safely serve a consumer, will be taken based on various internal PCA reporting mechanisms.
          Some of the major processes in place are PCA Problem Logs, Consumer Satisfaction
          Surveys, Incident Reports, LTC team meetings, ongoing review of Progress Notes, case
          conferences between Program Review Nurses and LTC program staff, and ongoing
          discussion with providers. The determination that a provider does not have the ability to
          respond to service requests to ensure a safe care plan will result in an on-site record audit
          and the potential of an evaluation home visit by PCA staff. Possible responses to clinical
          concerns include:

                 (1.)    Program Review Nurses will re-orient the agency and all staff to PCA
                         philosophy, care management principles, and expected nursing practices, if
                         determined that a lack of understanding is the cause of the deficit.

                 (2.)    The Program Review Nurse, in collaboration with the Contract Manager, will
                         place the agency on hold. Depending on the severity of the practice issues,
                         the provider will be required to demonstrate appropriate changes in practice
                         before reinstatement.


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                       (3.)    Where indicated, consumer(s) will be asked to select another provider.
                               Depending on the severity of the practice issues, the provider will be required
                               to demonstrate appropriate changes in practice before reinstatement.

                       (4.)    The PCA contract will be terminated and decertification action initiated.

        c.      Where a case conference is the source of reporting an “at risk” event, it will be the
                responsibility of the Nurse Consultant, Care Management Supervisor and Care Manager to
                document an accurate and timely report of the incident through a PCA Problem Log entry.
                The time frame for resolution of such incidents will be from immediate, for a life threatening
                situation, to within one month of the nurse or therapist’s last visit. Further activity will
                provide an immediate pathway for decisions, which may result in the actions above. Further
                incidents during a contract year can result in the termination of part or all referrals or
                termination as per this sanctions policy.

5.      Other

        a.      Providers are expected to adhere to and support the foremost principle of consumer
                autonomy in the selection of service providers. This includes the use of generally accepted
                marketing practices of their industry and/or as defined by the Philadelphia Corporation for
                Aging, Medical Assistance, Medicare, or JCAHO. Instances of violations will be addressed
                as follows:

                (1.)   Written notification to the provider and/or meeting to discuss violation.

                (2.)   Failure to comply after written notification can result in the provider being placed on
                       “hold” for new referrals.

                (3.)   Repeated violations or a refusal to comply can result in contract termination and/or
                       initiation of decertification actions.

        b.      Based on PCA Problem Logs, Incident Reports, complaints, Consumer Satisfaction survey
                results, and/or case conferences among Contract Managers and Care Managers, Care
                Management Supervisors, Nurse Consultants, and Assistant Directors of the LTC program
                and ongoing discussion with the provider that substantiate illegal or inappropriate provider
                activity, or inability to meet the requirements of the care plan or safely serve a consumer, the
                specific actions that follow will be taken by PCA:

                (1.)   Contract Managers will re-orient the agency to PCA philosophy, care management
                       principles, and expected performance, if determined that a lack of understanding is
                       the cause of the deficit.

                (2.)   The Contract Manager, will immediately place the agency on hold. Depending on the
                       severity of the issues, the provider will be required to demonstrate appropriate
                       changes in performance before reinstatement.

                (3.)   Where indicated, consumer(s) will be asked to select another provider. Depending on


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                       the severity of the issues, the provider will be required to demonstrate appropriate
                       changes in performance before reinstatement.

               (4.)    The PCA contract will be terminated and decertification action initiated.

c.      Where a case conference is the source of reporting a serious situation, it will be the responsibility of
        LTC staff to document an accurate and timely report of the incident through a PCA Problem Log
        entry. The time frame for resolution of such incidents will be from immediate, for a life threatening
        situation, to within one month of the reported incident for all others. Provider response to PCA
        decisions will determine further action by PCA, including hold status. Further incidents during a
        contract year may result in the termination of part or all referrals or termination as per this sanctions
        policy.




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                                    SECTION IV.



                           SERVICE STANDARDS &

        SERVICE SPECIFIC OPERATIONAL PROCEDURES




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A.      ADULT DAY CARE: STANDARDS


THE PROVIDER MUST BE LICENSED BY THE PENNSYLVANIA DEPARTMENT OF AGING,
PURSUANT TO PENNSYLVANIA CODE,
“TITLE 6. AGING, CHAPTER 11", AS AMENDED.

        1.     Service Reporting

               Persons providing Older Adult Daily Living services must comply with all reporting
               requirements as specified by the AAA.

        2.     Scheduling

               Days and times schedules for Older Adult Daily Living services must be consistent with the
               Care Plan provided by AAA.

        3.     Confidentiality

               All agencies that provide Older Adult Daily Living services must comply with all federal,
               state, and local laws relating to research on human subjects and consumer confidentiality.

               Agencies must provide all Care Managers with consent forms and approval from all
               appropriate review boards for those consumers who wish to be part of a research study.




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B.      ADULT DAY CARE - SERVICE SPECIFIC OPERATIONAL PROCEDURES

These operational procedures set forth requirements for facilities providing Adult Day Care service
to Philadelphia Corporation for Aging (PCA) consumers, of the Long Term Care (LTC) program
which encompass the Options and Aging Waiver payment sources. The operational procedures are
in addition to the Adult Day Care Standards, as well as those as delineated by the Pennsylvania
Department of Aging license standards pursuant to Pennsylvania code, “Title 6, Aging, Chapter 11”,
as amended.

        1.     License

               All providers must have demonstrated experience in the delivery of adult day care service to
               consumers and be in operation with all the necessary components, prior to being placed on a
               consumer selection list. All adult day care providers must have, as a minimum, a
               “Provisional” license from the Pennsylvania Department of Aging.

        2.     General Requirements

               a.     Administrative Structure and Organization

                      (1.)   The adult day care center shall have clearly delineated lines of authority and
                             supervisory structure.

                      (2.)   The adult day care center shall have a full-time administrator/program
                             director with the authority and responsibility to direct and manage the
                             operations of the center.

                      (3.)   The legal entity operating the adult day care center will furnish proof of
                             ownership by person, society, corporation, governing authority, or partnership
                             legally responsible for the administration and operation of a center. Such
                             proof shall include:

                             -       Indication of legal business structure and type of control. If the legal
                                     entity is a corporation, it shall submit a copy of the articles of
                                     incorporation. If a partnership, a copy of the partnership agreement.
                                     Copies of a fictitious name approval and a charter approval, if
                                     applicable.

                             -       Listing of all directors, board members, and share holders; preferably
                                     documented via a “certificate of incumbency” signed by the secretary
                                     of the corporation;

                             -       Copy of an IRS tax identification number, e.g. IRS notification letter
                                     or tax label.
               b.     Staffing

                      (1.)   The adult day care center staff will have experience working with older adults
                             with functional and/or cognitive impairments and meet the specific education,


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                       experience, and skill requirements for the following positions, as defined by
                       the PDA License requirements:

                       -       Program director/administrator;
                       -       Social Worker;
                       -       Registered Nurse or Licensed Practical Nurse;
                       -       Activities coordinator;
                       -       Program aides.

                (2.)   Use of volunteers to supplement staff is encouraged however they cannot be
                       used to fulfill minimum staffing requirements.

                (3.)   Staff persons may simultaneously perform the duties and responsibilities of
                       more than one position. In such instances, the staff person shall meet the
                       licensure requirement for each of the positions held, and at least the minimum
                       education or equivalent experience requirements for each of the positions
                       held.

          c.    Nutrition – adult day care centers may prepare food onsite or arrange for service
                from outside sources. In all instances, all meals served shall be based on the
                following:

                (1.)   Each meal shall conform to the requirements of the Nutrition Services
                       Incentive Program (NISP), Title III of the Older Americans Act as amended
                       (2000). Specifically, each meal shall provide at least one-third of the current
                       Dietary Allowances for persons aged 51 years and older, as established by the
                       Food and Nutrition Board of the National Academy of Science. Each meal
                       must also adhere to The Dietary Guidelines for American, Fifth Edition.

                (2.)   Each meal shall conform to the Philadelphia Corporation for Aging (PCA)
                       Congregate Meal Program Standards, which include the submission and
                       approval of two, six month, 20-day menu cycles.

                (3.)   All onsite and offsite meal preparation and serving areas must be inspected
                       and approved to assure compliance with local Health Department food
                       handling and serving regulations.

          d.    Unit of Service Defined

                (1.)   A full day of adult day care is defined as a consumer participating at a center
                       for duration of over 4 hours. A half-day of service is defined as consisting of
                       consumer participation of 4 hours or less.

                (2.)   Authorization for full day or half day of service is a function of a consumer
                       and/or caregiver needs as reflected in the plan of care and confirmed by a
                       service order.




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          e.    Referral Process

                (1.)   The PCA Care Manager will utilize the Adult Day Service Care Planning
                       Tool for all new referrals for adult day care service.

                (2.)   After confirming with the provider that a referral is being made, the PCA
                       Care Manager will fax a copy of the Tool in which the Care Manager will
                       have indicated/completed the PCA Assessment and Need sections, along
                       with brief explanations – as needed – in the Impairment section.

                (3.)   The adult day care provider will conduct their assessment of the consumer
                       and complete the Need and Impairment columns in the ADS Assessment
                       section. The completed form will be faxed back to the referring Care
                       Manager. Additional discussions and/or request for clarification can occur, as
                       needed.

                (4.)   If the consumer is determined appropriate for the program – by the center,
                       Care Manager, and if consumer is in agreement, service will be authorized
                       through the issuing of a Service Order.

          f.    Service Authorization and Days of Service Policy

                Adult Day Care service cannot be provided without prior written authorization by the
                LTC Care Manager, in accordance to the PCA Service Authorization Procedures

                Providers may accept consumer and/or caregiver initiated rescheduling of day of
                service within the same week. Approval by the Care Manager is not required in such
                instance nor is a new Service Order. However, it is imperative that the provider
                remind the consumer that adjustments in other scheduled services may also be
                required, e.g. personal care. When CCT-Shared Ride is involved, any rescheduling
                of days of service will require the provider to make the requisite arrangements with
                the CCT-Shared Ride Coordinator.

                On occasions where the length of an authorized unit of service is inadvertently
                affected by factors such as transportation problems through the CCT-Shared Ride
                vendor, inclement weather, and/or illness the adult day care provider will be paid for
                delivered service at the authorized unit of service level. However, the Care Manager
                needs to be notified of such instances or changes in the consumer’s circumstance so
                that, if needed, the consumer care plan can be adjusted.

                In addition, when making such schedule changes, consideration must be given to
                days at the beginning or end of the month, as the change may affect the total days
                billed for that period. When rescheduling within the same week results in an increase
                of total authorized units within a month, it is imperative for the provider to contact
                the Care Manager immediately so as to obtain a revised Service Order, confirming
                the change in authorization totals for both adult day care and meals.




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               g.     Reporting Requirements

                      (1.)   Adult Day Care providers are required to send a copy of the formal plan of
                             care for each consumer to the PCA Care Manager within thirty (30) days
                             from the start of service.

                      (2.)   Adult day care staff must communicate with the Care Manager to keep
                             him/her informed of any changes in the status of the consumer’s health and
                             overall well being, attendance, and incidents. Adult Day Care providers are
                             required to forward written progress reports to the Care Manager when
                             requested.

                      (3.)   The adult day care will comply with all reporting requirements specified by
                             PCA, including the reporting of Shared Ride transportation service.

               h.     The provider shall obtain the consumer’s signature on a standardized form
                      (attendance log, etc.) for each day the service is delivered to a PCA consumer.
                      Confirmation of attendance can be made by an authorized representative in
                      those documented instances where the consumer cannot sign due to physical
                      and/or cognitive limitations. If or when requested, consumers and/or caregivers
                      must be given a copy of the signed form as a confirmation of delivery of service.
                      Providers can utilize multi-part forms to facilitate this acknowledgement of the
                      receipt of service on a given day.

3.      Communicable Diseases

        a.     Adult day care providers are expected to follow procedures recommended in the Center of
               Disease Control (CDC) Guidelines and OSHA Regulations when caring for consumers with
               communicable diseases. Adult day care centers are responsible to provide appropriate in-
               services regarding these universal precautions.

        b.     The adult day care shall notify the PCA care manager upon determining or learning from
               another source, that a consumer has a communicable disease.

        c.     The provider must follow CDC and OSHA Guidelines regarding the disposal of
               contaminated needles.

        d.     All consumer-contact employees shall have a Mantoux Interacutaneous PPD Test
               according to CDC recommendations and, if the results are positive, it will be followed by
               appropriate physician directed treatment.

               In order to continue employment, the employee must be free of active TB. Verification by a
               physician that the employee is free of TB must be in the personnel file and updated every 2
               years, minimum. Chest X-rays are required based on physician’s advice.

        e.     All employees must be offered and/or received the Hepatitis B Vaccine designated by
               OSHA Regulations.



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C.      ATTENDANT CARE / ACT 150: SERVICE SPECIFICATIONS


        *NOTE: Applicable for only the designated Attendant Care/Act 150 Providers.


        1.     ATTENDANT CARE SERVICES – Transition of Services for Consumers Turning
               Age 60

               The Department of Public Welfare (DPW) Attendant Care Program is intended to enable
               mentally alert, physically disabled persons who cannot perform activities of daily living
               tasks by themselves to remain independent in their own homes. There are two distinct
               consumer categories within the Attendant Care Program: Attendant Care Waiver (where
               consumers are MA eligible), and Attendant Care Act 150, (where consumers are not MA
               eligible). Consumers in both categories of the DPW Attendant Care Program have the right
               to direct their own service. DPW Attendant Care consumers may also direct their attendant
               to perform certain health maintenance activities, which the consumer would elect to do if
               he/she were physically able. Note: the Commonwealth of Pennsylvania Department of
               Public Welfare Office of Social Program’s Revised Attendant Care Program Requirements,
               published April 1, 2002, inclusive of all subsequent policy changes, are hereby included by
               reference.

               When DPW Attendant Care Program – Act 150 consumers in Philadelphia County reach the
               age of 60, the Philadelphia Corporation for Aging (PCA) – as the designated local Area
               Agency on Aging (AAA), is required to ensure uninterrupted, appropriate levels of attendant
               care services to those consumers. The transition of services is governed by the Pennsylvania
               Department of Aging (PDA) Attendant Care policy – hereby included by reference. This
               policy allows DPW Attendant Care Program consumers to continue to receive attendant care
               services in the manner in which they are accustomed while also enabling these consumers
               entry into the aging services system.

               DPW Attendant Care consumers can continue to receive attendant care services from the
               same DPW Attendant Care service provider. PCA will enter into written agreements
               directly with the Attendant Care service providers to ensure the continuity of service for the
               Act 150 consumers. PDA will provide information regarding rate structure, based on DPW’s
               published rate guidelines.

               a.     Service Models

                      Attendant Care is “hands-on” and “hands-off” service provided to persons who are
                      unable to independently meet some or all of their needs relative to personal hygiene,
                      activities of daily living and managing their home, and where no resource (or only
                      partial) exists in the family or community. Attendant care may be provided up to
                      seven days per week. It shall be available during normal working hours, as well as
                      before and after working hours. Scheduling of service shall respond – to the extent
                      feasible, to the special needs of the individual.




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                “Hands-on” personal care assistance can include:

                -      Getting in and out of bed, wheelchair or motor vehicle;
                -      Assistance with ambulation – with or without mechanical aids, inside the
                       home;
                -      Routine bodily functions such as eating or feeding, meal preparation, and
                       toileting;
                -      Assistance with bathing dressing, personal hygiene; and
                -      Assistance with health maintenance activities.

                Consumer will receive attendant care service based on one of the following:

                (1.)   Consumer-Employer Model - The consumer is responsible for managing all
                       aspects of his/her attendant care service, such as: recruitment, hiring and
                       firing attendants, training, supervising, filing and paying all applicable taxes,
                       purchasing liability insurance, and arranging for back-up service. The
                       consumer is the employer of the attendant.

                (2.)   Combination Model - The consumer chooses certain aspects of their
                       attendant care service to manage, and the attendant care provider agency
                       and/or PCA is responsible for the remaining aspects of care. For example: the
                       consumer elects to recruit, hire, train and supervise the attendant, but not the
                       recording, filing and paying of employee taxes, etc.

                (3.)   Agency Model - The consumer is not responsible for the management of any
                       aspect of their care. PCA or the subcontracted attendant care provider would
                       employ the attendant and manage all aspects of the consumer’s care.

          b.    Role of the AAA in the Transition of Service

                DPW Attendant Care providers shall notify PCA at intervals of 18 months, 12
                months, and four months prior to a consumer’s 60th birthday, and provide copies of
                the notifications to the DPW Office of Social Programs and the consumer. As the
                local AAA, PCA will be responsible for the provision of Attendant Care services
                when the Act 150 consumers turn age 60.

                PCA, in its role as the purchaser of services for DPW Attendant Care Program
                consumers who turn age 60, shall be responsible for the following:

                (1.)   PCA is responsible to contact each Attendant Care Program consumer –
                       Waiver and Act 150, prior to their 60th birthday to schedule a “confirmation”
                       visit to acquaint the consumer with Aging services. Note: If an Attendant
                       Care Waiver consumer chooses to stay with that program, the PCA Care
                       Manager will inform the Attendant Care provider of that consumer decision.

                (2.)   Ensuring that the existing DPW cost- sharing arrangement (sliding fee scale)
                       continues as part of the Attendant Care provider’s care plan. Consumers
                       eligible for co-payment in the DPW Act 150 Attendant Care program will be


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                       re-assessed upon their transition to PCA services. Consumer fee assessments
                       will be determined as per DPW Attendant Care Program and Pennsylvania
                       Department of Aging requirements.

                       PCA will confirm to the Attendant Care providers, as well as the consumers,
                       the co-pay determination. The providers will be responsible for the collection
                       of and the reporting of their designated consumers’ co-payments. The
                       providers will “net out” those co-payments when submitting their invoices for
                       services to PCA. The existing DPW Attendant Care Program penalties for
                       failure to pay fees shall continue to apply.

                (3.)   PCA is in control of the care plan. Any changes to the consumer's original
                       Attendant Care provider care plan must receive prior approval by PCA and
                       Office of Long Term Living.

                (4.)   Situations may arise in which PCA determines that it would be more cost
                       effective to serve the consumer directly and not contract with the Attendant
                       Care provider. If the consumer's Attendant Care provider care plan remains
                       the same (same attendant, same hours, etc.) and the consumer agrees to the
                       change in service delivery, then the PCA shall contact PDA and request a
                       waiver to this policy.

                (5.)   Establishing time intervals to conduct "Progress Interviews" with the
                       consumer. The purpose of conducting periodic progress interviews is to
                       solicit input from the consumer regarding his or her continued satisfaction
                       with the existing service and to evaluate any changing needs of the consumer,
                       which may warrant PCA intervention.

                (6.)   Conducting an assessment of the consumer using the LOCA only when:

                       (a.)   It has first been discussed with the consumer and the consumer has
                              been educated regarding what the LOCA is and how and why it is
                              used; and

                       (b.)   It is requested by the consumer; or PCA determines that the
                              consumer's cognitive condition has declined to the point where only
                              PCA services are warranted; or the Attendant Care service provider
                              can no longer serve the consumer because the consumer is no longer
                              mentally alert or for some other reason AND the consumer is referred
                              to PCA by the Attendant Care provider to provide all services.

          c.    Supports Coordination and Financial Management Service

                (1.)   Support Coordination are those activities performed by the Attendant Care
                       providers to support those consumers who self direct their care through the
                       selection of the Consumer Employer or the Combination Model of service.
                       Support coordination activities can include, but is not limited to:




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                       (a.)   Assisting consumers to recruit, supervise, manage and train their
                              attendants;
                       (b.)   Credentialing all attendants hired by the consumer, to ensure
                              compliance with all PDA worker specifications and regulations;
                       (c.)   Performing criminal record check on all attendants hired by the
                              consumer, including emergency back-up workers, as well as
                              processing all I-9 forms and related Homeland Security compliant
                              forms.
                       (d.)   Providing training to consumers regarding all aspects of being an
                              employer, developing job descriptions, etc.

                       Note: Attendant Care providers will receive a monthly coordination fee for
                       those in the consumer directed Consumer Employed or Combination Model
                       of service.

                (2.)   Financial Management Services (FMS) are supportive services provided only
                       to participants (consumers) who use consumer-employer model services for
                       some or all of their individual service plan hours. When FMS is provided, the
                       participant is the common law employer of the direct care worker employed
                       under the consumer-employer model. FMS agencies reduce the employer-
                       related burden of participants using the consumer-employer model of services
                       through the provision of appropriate fiscal and supportive services. FMS
                       agencies must have a separate Employer Identification Number (EIN) for
                       FMS.

                       FMS includes performing the following tasks with the participant’s
                       authorization:

                       (a.)   On behalf of the participant employer, enrollment of the participant
                              into all applicable taxing authorities;
                       (b.)   Assisting participant to understand their responsibilities as an
                              employer;
                       (c.)   On behalf of the participant employer, processing employment
                              application package and documentation for prospective individual to
                              be employed (including verifying their workers’ qualifications and
                              clearances);
                       (d.)   On behalf of the participant employer, establishing and maintaining a
                              record for each individual employed and process all employment
                              records;
                       (e.)   On behalf of the participant employer, preparing and disbursing
                              payroll;
                       (f.)   On behalf of the participant employer, securing workers’
                              compensation or other forms of insurance and managing the claims;
                       (g.)   On behalf of the participant employer, withholding, filing, reporting
                              and depositing federal, state, and local income taxes in accordance
                              with federal IRS, state Department of Revenue Services, and local tax
                              bureaus rules and regulations;
                       (h.)   On behalf of the participant employer, withholding, filing, reporting,


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                               depositing and maintaining compliance with the claims and appeals
                               with the Pennsylvania and Federal Unemployment Compensation
                               Bureaus rules and regulations;
                       (i.)    On behalf of the participant employer, generating and distributing IRS
                               W-2’s, wage and tax statements and related documentation annually
                               to all member-employed caregivers who meet the statutory threshold
                               earnings amounts during the tax year by January 31st;
                       (j.)    On behalf of the participant employer, acting on behalf of the
                               participant receiving supports and services for the purpose of payroll
                               reporting;
                       (k.)    On behalf of the participant employer, distributing, collecting and
                               processing provider time sheets and attendance data as summarized on
                               payroll summary sheets completed by the participants;
                       (l.)    On behalf of the participant employer, securing business agreements
                               with any individual or entity that will be reimbursed with waiver
                               funding;
                       (m.)    On behalf of the participant employer, establishing and maintaining
                               all FMS related participant records with confidentiality, accuracy, and
                               appropriate safeguards;
                       (n.)    Participating in the Commonwealth of Pennsylvania’s quality
                               management strategy;
                       (o.)    On behalf of the participant employer, purchasing other forms of
                               insurance, including healthcare, as appropriate;
                       (p.)    On behalf of the participant employer, verifying weekly service hours
                               in relationship to payroll in order to ensure correct billing, problem
                               resolution, and alternate billing procedures;
                       (q.)    On behalf of the participant employer, processing judgments and
                               wage garnishments and requests for employee wage information;
                       (r.)    Rescinding or revoking all authorizations when a participant leaves
                               the program;
                       (s.)    Maintaining compliance with all applicable regulations and statutes,
                               such as the Bureau of Program Integrity’s (BPI) fraud and abuse
                               policies;
                       (t.)    Collecting co-pays from applicable Act 150 consumer employers; and
                       (u.)    Providing reports and documentation to the Department as requested.

                       Note: effective August 1, 2007, Attendant Care providers will receive a
                       separate fee -in addition to the monthly coordination fee, for the Financial
                       Management Services (FMS) detailed above. The additional FMS fee is
                       limited to those in the consumer directed Consumer Employed or
                       Combination Model of service.

          d.    Personal Emergency Response Systems (PERS)

                Personal Emergency Response Systems (PERS) is an electronic device which
                enables certain high-risk consumers to secure help in an emergency; see PERS
                standards included in the PCA Contract, Exhibit “A” attachment. PERS service is
                limited to those consumers who live alone or who are alone for significant parts of


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                the day, have no regular caregiver for extended periods of time, and who would
                otherwise require extensive routine supervision.

                Service authorization for PERS is coordinated by the Attendant Care provider with
                the PCA Care Manager. The Attendant Care provider should establish PERS vendor
                agreements for equipment installation and monthly monitoring cost for the Attendant
                Care consumers. Note: effective 10/1/07, the monthly monitoring cost for PERS
                service is inclusive of installation costs.




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D.      COMPANION SERVICES: STANDARDS


        1.     DESCRIPTION OF ACTIVITIES

               Companion Services are provided in accordance with a therapeutic goal in the care plan and
               are not merely diversional in nature.

               Activities may include, but are not limited to the following:

               a.     Accompanying consumer on daily walks.

               b.     Reminding consumer to begin or finish meals.

               c.     Accompanying consumer to appointments, errands, etc.

               d.     Socialization activities, such as reading books, writing letters, etc.

               e.     Casual physical assistance, such as assisting the consumer in putting on a coat, etc.

        2.     STANDARDS FOR COMPANIONS

               a.     Ability to read, write and follow instructions.

               b.     Understanding and knowledge of the special needs of older chronically ill
                      individuals.

               c.     Good personal grooming habits.

        3.     COMMUNICABLE DISEASES

               a.     Providers are expected to follow procedures recommended in the Center for Disease
                      Control (CDC) guidelines and OSHA regulations. Providers are responsible to take
                      appropriate action and provide in-services regarding these universal precautions.
                      (CDC toll free number is 1-800-342-2437.)

                      Providers are also required to provide appropriate protective articles such as, but not
                      limited to, aprons, gloves, and masks.

               b.     Based on CDC guidelines, the provider shall develop a written policy regarding
                      communicable diseases.

               c.     The Provider shall notify the Care Manager, or supervisor, upon determining, or
                      learning from another source, that one of their workers or a consumer has a
                      communicable disease.




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          d.     PPD Test - A Mantoux Intracutaneous PPD test using the two-step procedure (the
                 tine test is not an acceptable alternative), shall be administered to all consumer-
                 contact employees before assigning to a work, and yearly, thereafter. If the results of
                 the PPD test are positive at any time, it shall be followed by an examination by a
                 physician and chest x-ray (if indicated) and any appropriate treatment prescribed.

                 An infected worker shall receive follow-up care as required by a physician and shall
                 not begin or resume work to consumers until discharged by the physician as no
                 longer contagious.

   4.     TRAINING STANDARDS

          Must be oriented to the purpose and background of the Home and Community Based
          Waiver.

   5.     RECORDS AND DOCUMENTATION

          a.     Provider must maintain service records that include a service order for tasks to be
                 performed.

          b.     Report form for the companion to document changes or other observed consumer
                 problems.

          c.     Individual time slips must be signed by the consumer or family member/caregiver
                 and the companion to document each unit of service billed.

   6.     SERVICE REPORTING

          Persons providing Companion services must comply with all reporting requirements as
          specified by the Area Agency on Aging.

   6.     SCHEDULING

          Days and times scheduled for companion services must be consistent with the Care Plan
          provided by the AAA.

   8.     CONFIDENTIALITY

          All agencies that provide Companion services must comply with all federal, state and local
          laws relating to research on human subjects and consumer confidentiality.

          Agencies must provide all Care Managers with consent forms and approval from all
          appropriate review boards for those consumers who wish to be part of a research study.




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E.      COUNSELING: STANDARDS

        1.     DEFINITION

               A broad array of health and mental health related counseling services to include but not
               limited to the following:

                   problem solving and coping skills,

                   nutrition education, counseling and/or diet instruction,

                   music therapy,

                   alcoholism,

                   drug dependency,

                   individual/marital/family stress,

                   family problems including situations of abuse or neglect,

                   detection and treatment of depression and other mental health conditions.

        2.     EDUCATIONAL QUALIFICATIONS

               All in-home counselors enrolled in the Medicaid Waiver program will have the appropriate
               credentials as deemed valid by experts in their specialized areas. Examples include:

                   Masters Degree or Ph.D. in Counseling; Social Work; Clinical Psychology; Educational
                    Psychology or Music Therapy;

                   Nursing Masters Degree in Psychiatric Adult Mental Health;

                   Registration with the American Dietetic Association;

                   License as required by that profession/discipline, i.e. PA license for MSW, etc.

        3.     SERVICE ACTIVITIES

                   Individual counseling
                   Marital/couple counseling
                   Family counseling
                   Group counseling

        4.     UNIT OF SERVICE SPECIFICATION

               a.     Visits will consist of approximately one hour spent with the consumer.



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          b.     The consumer assessment should include the counselor’s problem
                 identification, goal setting, time frame, treatment techniques and recommendation.

          c.     Every assessment and every visit will be documented by the counselor in a clinical
                 progress note.

   5.     SERVICE AUTHORIZATION

          a.     AAA Care Managers will assess the need for mental health assessment and/or
                 intervention and refer the consumer/caregiver to the counselor/agency as part of the
                 consumer's comprehensive care plan.

          b.     The counselor will discuss the case with the Care Manager and make an appointment
                 to assess the consumer’s situation.

          c.     After the assessment, the counselor will write up the assessment, and propose a
                 preliminary plan for treatment, should it seem appropriate, to the Care Manager.

          d.     Together they will project units of service.

          e.     The counselor will keep a case record on each consumer served, containing pertinent
                 clinical information.

          f.     The counselor will keep a monthly log, listing consumers' names and dates of actual
                 visits, and recording supervisory conferences, as they are completed. Individual time
                 slips must be signed by the consumer or family member/caregiver and the counselor
                 to document each unit of service billed.

   6.     SERVICE REPORTING

          Persons providing counseling services must comply with all reporting requirements as
          specified by the Area Agency on Aging.

   7.     SCHEDULING

          Days and times scheduled for counseling must be consistent with the care plan provided by
          the AAA.

   8.     INSURANCE

          Agencies who wish to provide Companion services will be required to attest to having the
          following types of insurance in amounts consistent in the industry:

          a.     General liability;
          b.     Professional liability;
          c.     Automobile liability covering owned, non-owned and hired vehicles;
          d.     Workman Compensation as required by law;
          e.     Employer’s liability of accident and disease.


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   9.     CONFIDENTIALITY

          All agencies who provide counseling services must comply with all federal, state and local
          laws relating to research on human subjects and consumer confidentiality.

          Agencies must provide all Care Managers with consent forms and approval from all
          appropriate review boards for those consumers who wish to be part of a research study.




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F.      COUNSELING SERVICE: SPECIFIC OPERATIONAL PROCEDURES

These Operational Procedures are in addition to the Counseling Standards. They delineate further
expectations for providers delivering service to Philadelphia Corporation for Aging (PCA)
consumers in the Long Term Care (LTC) Program, which encompass the Options and Aging Waiver
payment sources.

        1.     Definition and Operating Principles

               a.     The primary objective of in-the-home mental health counseling service is the
                      provision of short term, goal oriented counseling for consumers and/or their
                      caregivers in order to restore, remediate or rehabilitate in order to improve
                      functioning and independence.

               b.     In addition to the array counseling services identified in the Counseling Standards,
                      counseling includes:

                      -      Telephone supportive therapy;
                      -      Music Therapy.

               c.     When applicable, service providers must be Medicare certified and have a
                      provider number for counseling service.

               d.     PCA / LTC program shall be the payers of last resort. Providers shall bill
                      counseling service to third party payers – ( Medicare, MA fee schedule, managed
                      care), when eligible and indicated.

        2.     Staffing

               a.     Providers will utilize staff that has the appropriate credentials as deemed valid by
                      experts in the industry. Exceptions to staffing requirements may only be made
                      with prior written approval by PCA.

               b.     Supervisors must have a Master’s Degree, minimum, and a reasonable length of
                      clearly delineated experience in therapeutic counseling and supervision of clinicians.

               c.     Providers shall make available the services of a psychiatrist, when needed, for the
                      purpose of consultation and clinical support to counselors and supervisors.

        3.     Service Authorization and Reporting

               a.     No service may be provided without prior written authorization by the LTC Care
                      Manager, in accordance to the PCA Service Authorization Procedures.

               b.     An initial assessment shall be completed within ten (10) working days of the receipt
                      of a service order. The initial assessment evaluation results will be forwarded to the
                      referring care manager within ten (10) working days of the evaluation visit. The
                      initial evaluation shall include:


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                -    Diagnosis;
                -    Therapeutic goals;
                -    Plan of treatment.

          c.    Clinical progress notes that will contain sufficient clinical content regarding the
                treatment process and visit, must be maintained in individual consumer records. A
                clinical progress report that includes goals and progress towards achieving those
                goals will be forwarded to the LTC Care Manager on a monthly basis.

          d.    The provider shall obtain the consumer’s signature (or that of other authorized
                representative) on a time slip or other standardized form each time a service is
                delivered to a PCA consumer. Consumers must be given a copy of the signed form
                as a confirmation of delivery of service. It is recommended that providers utilize
                multi-part forms so that the consumer can receive their copy as an acknowledgement
                of the receipt of service on the given day.




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G.      PROFESSIONAL EVALUATION: SERVICE SPECIFIC OPERATIONAL PROCEDURES

        1.     General Information

               These Operational Procedures delineate further contractual requirements for
               Providers of Medical, Psychiatric, Psychological and OBRA Psychological
               consultations and evaluations. The following services may be ordered by
               representatives of PCA’s LTC Program: (Options), LTCA (Long Term Care Access)
               or OAPS (Older Adult Protective Services) Departments:

               -     Medical Physician Services

                     Provide medical consultations, case reviews and training to PCA programs;
                     participate at court hearings or appeals, and provide home visits when requested.
                     Refer to 2. below Medical Physician Services for a detailed description of services
                     required.

               -     Psychiatric Physician Services

                     Provide psychiatric evaluations, case reviews and training to PCA programs;
                     participate in court proceedings and appeals; and perform home visits.
                     Refer to 3. below Psychiatric Physician Services for a detailed description of services
                     required.

               -     Psychological Evaluation

                     Provide psychological evaluations, case reviews and training to PCA programs;
                     participate in court proceedings and appeals; and perform home visits. Refer to 4.
                     below for a detailed description of services required.

               -     OBRA Psychological Evaluations

                     Provide specialized consultative, training and evaluation services relating to Mental
                     Retardation or a Related Condition as required under OBRA at the request of PCA’s
                     LTCA Department. Refer to 5. below for a detailed description of services required.

               a.    INTAKE

                     (1.)   When the need for professional consultation or evaluation is identified, the
                            care manager, assessor, investigator or supervisor (“PCA Representative”)
                            will contact the Provider, selected by the consumer when appropriate, to
                            make the initial referral and to arrange for a home visit (if required) or other
                            service, which shall be performed by Provider within five (5) working days,
                            or within 24 hours in the event of an emergency.

                     (2.)   Upon confirmation of a date for the evaluation, the Care Manager will
                            forward a Service Order to the Provider authorizing service.



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                (3.)   To the extent that the above is at variance with the specific requirements of
                       the Attachment directly applicable to the services ordered, the requirements
                       of that Attachment shall control.

          b.    SERVICE DELIVERY

                (1.)   Upon receipt of the service order, the Provider will confirm the scheduled
                       date of evaluation with the PCA Representative. If indicated after initial
                       consultation with the Provider, a joint visit may be made with the PCA
                       Representative and any other providers involved in the consumer’s plan of
                       care.

                (2.)   Provider staff needs to communicate with the PCA Representative to keep
                       PCA informed of any changes in the consumer’s health status.

                (3.)   Provider staff shall communicate with the PCA Representative as follows:

                       (a.)   Within 24 hours of the initial contact with consumer, consumer
                              records or other provider involved in the consumer’s plan of care, the
                              results of the visit, review or contact shall be provided by phone to the
                              PCA Representative. The Provider will advise the PCA
                              Representative of any diagnosis and recommended plan of care. No
                              additional visits are to be made without a further service order.

                              (b.)    When there is a professional conflict regarding the delivery of
                              care between the Provider and other professionals.

                              (c.)  When the consumer is hospitalized or experiences a health
                              emergency.

          c.    REPORTING REQUIREMENTS

                (1.)   A written report of the evaluation findings will be forwarded to the PCA
                       Representative by the fifth (5th) working day following the visit or other
                       consultative activity. Evaluation findings for emergency request will be
                       submitted to the PCA Representative within 24 hours after the visit or other
                       consultative activity.

                (2.)   A telephone report of the evaluation will be provided to the PCA
                       Representative within 24 hours of the assessment visit.

                (3.)   To the extent that the above is at variance with the specific requirements of
                       the Attachment directly applicable to the services ordered, the requirements
                       of that Attachment shall control.




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          d.    STAFF QUALIFICATIONS

                (1.)   Providers will assign staff that has the following qualifications:

                       (a.)   Medical Physicians - must be board certified in internal medicine (and
                              preferably with added qualification in geriatric internal medicine);
                              have current Pennsylvania license; have experience in aging and
                              community-based care; and have experience in working with social
                              workers, nurses, and other health and social service professionals.

                       (b.)   Psychiatric Physicians - must be board certified or board eligible in
                              psychiatry (and preferably with added qualification in geriatric
                              psychiatry); have current Pennsylvania license; and have admitting
                              privileges at a local hospital.

                       (c.)   Psychologists - must have a Ph.D. level degree and be Pennsylvania
                              licensed clinical psychologists.

                (2.)   Provider shall submit for review and approval any exceptions to the above
                       staff requirements, in writing, addressed to the Contract Manager in PCA’s
                       Business Administration Department.

                (3.)   Provider shall notify the Contract Manager in the Business Administration
                       Department if there is any change in the roster of professionals assigned to
                       perform work under the Agreement.

                (4.)   To the extent that the above is at variance with the specific requirements of
                       the Attachment directly applicable to the services ordered, the requirements
                       of that Attachment shall control.

          e.    COMMUNICABLE DISEASES

                (1.)   When performing services under the Agreement, Provider shall comply with
                       all applicable law and adhere to all generally recognized professional
                       standards relating to communicable diseases, including but not limited to
                       Center for Disease Control (CDC) guidelines and OSHA regulations.
                       Provider shall provide its staff with appropriate training and supervision in
                       these areas, including in the use of universal precautions. (A training tape is
                       available from CDC upon request; the CDC toll-free number is 1-800-232-
                       4636).

                       Provider shall also provide to its staff appropriate protective articles
                       including, but not limited to, aprons, gloves, masks, and gowns as needed.

                (2.)   Provider shall develop written policies regarding communicable diseases
                       consistent with CDC guidelines, OSHA requirements and generally
                       recognized professional standards, and shall submit copies of these to the
                       PCA Contract Manager.


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                (3.)   Provider shall notify the PCA Representative upon determining that a
                       consumer has a communicable disease.

                (4.)   Provider shall adhere to applicable law, including but not limited to CDC and
                       OSHA guidelines and generally recognized professional standards, regarding
                       the disposal of medical waste.

                (5.)   To the extent that the above is at variance with the specific requirements of
                       the Attachment directly applicable to the services ordered, the requirements
                       of that Attachment shall control.




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2.      Medical Physician Services

        a.     Scope of Services:

               (1.)   The use of Physician evaluations or consultations are intended to:

                      (a.)   Evaluate at-risk consumers who do not currently have a primary physician or
                             those whose primary physicians are not responsive to the consumers’ needs;
                      (b.)   Complete MA51 for those consumers who do not have an identified primary
                             physician;
                      (c.)   Provide consultation in those difficult or borderline level of care and/or locus
                             of care decisions;
                      (d.)   Provide evaluations and/or consultations in those instances where there is
                             anticipation of a formal appeal of level and/or locus of care decisions.

               (2.)   The consumer population will include adults age 18 and over. However, the majority
                      of consumers will be over the age of 65.

               (3.)   Upon request, the physician consultant will make home visits.

        b.     Provider Responsibilities:

               (1.)   Review completed assessments and/or care plans of consumers selected by PCA with
                      Nurse Consultants, Supervisors and other PCA Representatives.

               (2.)   Consult with consumer’s physician and/or other health and social service
                      professionals regarding consumer’s recommended LOC and/or community based
                      home health care needs. If necessary, visit consumers at their home for final
                      recommendations.

               (3.)   Recommend a LOC determination when there is a disagreement among PCA
                      supervisors regarding the most appropriate LOC.

               (4.)   Review care plans of community based consumers from a quality assurance
                      perspective and make such recommendations, as the consultant deems appropriate.

               (5.)   Provide documentation of case review and recommendation within the case file of
                      consumers selected for consultation.

               (6.)   Participate when requested by PCA in supervisory or team conferences regarding
                      selected consumers for Long-Term Care programs.

               (7.)   Provide training requested by PCA through in-service training sessions.

               (8.)   Attend staff meetings as requested by PCA to review program implementations,
                      procedures and policies.




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          (9.)    Participate as requested by PCA in fair hearings or appeals processes or as witness in
                  court proceedings.

          (10.)   Provide medical information for consumers who do not have a physician relative to
                  the MA-51 form.

          (11.)   Provide home visits for Older Adults Protective Services consumers.

          (12.)   Coordinate with PCA and hospital or geriatric practice on use of students and
                  residents.

          (13.)   Be available up to six (6) hours per week, fifty (50) weeks per year, to provide the
                  above services.

          (14.)   Be available for emergencies on 24 hours notice.

      If these services are unavailable during vacation periods, backup telephone consultation,
      at a minimum, and other services mutually agreeable to the parties shall be provided by a
      member of the Provider’s internal medicine medical staff.




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3.      Psychiatric Physician Services

        a.     Scope of Service

               The primary objective of a Psychiatric Evaluation is the physical, functional, and mental
               health assessment of homebound elderly consumers who are referred by either the Options,
               OAPS, or LTCA Departments. The psychiatric evaluation is used in assisting PCA in the
               development of a consumer’s plan of care and/or the need for protective service or other
               (including emergency) intervention. On occasion, the psychiatrist may also be needed to
               give testimony in legal proceedings regarding a consumer’s mental status.

               Evaluations are to be provided by a Board certified or Board eligible psychiatrist licensed to
               practice in the state of Pennsylvania. Certain aspects of evaluations may also be conducted
               by gero-psychiatric nurses under the supervision of a licensed psychiatrist.

               (1.)   Psychiatric Evaluation - the psychiatrist or psychiatric nurse shall perform an
                      assessment of mental status, history, and need for treatment of referred consumers.
                      In emergency situations, the psychiatrist shall focus on evaluating the consumer’s
                      ability to receive and evaluate information effectively and communicate decisions
                      essential to the health and safety and the management of finances. Unless otherwise
                      specified, evaluations will be conducted in the person’s home. Consumer
                      evaluations shall be coordinated with the referring PCA Representative, within 5
                      working days from the date of the referral. Emergency evaluation requests shall be
                      conducted within 24 hours. If appropriate, the psychiatrist shall develop a
                      recommended treatment plan, which may include medication, outpatient psychiatric
                      services, supportive services, or in-patient psychiatric treatment. When
                      hospitalization is needed, the psychiatrist shall facilitate admission to the appropriate
                      licensed hospital. All medical treatment and/or hospital admissions shall be
                      coordinated with the consumer’s physician.

               (2.)   Participation in Legal Proceedings - As needed, the psychiatrist shall participate in
                      legal proceedings that may include:

                      (a.)    Petition for a 302 involuntary commitment for psychiatric evaluation;

                      (b.)    Testifying at hearings for a 303 or 304 commitment;

                      (c.)    Testifying in court as to consumer competency in guardianship hearings;

                      (d.)    Providing testimony as to consumer mental capacity in court petitions for
                              emergency orders under the Older Adults Protective Services Act. Such
                              testimony may be made orally or in writing at PCA’s direction.

               (3.)   Documentation of evaluations is to be reported as follows:

                      (a.)    If requested, a verbal/telephone report of the evaluation shall be provided to
                              PCA within 24 hours of the assessment visit.



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                (b.)   A written report of the evaluation findings shall be forwarded to PCA by the
                       5th working day following the assessment visit.

                (c.)   Evaluation findings for emergency requests shall be submitted to PCA within
                       24 hours after the assessment visit.




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4.      Psychological Evaluations

        a.     Scope of Service

               The primary objective of a Psychological Evaluation is the functional and mental health
               assessment of homebound elderly consumers who are referred by the Options, OAPS, or
               LTCA Departments. The psychological evaluation is used in assisting PCA in the
               development of a consumer’s plan of care and/or the need for protective service or other
               (including emergency) intervention. On occasion, the psychologist may also be needed to
               give testimony in legal proceedings regarding a consumer’s mental status.

               Evaluations are to be provided by a Ph.D. level psychologist licensed to practice in the state
               of Pennsylvania.

               (1.)   Psychological Evaluation - the psychologist shall perform an assessment of mental
                      status, history, and functional capacity of referred consumers. In emergency
                      situations, the psychologist shall focus on evaluating the consumer’s ability to
                      receive and evaluate information effectively and communicate decisions essential to
                      the health and safety and the management of finances. Unless otherwise specified,
                      evaluations will be conducted in the person’s home. Consumer evaluations shall be
                      coordinated with the referring PCA Representative, within 5 working days from the
                      date of the referral. Emergency evaluation requests shall be conducted within 24
                      hours.

               (2.)   Participation in Legal Proceedings - As needed, the psychologist shall participate in
                      legal proceedings that may include:

                      (a.)    Petition for a 302 involuntary commitment for psychiatric evaluation;

                      (b.)    Testifying at hearings for a 303 or 304 commitment;

                      (c.)    Testifying in court as to consumer competency in guardianship hearings;

                      (d.)    Providing testimony as to consumer mental capacity in court petitions for
                              emergency orders under the Older Adults Protective Services Act. Such
                              testimony shall be given orally or in writing at PCA’s direction.

               (3.)   Documentation of evaluations is to be reported as follows:

                      (a.)    If requested, a verbal/telephone report of the evaluation shall be provided to
                              PCA within 24 hours of the assessment visit.

                      (b.)    A written report of the evaluation findings shall be forwarded to PCA by the
                              5th working day following the assessment visit.

                      (c.)    Evaluation findings for emergency requests shall be submitted to PCA within
                              24 hours after the assessment visit.



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5.      Responsibilities of the OBRA qualified Mental Retardation Provider


        a.     Provider shall make available the services of a licensed, Ph.D. level, clinical psychologist
               with special training and experience in the evaluation of mental retardation for the purpose
               of assessing an applicant’s need for active treatment as required under OBRA. These
               services must be available at least two (2) hours per week, Monday through Friday, between
               8:30 am and 5:00 pm. Services shall include record review, telephone consultation in fifteen
               (15) minute minimum blocks of time, in-home evaluation, and other related activities
               appropriate and necessary to the individual case. Travel time is allowable at the hourly rate.
               Home visits are required when the individual applicant has not been evaluated previously by
               a qualified professional for the purpose of determining mental retardation or a related
               condition and measuring IQ.

        b.     The psychologist shall:

               (1.)    Identify the applicant’s intellectual functioning measurement;
               (2.)    Validate that the applicant has “mental retardation or a related condition”; and
               (3.)    Assess whether the applicant needs active treatment in order to function.

        c.     The psychologist may be required to provide one or more in-service training sessions to
               LTCA staff in the area of Mental Retardation or Other Related Conditions. In-service
               training sessions shall be one (1) to two (2) hours. A maximum of two (2) hours of
               preparation time is allowable at the hourly rate for each in-service training session.

        d.     The psychologist shall provide information to the Department of Public Welfare that
               identifies the extent to which an applicant compares with each of the following
               characteristics, commonly associated with the need for active treatment:

               (1.)    Inability to take care of most personal care needs;
               (2.)    Inability to understand simple commands;
               (3.)    Inability to communicate basic needs and wants;
               (4.)    Inability to be employed at a productive wage level without systematic long term
                       supervision or support;
               (5.)    Inability to learn new skills without aggressive and consistent training;
               (6.)    Inability to apply skills without aggressive and consistent training;
               (7.)    Without direct supervision, inability to demonstrate behavior appropriate to the time,
                       situation or place;
               (8.)    Demonstration of severe maladaptive behavior(s) which place the person or others in
                       jeopardy to health and safety;
               (9.)    Inability or extreme difficulty in making decisions requiring informed consent; and
               (10.)   Presence of other skill deficits or specialized training needs which necessitates the
                       availability of trained Mental Retardation personnel, 24 hours per day, to teach the
                       person to learn functional skills.




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H.      HOME HEALTH CARE: STANDARDS

Home health services include home health aide, nursing care, occupational therapy, physical therapy, and
speech therapy provided to an individual to enable them to remain in the community. These professionals
may be required to work as a team in their approach to the consumer’s care. Duration and scope of the
services are limited only by the care plan.

1.      SPECIAL ELIGIBILITY CRITERIA

        a.     Eligibility for Home Health Care service is established on the basis of a comprehensive
               needs assessment conducted by the AAA Care Management Unit.

        b.     The need for Home Health Care service must be confirmed by the nurse consultant and the
               Care Manager.

               (1.)   The nurse consultant will review the Care Management Assessment and other
                      pertinent medical information, including information obtained by contracting health
                      care providers who have cared for the consumer, to assure the appropriateness of the
                      service.

               (2.)   The nurse consultant may perform elements of a nursing evaluation, including
                      examining the consumer to assess a particular problem if there is a question of the
                      need or the kind of home care.

               (3.)   The nurse consultant may not carry out any treatments or clinical interventions.

               (4.)   The nurse consultant assists in the development of the care plan as it relates to Home
                      Health Care service.

        c.     Home Health Care service must be ordered by a primary physician.

               (1.)   The order must reflect the consumer’s medical condition and/or disability.

               (2.)   The order must include the specific nursing and/or therapeutic service required.

               (3.)   The order must be obtained by the Home Health service provider prior to service
                      authorization.

               (4.)   The order for continuation of service must be obtained every sixty days.

        d.    The registered nurse and therapist, if therapy service is being rendered, must evaluate the
              consumer to determine the consumer’s potential for rehabilitation and to enable the therapist
              to develop or modify a plan of care for him/her prior to service and every 60 days. This plan
              and recommendation for service must be submitted to the Care Management Unit prior to
              service authorization.

               If skilled care is not required, the services of the home health aide will be provided only as
               long as the need for supportive service continues. This necessitates that the registered nurse


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               or therapist performs a sixty-day evaluation to monitor the consumer’s improvement or
               regression. With each evaluation, instructions must be written for the home health aide
               including any changes in how supportive activities are to be rendered.

2.      ACTIVITIES FOR HOME HEALTH AIDE

        a.     Home Health Aide services are provided by a supervised aide who may be a trained home
               health aide or a license practical nurse. In addition to personal care, home health activities
               include:

               (1.)    Performing simple measurements and tests to monitor the consumer’s medical
                       condition including vital signs, simple urine checks for sugar and albumin and
                       measuring intake and output.

               (2.)    Assisting with ambulation when the consumer also uses an ambulation aide.

               (3.)    Assisting with other medical equipment use.

               (4.)    Assisting with exercises taught by a nurse or physical therapist.

               (5.)    Changing and/or reinforcing simple dressings on stable surface wounds.

               (6.)    Low level care of decubitus ulcers (as directed by a registered nurse).

               (7.)    Caring for well-healed normal functioning colostomy.

               (8.)    Assisting with changing of a colostomy bag (as directed by a registered nurse).

               (9.)    Monitoring of dietary habits and preparing special diet meals.

               (10.)   Assisting in retraining the consumer in self-help skills.

               (11.)   Reporting changes in the consumer’s condition and needs to the registered nurse
                       supervisor.

3.      STANDARDS FOR HOME HEALTH AIDE

        a.     Appropriately trained (see training standard).

        b.     Supervised by a licensed practitioner.

4.      TRAINING STANDARDS FOR HOME HEALTH AIDE

        Basic training of a minimum of 60 hours must be completed during the first 3 months of
        employment. (Suggested curriculum example: National Homecaring Council, "Instructions of the
        Homemaker-Home Health Aide" using at a minimum the 60 hour classroom modules including an
        Add-on Module dealing with Aging in place of the units covering Children, Mothers and Babies.)
        This may be waived if the Home Health Aide worker provides documentation of completion of


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        related training and/or is able to demonstrate competency in all skilled areas required in the basic
        training. In-service training shall be ongoing and home health aide workers must have demonstrated
        competency in procedures and activities they are asked to perform.

5.      SUPERVISION STANDARDS

        a.     Home Health Aide services must be supervised by a registered nurse and are provided under
               physician’s orders. Home Health aides are supervised by the subcontract agency's registered
               nurse and/or the therapist if they are assisting with therapeutic activities.

        b.     The supervision must occur in the consumer’s residence every two weeks with the
               supervisor reassessing the consumer’s situation, monitoring and assessing the home health
               aide job performance. It is not required that the home health aide be present every two
               weeks during the supervisory visit in the consumer’s home, but it encouraged that he/she is
               present during these visits as often as possible.

               It is required, however, that included in the supervisory notes there be documented
               communication between the registered nurse supervisor and the home health aide at least
               every two weeks, regarding the consumer’s condition, response to service and satisfaction,
               the home health aide’s job performance, re-evaluation of the care plan meeting consumer’s
               needs, etc., and any other pertinent information regarding the consumer’s condition, aide job
               performance or care plan implications.

6.      RECORDS AND DOCUMENTATION

        a.     The Home Health Care provider must maintain a standardized record keeping system. The
               system must ensure uniformity and consistency in documentation of the service provision,
               the consumer’s response to the service, and other observations made of the consumer.

        b.     Consumer information must be maintained in a confidential manner.

        c.     A separate record must be maintained for each consumer. The record must include:

               (1.)   the physician order;

               (2.)   AAA Service Authorization Form;

               (3.)   the plan of care established by the nurse and/or therapist;

               (4.)   the nurse or therapist assignment to the home health aide;

               (5.)   a record of supervisory visits for the home health aide;

               (6.)   documentation of each visit made to the consumer (to include changes in a
                      consumer’s condition) through a report to the Care Management Unit;




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               (7.)   Pertinent consumer information obtained during the supervisory visits and home
                      health provider contact must be included in agency reports shared with the AAA
                      Care Manager and physician of record;

               (8.)   Individual time slips signed by the consumer or family member/caregiver and the
                      field staff worker to document each unit of service billed.

7.      ACTIVITIES FOR NURSING CARE

        a.     Providing either a basic general nursing evaluation or a specialty nursing evaluation of the
               consumer (by a registered nurse only).

               (1.)   Basic General Nursing Evaluation: a basic general nursing evaluation completed by
                      the Medicaid provider’s registered nurse to evaluate and monitor the general health
                      and medical needs of the consumer in order to make recommendations and develop a
                      nursing care plan for the registered nurse, licensed practical nurse, and/or home
                      health aide to carry out the physician’s recommended health care plan, and to carry
                      out teaching for implementation of the health care plan. This nursing evaluation
                      includes but not limited to: living conditions, health history, current health status
                      (including taking of vital signs and any other "hands-on necessary to complete the
                      evaluation), medication review, review of systems, etc. This general nursing
                      evaluation is usually completed initially and then on an on-going basis, as needed, as
                      part of the home health and is considered an integral part of the unit of service
                      provided by the home health workers. The information obtained from the nursing
                      evaluation is documented and shared with the AAA Care Manager and the physician
                      of record.

               (2.)   Specialty Nursing Evaluation: a specialty nursing evaluation completed by a
                      registered nurse with specialty training, education, experience and knowledge to
                      make specialty recommendations and develop a nursing care plan to carry out the
                      physician’s approved plan of care or to carry out intensive teaching in a special area
                      (e.g., incontinence training, ostomy care, wound care). This nursing evaluation
                      includes, but not limited to the above areas, including any "hands-on” with
                      concentration on specific areas related to the reason for the request, and the specialty
                      nurse contracted to perform this type of evaluation, would generally make only one
                      or two visits and the evaluation is contracted for at the discretion of the AAA site.
                      Again, the information obtained from the evaluation is documented and shared with
                      the AAA Care Manager and physician of record.

        b.     Developing a nursing care plan (by a registered nurse only). Licensed practical nurses may
               assist and participate in the development and planning of nursing care.

        c.     Implementing a nursing care plan.

        d.     Administering of physician’s prescribed medications.




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         e.     Teaching and training activities which require the skills and knowledge of a nurse, e.g.,
                special diet, medication management, insulin administration, enteral or parenteral feeding,
                decubitus care, ostomy care, and catheter care.

         f.     Performing medical treatments as order by the physician.

         g.     Performing nursing skills and procedures which are usual, customary practice as permitted
                by the "Professional Nursing Law” for licensed nurses and for which the nurse assigned can
                demonstrate educational preparation, experience and knowledge.

         h.     Maintaining clinical documentation of all nursing activities and visits.

         i.     Obtaining new medical orders (by a registered nurse only) from the consumer’s physician as
                indicated.

         j.     Monitoring of consumer’s physical and mental status in order to prevent hospitalization and
                regression of consumer status and to report any changes in condition of needs to the AAA
                Care Manager and physician of record.

8.       NURSING STANDARDS

         a.     Nursing Care is provided by an individual currently licensed to practice in Pennsylvania as a
                registered nurse or a licensed practical nurse under the direction of a registered nurse.

9.       RECORDS AND DOCUMENTATION

          (Same as Home Health Aide)

10.      ACTIVITIES FOR OCCUPATIONAL THERAPY

         a.     Develop a restorative and/or maintenance therapy plan of treatment with physician approval.

         b.     Implement therapeutic tasks and activities to restore sensory-integration functions
                (perceptual problems due to loss of vision, touch, hearing, etc.).

         c.     Teach consumers ways to protect joints from injury while doing activities of daily living and
                instrumental activities of daily living.

         d.     Design, fabrication, and application of splints not including orthotic devices or prostheses.

         e.     Teach compensatory techniques to improve the level of independence in activities of daily
                living and instrumental activities of daily living.

11.      OCCUPATIONAL THERAPIST STANDARDS

         a.     Occupational therapy is provided by a therapist currently licensed to practice in the
                Commonwealth. The occupational therapist is responsible for consulting, evaluation,




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                teaching and providing occupational therapy procedures to consumers under physician
                direction.

12.      RECORDS AND DOCUMENTATION

         (Same as Home Health Aide).

13.      PHYSICAL THERAPY ACTIVITIES

         a.     Develop a restorative and/or maintenance therapy plan of treatment (common treatment
                procedures include hot packs, paraffin baths, gait training, ultra-sound, range of motion
                testing, therapeutic exercises, etc.) with physician approval.

         b.     Teach positioning and proper body mechanics for lifting and transferring consumers.

14.      PHYSICAL THERAPISTS STANDARDS

         a.     Physical therapy is provided by an individual currently licensed as a physical therapist by the
                Commonwealth. The physical therapist is responsible for consulting, evaluating, teaching,
                and providing physical therapy procedures to consumers under physician direction.

15.      RECORDS AND DOCUMENTATION

         (Same as Home Health Aide).

16.      ACTIVITIES FOR SPEECH THERAPY

         a.     Develop a restorative and/or maintenance therapy plan of treatment with physician approval.

         b.     Evaluate and develop a treatment program for speech problems.

         c.     Evaluate and develop a treatment program to address problems of dysphagia (difficulty
                swallowing).

17.      SPEECH THERAPIST STANDARDS

         a.     Speech therapy is provided by a individual currently licensed in speech and language therapy
                by the Commonwealth. The therapist is responsible for consulting, evaluating, teaching and
                providing speech therapy procedures to consumers under physician direction.

18.      RECORDS AND DOCUMENTATIONS

         (Same as Home Health Aide)

19.      SERVICE REPORTING

         Persons providing Home Health Care services must comply with all reporting requirements as
         specified by the Area Agency on Aging.


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20.      SCHEDULING

         Days and times schedules for Home Health Care must be consistent with the Care Plan provided by
         the AAA.

21.      INSURANCE

         Agencies who wish to provide Home Health Care services will be required to attest to having the
         following types of insurance in amounts consistent in the industry:

                a.     General liability;
                b.     Professional liability;
                c.     Automobile liability covering owned, non-owned and hired vehicles;
                d.     Workman Compensation as required by law;
                e.     Employer’s liability of accident and disease.

22.      CONFIDENTIALITY

         All agencies who provide Home Health Care services and comply with all federal, state and local
         laws relating to research on home subjects and consumer confidentiality.

         Agencies must provide all Care Managers with consent forms and approval from all appropriate
         review boards for those consumers who wish to be part of a research study.




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I.      HOME HEALTH CARE: SERVICE SPECIFIC OPERATIONAL PROCEDURES


These Operational Procedures are a supplement to the Home Health Care Standards, and as such
they delineate further clinical expectations for Home Health Providers giving skilled home health
care to PCA consumers of the LTC Programs which encompass the Options and Aging Waiver
payment sources. When there is a difference between the Home Health Care Standards and these
Service Specific Operational Procedures, the more stringent requirement prevails.

NOTE: Home Health Agency (HHA) refers to skilled Medicare certified Home Health Provider

1.      INTAKE

        a.     When making a referral, the LTC staff will indicate the type of service and time frame in
               which the visit is to be made. The PCA Care Manager will be responsible to identify their
               Registered Nurse Consultant (RNC) on the referral and/or indicate it in the “special
               instructions” section of the Service Order.

               If the Home Health Agency is not able to meet the request, the LTC staff person will refer
               the consumer to another Home Health Agency of his/her choice.

        b.     The LTC staff will discuss with the HHA intake staff the source of payment for the visit(s).
               Pennsylvania Department of Aging (PDA) and Department of Public Welfare (DPW)
               mandate providers to exhaust all other insurance, including Medicare and Medicaid
               (MA), before payment can be authorized through Options or Aging Waiver programs.
               Note: providers must obtain prior authorization from MA for all medically necessary
               home health visits for eligible consumers.

               In cases where the LTC staff requests a skilled evaluation visit and it is agreed that the
               consumer services will not be covered by third party payers, PCA will reimburse for the
               visit. The LTC staff person will take under advisement a request by a nurse for a second visit
               to assess a consumer fully, consistent with CMS regulations.

        c.     Skilled care visits paid by PCA may occur only after the skilled home health agency
               has received a service order. The date this service order is received becomes the
               referral date for all skilled services. Care managers may note in the special instructions
               the time frame within which the visit must occur. If a visit is needed within twenty-four
               hours the service order will be preceded with a telephone call to the provider and the visit
               made prior to receiving the service order. All providers MUST comply with DPW process
               regulations before initiating services, e.g. the completion of the Eligibility Verification
               System (EVS) check and prior authorization.

        d.     PCA service orders constitute payment authorization for services delivered.

2.      COORDINATION & DELIVERY OF CARE

        a.     The LTC Programs expect all of the skilled home health evaluations to follow


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          CMS/OASIS/PPS regulations and PCA specifications. This includes a thorough
          assessment, plan of treatment, and nursing care plan. The skilled services will follow a care
          plan or critical pathway, which meets consumer goals. Since LTC consumers have both
          acute and chronic illnesses PCA expects that the HHA staff will be knowledgeable and
          skilled in defining, monitoring and intervening with any health issues or concerns that
          impact on LTC consumers. Such health issues may include the following: incontinence,
          nutrition, depression, polypharmacy, pressure ulcer management and impaired mobility.
          RNs will discuss all of these areas of need and any other needs which impact on or cause an
          improvement or deterioration in the consumer's health status with the Care Manager. The
          HHA’s RN and the PCA Care Manager, together with the PCA Registered Nurse
          Consultant (RNC), will attempt to jointly resolve and/or problem solve all issues of a
          clinical or payment nature. PCA staff will make the final decision in any disputes.

   b.     The LTC programs expect that care will be provided to consumers using an interdisciplinary
          team approach. HHA staff needs to communicate with the Care Manager and their RNC to
          keep him/her informed of any changes in the consumer’s health status. The HHA is
          expected to communicate with the PCA Registered Nurse Consultant (RNC) at the
          following times:

          (1.)   Within one business day after completion of the initial assessment, the HHA’s RN
                 must contact the RNC to establish the payer of service and the recommended visit
                 pattern.
          (2.)   When the agency completes an episode of care and recertifies the consumer for a
                 second episode of care or discharges the consumer from skilled home health care.
                 (Please note this change from previous requirements).
          (3.)   When there is a significant change in the consumer’s health condition.
          (4.)   When there are any consumer complaints regarding health-related aspects of their
                 care.
          (5.)   When other agencies are not performing or delivering requested care such as
                 personal care, transportation, meals, or adult day care. This primarily is the
                 consumer’s responsibility, except when dementia or caregiver absence exists and non
                 performance impacts on consumer’s safety or health status.
          (6.)   When the consumer is hospitalized or experiences a health emergency.
          (7.)   When there is a professional conflict regarding the delivery of care between HHA's
                 and other professionals.
          (8.)   When the HHA expects to discharge the consumer from third party payer services or
                 resume PCA paid services.
          (9.)   Reports from HHA’s RN are to be given to the RNC regarding all clinical issues. In
                 the RNC is not available, voice mails messages can be left, and in an emergency the
                 PCA Care Manager or the Care Manager Supervisor can be contacted.

   c.     LTC programs have a Supervisor on-call from 8:30-5:00 Monday through Friday to address
          any problems or concerns that may arise in the Care Manager or RNC’s absence.

   d.     There may be situations that arise when a consumer’s needs are complex and require the
          LTC Care Manager to request consultations from various specialists, for example: wound
          care, psychiatrist, psychiatric nurse, or mental health counselors. The LTC Programs expect
          that HHA staff be available to discuss consumer situations with the consultants and to follow


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               their recommendations and coordinate care, when indicated. If HHA staff should disagree
               with their recommendations they need to contact the LTC RN Consultant and explain their
               concerns.

        e.     The LTC programs expect that there may be times when conferencing either in person or by
               phone with all health team members and/or family members may need to occur.

3.      PLAN OF TREATMENT

        a.     All care given by Home Health Agency staff will be under the direction of the
               consumer’s physician.

        b.     It is expected that the Home Health Agency will be responsible for obtaining the physician’s
               orders and signature on the plan of treatment (CMS form 485 and 487) and submit a copy to
               the LTC Care Manager.

        c.     It is expected that the Home Health Agency will follow all the Medicare Regulations in
               providing care to LTC consumers under third party payer conditions of participation. This
               includes the need for CMS defined homebound status.

4.      REPORTING/PROGRESS NOTES.

        a.     The Home Health Agency is required to keep records on each consumer according to CMS
               Guidelines and the Home Health Care Standards. Reporting requirements remain the
               same for all LTC skilled nursing and physical therapy consumers authorized to a PCA
               provider, irrespective of reimbursement source. The LTC Program needs to receive
               copies of the initial assessment from all disciplines, initial plan of treatment (485), and
               discharge summary no later than one week after care was delivered. The following
               Reporting Guidelines must be followed for Skilled Nursing and PT visits:

               (1.)   The reports to PCA shall contain:
                      (a.)   Initial (485) Plan of Treatment;
                      (b.)   Initial Skilled Progress Note or last page of OASIS with summary of
                             findings;
                      (c.)   Discharge Summaries for PCA and third party payers.

                      Please Note: All PCA RNC or Care Manager initiated transfers or discharges
                      must allow the home health agency an appropriate visit for closure under that
                      episode of care.

                      Contents of verbal reports to the RNC should include the following:

                             (i.)     Consumer name;
                             (ii.)    Name of RN making the visit;
                             (iii.)   RN’s agency name;
                             (iv.)    Date of most recent visit;
                             (v.)     Vital signs and changes of any significance based on ranges being
                                      reported per 485;


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                         (vi.)   A summary of diagnoses and treatments as they relate to the current
                                 episode of care. This summary will include any observation noted in
                                 the Summary, along with Care Plan interventions.

          (2.)    Review of payer sources:
                  (a.)  Current visit pattern;
                  (b.)  Type of payer source (potential third party);
                  (c.)  Primary diagnosis for episode of care;
                  (d.)  Goals of episode of care and were the goals achieved;
                  (e.)  Anticipated date of discharge from episode of care and anticipated number of
                        recertification under any payer source.

          (3.)    Upon request, all agencies will forward copies of documentation (other than those in
                  #1. above) for review by the PCA Nurse Consultant.

          (4.)    Reports are required for the one visit paid by PCA (Options or Aging Waiver) and all
                  third party billed visits under Medicare, MA, and any HMO. Additional reports
                  may be requested when warranted due to any significant changes in the
                  consumer’s status. Reports may be made by e-mail, phone or fax to RNC.

     b.   The Home Health Agency is required to keep written documentation on each visit with the
          PCA consumer in the form of progress notes. Progress notes and OASIS reassessment notes
          will include the following:

          (1.)    All required OASIS and agency conforming PPS documentation.

          (2.)    Consumer’s name, Care Manager’s name, date and time of visit.

          (3.)    Observation and documentation of the consumer’s physical, mental, and cognitive
                  status.

          (4.)    Teaching and treatments given including consumer’s response with regards to
                  understanding of instructions.

          (5.)    Evaluation of progression/regression based on measurable/observable data with a
                  modification of goals.

          (6.)    Contact with the physician, RNC, Care Manager or other agencies providing care.

          (7.)    Home health aide supervisory visits per third-party payer guidelines established by
                  CMS .

          (8.)    Explanation of treatment goals and consumer/caregiver agreement with stated goals.

          (9.)    Specific plan for subsequent visit and date of the next projected visit.

          (10.)   Reasons why staff is unable to provide authorized service, if applicable.



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          (11.)   Signed verification by the consumer or caregiver that the visit was made. A
                  signature is required for each visit made by a RN, OT, PT, ST, ET, and home
                  health aide.

                  *The provider shall obtain the consumer’s signature (or that of other authorized
                  representative) on a time slip or other standardized form each time a service is
                  delivered to a PCA consumer. Consumers must be given a copy of the signed
                  time slip or form as a confirmation of delivery of service. It is recommended that
                  providers utilize multi-part forms so that the consumer can receive their copy as
                  an acknowledgement of the receipt of service on the given day.

     c.   Verbal reports to the designated care management team’s RNC for all Physical Therapy,
          Occupational Therapy, and/or Speech Therapy consumer visits, which must include the
          following, where applicable:

          (1.)    Therapeutic rehabilitative goals based on a thorough and complete functional
                  assessment.

          (2.)    An assessment of any potential third party payer reimbursable diagnoses and
                  treatments.

                  (a.)   Anticipated outcomes of your therapeutic interventions.
                  (b.)   DME equipment needs of the consumer (both PCA and those paid by third
                         party payer).
                  (c.)   Anticipated safety check follow-up visit for all equipment ordered and/or
                         installed.
                  (d.)   Anticipated discharge date whether by PCA or third party payers.

     d.   Documentation must be available to the PCA RNC, Care Managers and their supervisors
          upon request. The request will include the current episode of care only.

     e.   The Home Health Agency staff will submit a discharge summary, by discipline, which
          outlines the following:

          (1.)    Admission and discharge dates.
          (2.)    Summary of care that was provided listing initial goals and final outcome.
          (3.)    Consumer’s condition at discharge including medications, vital sign range, activity
                  level, and cognitive status.
          (4.)    Signature of the consumer verifying that he/she has been advised of discharge.

     f.   The Home Health Aide will keep a dated record of each contact with the consumer and
          record services provided observations of consumer and supervisory visit when it is made by
          the home health agency staff. This record is to be dated and signed by the consumer and
          home health aide.




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5.      STAFF QUALIFICATIONS

        The Home Health agency will select staff to deliver care to LTC consumers who have to attend
        PCA’s orientation to its programs. The staff must meet the qualifications delineated below in
        section A. PCA’s experience has shown that relationships and communications are enhanced when
        a core group of provider staff are assigned to work with the LTC consumers.

        a.     The Home Health Agency will assign field staff who have the following qualifications as
               listed below:

               (1.)   Registered Nurses - have a minimum of two years of nursing experience.

               (2.)   Psychiatric Nursing- Qualifications for Psychiatric nurses providing Evaluation and
                      Therapy in the home are those mandated by the Medicare Intermediary as part of
                      their medical policy manual.

                      Note: These requirements may change at any time based on the intermediary’s
                      decision. Please review www.myhomehealth.com or the CAHABA Web site for
                      updated information.

               (3.)   Enterostomal Therapy Nurses (ET) - must have two years of nursing experience in
                      enterostomal therapy.

                      The ET nurse must have graduated from an accredited school of nursing and
                      graduated from an accredited Enterostomal Therapy Nurse Education Program
                      approved by the International Association for Enterostomal Therapy and be board
                      certified or board eligible.

                      The ET nurse shall sit for and pass the board certification examination within one
                      year of employment by subcontractor.

                      For the purpose of this service, PCA requires that enterostomal nurses providing care
                      have the CETN (Enterostomal Therapy Nurse Certification) or CWOCN (Wound
                      Ostomy Continence Nurse Certification) certification. PCA will only utilize
                      enterostomal nurses who are CETN or CWOCN certified for ostomy and wound
                      care. PCA expects ET nurses to sit for boards every 5 years to ensure that the care
                      provided will be according to the latest standards of care.

               (4.)   Home Health Aides - have completed a 75 hour approved Medicare Training
                      Program, have a high school diploma or General Equivalency Diploma (GED).

               (5.)   Physical Therapists - have a minimum of two years of physical therapy experience.

               (6.)   Occupational Therapists - have a minimum of two years of occupational therapy
                      experience.

               (7.)   Speech Therapists - have a minimum of one-year experience in speech therapy.



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        b.     All RN staff, including both agency administrators and subcontracted professional
               staff, are required to attend a PCA Orientation before they can serve any PCA
               consumers, unless a waiver certificate is granted by the Program Review Nurses.
               Resumés for all professional staff need to be submitted to the Contract Manager and
               Program Review Nurses, prior to attending the Orientation. Requests for a waiver must be
               made in writing, accompanied by the resumé and license.

        c.     The Philadelphia Corporation for Aging reserves the right to request the Home Health
               Agency to remove individual staff from providing care to specific consumers or from seeing
               any PCA consumers.

        d.     The Home Health Agency will notify the Contract Manager in the Business
               Administration Department in the event of any resignation of a staff member who
               administers the program or provides care to our consumers.

        e.     The Home Health Agency will assume responsibility for the supervision of its staff as well
               as subcontracted specialists to assure the delivery of quality care. The RN will provide
               supervision of the Home Health Aide according to CMS Guidelines.

6.      COMMUNICABLE DISEASES

        a.     When caring for consumers with communicable diseases, PCA expects provider agencies to
               follow procedures recommended in the Center for Disease Control (CDC) guidelines and
               OSHA regulations. Agencies are responsible to provide appropriate In-services regarding
               these universal precautions. (A training tape is available from CDC upon request. The CDC
               toll-free number is 1-800-232-4636).

               Home Health agencies are also required to provide appropriate protective articles such as,
               but not limited to, aprons, gloves, masks, and gowns as needed.

        b.     Based on CDC guidelines, the provider shall develop a written policy regarding
               communicable diseases. That policy must meet State/Federal requirements.

        c.     The provider shall notify the PCA RNC or Care Manager upon determining or learning from
               another source that a consumer has a communicable disease. If this knowledge is from
               another source, they must still notify the PCA RNC and/or Care Manager that the consumer
               has a communicable disease.

        d.     The provider must follow CDC and OSHA Guidelines regarding the disposal of
               contaminated needles.

        e.     Before being assigned to a case, and annually, all consumer-contact employees shall have a
               Mantoux Intracutaneous PPD test according to CDC recommendations and, if the results are
               positive, it will be followed by appropriate physician directed treatment.

               In order to continue employment, the employee must be free of active TB. Verification by a
               physician that the employee is free of TB must be in the personnel file and updated annually.
               Chest X-rays are required based on physician’s advice.


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        f.     All employees must be offered and/or receive the Hepatitis B Vaccine as designated by
               OSHA regulations.

7.      CERTIFICATION AND QUALITY OF CARE STANDARDS.

        a.     It is expected that the Home Health Agency will be currently certified by Medicare to deliver
               home health care services and will provide PCA with its current Medicare Survey results.
               Verification of CHAPS or JCAHO survey accreditation shall be provided to PCA, if
               applicable.

        b.     The LTC Program will use the Clinical Practice Guidelines as published by U.S. Department
               of Health and Human Services under the Agency for Health Care Policy and Research
               (AHCPR) and any professional Standards of Practice for care of the older adult, as
               guidelines while auditing.

        c.     The Home Health Agency will adhere to all of the following Federal Guidelines: CMS,
               OSHA, PPS and CHAPS or JCAHO if applicable.




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J.      HOME SUPPORT SERVICE STANDARDS

        1.     DESCRIPTION OF ACTIVITIES

               Home Support Services include instruction on managing the household as well as hands-on
               assistance. Allowable activities include:

               a.     Basic housekeeping and home management necessary to ensure safe and sanitary
                      conditions;

               b.     Instructions in home management. Home management includes such things as
                      maintaining an orderly environment, proper food storage, preparation of shopping
                      lists, maintaining appliances in safe working conditions;

               c.     Shopping assistance with or without the consumer;

               d.     Personal laundry and mending of clothing;

               e.     Transportation of the consumer by a Home Support worker to complete chores or
                      keep appointments. This should occur when Transportation services are
                      inappropriate or unavailable;

               f.     Labor intensive low cost home repair. Chores necessary for reasons of a consumer’s
                      health and safety;

               g.     Ground maintenance when necessary to maintain a consumer in his/her home;

               h.     Meal planning and preparation;

               i.     Escort to medical facilities;

               j.     Observing and communicating health and other problems to a supervisor;

               k.     Extermination services - extermination services should only occur to ensure the
                      consumer’s health or welfare;

               l.     Dumpster rental - Dumpster rental may be required on a temporary job specific basis
                      for the purposes of intensive home repair, ground maintenance, or major clean up.
                      Monthly maintenance fees would not be covered;

               m.     Financial management - financial management includes routine financial transactions
                      for consumer’s unable to conduct their day-to-day affairs without some assistance,
                      e.g. paying bills and checkbook balancing.




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   2.     STANDARDS FOR HOME SUPPORT WORKERS

          a.    Qualifications and selection of Home Support Workers must follow personnel
                policies that include:

                (1.)   Home Support Workers must have the ability to understand and carry out
                       simple instructions.

                (2.)   A personal interview and follow-up of references provided by the workers.
                       Documentation of follow up must be incorporated into the worker’s
                       personnel file. Appropriate references include:

                       (a.)   one verifiable work reference indicating a minimal length of
                              employment of two years or,

                       (b.)   one verifiable work reference if employed less than two years plus one
                              verifiable personal reference,

                       (c.)   two verifiable personal references.

                (3.)   In recruiting, there must be assurance of compliance with Title VI of the Civil
                       Rights Act of 1964.

                (4.)   Agencies that provide Home Support services must assure that home support
                       workers comply with federal, state and local health requirements related to
                       communicable diseases. All field staff must receive a PPD test - the results
                       of which are maintained in their files.

                (5.)   There must be documentation that any worker who transports consumers in
                       the line of duty possesses a currently valid driver’s license and appropriate
                       insurance.

                (6.)   Workers must receive a copy of a job description, personnel policies and
                       wage scale for the position.

                (7.)   These tasks are provided by paraprofessionals with supervision. Supervision
                       by a Registered Nurse is not required.

   3.     TRAINING STANDARDS

          a.    Home Support Workers must be oriented to the purpose and background of AAA
                Programs.

          b.    No specific pre-service training is required of Home Support Workers, however, they
                must demonstrate knowledge and ability to perform the activities assigned. Methods
                for determining this include but are not limited to:

                (1.)   previous job experience,


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                 (2.)   verification by previous employer,
                 (3.)   of a questionnaire testing the worker’s knowledge.

          c.     Providers must establish regular in-service training for Homemaker staff. Topic
                 areas must include:

                 (1.)   principles of cleanliness and home safety,
                 (2.)   communication with older persons,
                 (3.)   understanding aging and functionally impaired persons,
                 (4.)   observing, appraising and reporting changes in consumers’ situations.

          d.     Documentation of demonstrated skill and in-service training must be maintained as
                 part of the worker’s personnel record.

   4.     RECORDS AND DOCUMENTATION

         a.      Provider must maintain service records that include a service order for tasks to be
                 performed and a report form requiring a consumer’s signature verifying the length of
                 time spent and satisfactory completion of the service.

         b.      Report form for the Home Support Workers to document changes or other observed
                 consumer problems.

         c.      AAA must maintain records required by the Department of Aging for program and
                 financial reporting.

         d.      AAA (or its subcontractor) must maintain service records that include a service order
                 for tasks to be performed and a report form requiring a consumer’s signature
                 verifying the length of time spent and satisfactory completion of the service.

   5.     SERVICE REPORTING

          Persons providing Home Support services must comply with all reporting requirements as
          specified by the Area Agency on Aging.

   6.     SCHEDULING

          Days and times scheduled for Home Support must be consistent with the Care Plan provided
          by the AAA.

   7.     INSURANCE

          Agencies who wish to provide Home Support services will be required to attest to having the
          following types of insurance in amounts consistent in the industry:

          a.     General liability;
          b.     Professional liability;
          c.     Automobile liability covering owned, non-owned and hired vehicles;


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          d.     Workman Compensation as required by law;
          e.     Employer’s liability of accident and disease.

   8.     CONFIDENTIALITY

          All agencies who provide Home Support services must comply with all federal, state and
          local laws relating to research on human subjects and consumer confidentiality.

          Agencies must provide all Care Managers with consent forms and approval from all
          appropriate review boards for those consumers who wish to be part of a research study.




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K.      HOME SUPPORT: SERVICE SPECIFIC OPERATIONAL PROCEDURES


These Operational Procedures are in addition to the Home Support Service Standards related to
heavy cleaning. They delineate further expectations for providers administering care to Philadelphia
Corporation for Aging (PCA) consumers, of the Long Term Care (LTC) Program which encompass
the Options and Aging Waiver payment sources. For other home support tasks, refer to the Personal
Care, Respite and Home Support Service Specific Operational Procedures.

        1.     SCHEDULING

               a.    Once the referral is made, the provider must contact the Care Manager within 24
                     hours if unable to meet the request for service. After accepting a referral, completion
                     of the service is expected within fifteen working days maximum of receipt of a
                     service order. Any anticipated delay will be immediately communicated to the Care
                     Manager.

               b.    The specific time and day for which service is scheduled shall be at the consumer’s
                     convenience. There is no restriction on providing service on Saturdays and Sundays,
                     assuming full consumer agreement; however, PCA will not reimburse at a higher unit
                     cost for such service.

               c.    The provider must contact the Care Manager: 1) to inform him/her of the
                     scheduled date for service once determined and 2) when work is completed.

               d.    Any problems in contacting, scheduling or tasks should be reported to the
                     appropriate Care Manager promptly, and noted on a Chore Service activity report.

        2.     DESCRIPTION OF SERVICES

               a.    Work Estimate

                     (1.)   An appointment with the consumer shall be made by phone prior to making
                            the estimate visit and prior to scheduling work to be done. The PCA Care
                            Manager will help with any special arrangements needed, such as the
                            consumer leaving for a period of time, preparation of the consumer for
                            expected disruption, arrangements for others to be there during the job,
                            arrangements to get into the home, etc.

                     (2.)   A home visit to the consumer, within three (3) days of the initial referral,
                            shall be made by an identified person from the provider agency to finalize the
                            request, to estimate the time needed to perform the work requested, and to lay
                            any needed groundwork in preparation for the job. These findings must be
                            communicated to the PCA Care Manager, and a service order will be
                            generated authorizing the estimated hours.

                     (3.)   If, during the estimate visit, the provider agency observes work needed, but
                            not requested by PCA, they will contact PCA’s Care Manager to discuss the


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                       observations. All changes to the original request must be approved by the
                       Care Manager prior to provision of service.

          b.    Heavy Cleaning

                (1.)   Heavy cleaning is cleaning requiring substantial effort. Generally, moderate
                       to severe dirt has accumulated in normally used living areas, and extremely
                       uncomfortable conditions and/or extraordinary filth may be present. Such
                       conditions may be due to uncontrolled pets, lice or fleas, and/or waste or
                       debris build-up. Window cleaning and/or a severe rug problem may also
                       exist. Heavy cleaning is done for persons who have been unable to meet
                       independently the cleaning needs relating to a sanitary environment and
                       where no resource in the family or community exists. The tasks requested by
                       PCA will vary from case to case.

                       Note: general outside cleaning may include collection and disposal of
                       trash and window cleaning. It does not include gardening or snow
                       removal.

                (2.)   Needed cleaning supplies shall be provided by the provider agency, unless
                       during the estimate visit, it has been determined and agreed that the consumer
                       would prefer to provide these supplies. If a consumer cannot be removed
                       during cleaning, the provider shall have available a range of cleaning
                       materials. Special consideration is to be given to the type of supplies used in
                       relation to their potential for causing allergic or other reactions.

          c.    Hauling

                (1.)   Hauling is requested only with Heavy Cleaning and is to be billed separately,
                       at a prior approved, individualized price, based on prices quoted as part of
                       price negotiations.

                (2.)   Hauling is only considered appropriate when it requires the use of a
                       dumpster/special truck for removal of extreme accumulations of trash. When
                       requesting approval, the nature of the material to be removed shall be
                       specified as substantiation for the size of the dumpster/truck indicated.

          d.    Hours of Service

                (1.)   Ordering - PCA will order heavy cleaning and indicate whether a dumpster
                       (or hauling) is needed. The provider is expected to provide and schedule
                       the ordered service based on the exact requests. Any difference of
                       opinion should be communicated immediately to the appropriate PCA
                       staff person, as any deviation in service or billing, not approved by PCA,
                       will result in non-payment of the invoiced hours.

                (2.)   21-Hour Limit - Any job estimate that exceeds 21 hours (22 hours or more)
                       must be approved by the LTCO Care Manager Supervisor before work is


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                       begun.

                (3.)   Hourly Rate Computation - The estimated hours represents person hours.
                       For example, three people working together for eight hours would be 24
                       person hours for a 24-hour estimate. The hourly rate is the charge per person,
                       per hour. Actual person-hours are to be documented through the use of time-
                       slips.

                       Note: Hourly costs for estimating and inspection shall be included
                       (loaded) in computing the hourly rate and shall not be billed as hours
                       worked.

          e.    Work Inspection

                (1.)   A home visit to the consumer after completion of the work shall be made by
                       an identified person from the cleaning provider to inspect and certify that the
                       work performed meets the original plan, has corrected the initial conditions
                       and is of high quality. Any variances from the requested plan found at
                       inspection shall be corrected prior to final certification by the provider
                       agency.

                (2.)   It is expected that if, at the time of the inspection, the work does not meet
                       quality standards, the provider will take action immediately to correct the
                       situation. If the desired level of correction has not been met through
                       extenuating circumstances, not related to the provider, the chore provider will
                       communicate the observations to the consumer’s Care Manager.

          f.    Work Completion Notification

                (1.)   The consumer’s PCA Care Manager shall be called to report that the work
                       has been completed, including any other appropriate observations, within 24
                       hours of verifying that the work performed meets the quality standards of the
                       chore provider.

                (2.)   If direct contact cannot be made, the PCA Care Manager’s Supervisor shall
                       be notified. If suitable contact cannot be made within the required time frame,
                       a written message shall be sent immediately to the Care Manager.

          g.    Follow-up

                (1.)   The Care Manager is expected to visit, or contact when appropriate, the
                       consumer within 5 days of completion of the job to verify the results and
                       determine if the work requested satisfies the purposes defined in the
                       consumer’s care plan. If the results are unsatisfactory, the Care Manager will
                       contact the provider directly and work out a resolution.

                (2.)   If tasks not originally requested are identified, a follow up service order will
                       be arranged with the provider, following normal procedures.


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   3.     REPORTING REQUIREMENTS

          a.     Service Activity Reports

                 (1.)    A consumer-by-consumer listing of all cases referred for service, estimated
                         for service, or completed during the week, shall be completed by the provider.

                 (2.)    The report is to be kept on file at the agency for review by PCA during
                         regular monitoring, or it may be reviewed as a separate audit. Should there
                         be a concern or specific issue observed at the consumer’s home, it is to be
                         reported to the Care Manager.

                 (3.)    Issues requiring immediate follow up should be communicated to the PCA
                         Care Manager. In their absence, the Care Manager Supervisor, the Nurse
                         Consultant or the Supervisor on call should be contacted. It is expected that
                         reporting requirements will be strictly adhered to.

                 (4.)    The Service Activity Reports shall be the basis for invoicing submitted by the
                         provider agency. Figures on the Service Activity Report are to be based on
                         dated time slips signed by the consumers and workers, which show actual
                         hours of work provided to each consumer, as indicated on the service order.
                         Appropriate information, including time slips, is to be maintained in the
                         provider agency’s records for justification of the reports submitted, and is
                         subject to periodic review by PCA staff.

                 (5.)    The provider shall obtain the consumer’s signature (or that of other
                         authorized representative) on a time slip or other standardized form
                         each time a service is delivered to a PCA consumer. Consumers must be
                         given a copy of the signed form as a confirmation of delivery of service.
                         It is recommended that providers utilize multi-part forms so that the
                         consumer can receive their copy as an acknowledgement of the receipt of
                         service on the given day.

          b.     The provider agency is encouraged to report any concerns it may have about a
                 consumer based on worker/supervisor observations. The report may be verbal or
                 written, and is to be submitted to Care Managers and the PCA Contract Manager.

   4.     IDENTIFICATION OF CHORE WORKERS

          All field workers will be given provider issued photo identification cards. Photo
          identification must be shown prior to entry into consumers’ homes and must be visible at all
          times when in consumer’s homes.

   5.     SUPERVISION AND JOB PERFORMANCE

          a.     Every job shall be staffed by an identified Supervisor, Foreman or Team Leader.
                 Every employee used for a PCA consumer shall be trained prior to his/her service


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                being rendered.

          b.    Any employee used to perform a job alone shall also have been monitored and
                witnessed on the job at least three times by a management level employee
                (Supervisor, Foreman) and shall be monitored periodically, but no less than once
                each quarter.

          c.    Documentation of employee skill level, of persons providing service monitoring
                visits and training, must be maintained by the provider agency and available for
                reporting and inspection.


          d.    Field supervision shall be performed by a competent professional with demonstrated
                experience in the cleaning field.

          e.    When changes occur on the administrative level, the PCA Contract Manager is to be
                notified in writing, in advance, if known; or immediately upon such change. When
                the change involves a change in administrative or supervisory personnel, a resume
                for the new employee shall be included with the written notification.

   6.     RECRUITMENT OF STAFF

          a.    When recruiting workers, the following applicants, who meet the requirements, shall
                be given priority: public assistance recipients, individuals of minority groups and
                elderly persons.

          b.    Cleaning workers may be recruited for either full or part-time service in accordance
                with the demands on the agency, and the ability of the person to meet full or part-
                time job assignments.

          c.    Individuals with special knowledge, such as different cultural backgrounds,
                languages or experience with various groups of older or chronically ill persons shall
                be sought by the provider in order to make available a variety of competencies to
                meet special situations.

          d.    The provider agency shall maintain sound, accepted personnel policies to minimize
                personnel turnover, which would adversely affect the delivery of service

   7.     COMMUNICABLE DISEASES

          a.    PCA expects provider agencies to follow procedures recommended in the Center for
                Disease Control (CDC) guidelines and OSHA regulations. Agencies are responsible
                to provide appropriate In-services regarding universal precautions. (A training tape
                is available from CDC upon request. The CDC toll-free number is 1-800-232-4636.)

                Provider agencies are also required to provide appropriate protective articles such as,
                but not limited to, aprons, gloves, masks, and gowns as needed.




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          b.    Based on CDC Guidelines, the provider shall develop a written policy regarding
                communicable diseases. That policy must meet State/ Federal requirements.

          c.    The provider must follow CDC and OSHA Guidelines regarding the disposal of
                contaminated needles.

          d.    Before being assigned to a case, and annually, all consumer-contact employees shall
                have a Mantoux Intracutaneous PPD test according to CDC recommendations,
                and, if the results are positive, it will be followed by appropriate Physician directed
                treatment.

                In order to continue employment, the employee must be free of active TB.
                Verification by a Physician that the employee is free of TB must be in the personnel
                file and updated annually. Chest X-rays are required based on a physician’s advice.

          e.    All employees must be offered and/or receive the Hepatitis B Vaccine as designated
                by OSHA Regulations.




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L.      HOME SUPPORT EXTERMINATION: SERVICE SPECIFIC OPERATIONAL
        PROCEDURES


These Operational Procedures are in addition to the Home Support Service Standards as they relate
to extermination service. They delineate further expectations for providers serving Philadelphia
Corporation for Aging (PCA) consumers, of the Long Term Care (LTC) Program which encompass
the Options and the Aging Waiver payment sources. For other home support tasks, refer to the
Personal Care, Respite and Home Support Service Specific Operational Procedures.

Note: Extermination service will not be provided to LTC consumers residing in public housing,
subsidized housing, etc. as these entities are responsible for providing this service for their residents.

        1.     SCHEDULING

               a.     Once the extermination referral is made, the provider must contact the Care Manager
                      within 24 hours if unable to meet the request. In such instances, the Care Manager
                      will refer the consumer to another agency of their choice.

               b.     PCA expects prompt and courteous service to be provided to consumers.
                      Completion of the service is to be within five (5) working days, of receipt of the
                      service order. The provider will notify the Care Manager of the date that the job is to
                      be performed at the consumer’s residence. The PCA Care Manager must be notified
                      immediately if performance will be delayed.

               c.     No extermination service is to be performed by the provider without the service
                      order. Immediate requests for service may be referred to a provider through a verbal
                      authorization; however, a service order must be initiated.

               d.     The specific time and day for which service is scheduled shall be at the consumer’s
                      convenience. There is no restriction on providing service on Saturdays and Sundays,
                      assuming full consumer agreement; however, PCA will not reimburse at a higher unit
                      cost for such service.

               e.     Providers are required to notify the Care Manager and document when a consumer
                      has refused service, not available for service, or when access to the property has been
                      denied.

               f.     Should the provider not adhere to the follow-up schedule, PCA may deny payment
                      for follow-up units invoiced by the provider that is not consistent with the authorized
                      service delivery pattern.

        2.     IDENTIFICATION OF EXTERMINATION WORKERS

               All extermination workers will be given provider issued photo identification cards. Photo
               identification must be shown prior to entry into consumers’ homes and must be visible at all
               times when in consumers’ homes.


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   3.     ASSESSMENT/ESTIMATE

          a.     Provider must complete an initial assessment of the problem area and provide an
                 estimate for correction of the pest infestation. The assessment/estimate visit must
                 occur within three (3) working days of the referral. Provider’s assessment must
                 include: identification of the problem, the proposed plan of treatment, and the
                 expected duration of treatment. The provider will follow up with the Care Manager
                 within three (3) working days of the assessment/estimate visit to discuss their
                 findings. The Care Manager will generate a service order based on an agreed upon
                 course of action based on the findings of the estimate visit. The Care Manager will
                 help with any special arrangements needed, such as the consumer leaving for a period
                 of time, preparation of the consumer for expected disruption, arrangements for others
                 to be there during the job, arrangements to get into the home, etc.

          b.     Special consideration is to be given to the type of supplies used in relation to their
                 potential for causing allergic or other reactions. If a consumer cannot be removed
                 during the extermination, the provider shall have alternate treatments available.

          c.     If, during the assessment visit, the provider observes work needed, but not requested
                 by PCA, they will contact the Care Manager to discuss the observations. The Care
                 Manager, prior to the provision of service, must approve any deviation from the
                 plan outlined during the evaluative visit by subsequently issuing a modified
                 service order.

          d.     Extermination supplies, and any other usual equipment needed, shall be the
                 responsibility of the provider agency and shall be reflected in the unit price
                 negotiated with the Business Administration Department of PCA.

   4.     EXTERMINATION SERVICE

          Extermination service is defined as an intervention required to eliminate infestation of
          roaches and related household insects, fleas, lice, mites, maggots, termites, and rodents.
          Extermination is a service that can be provided directly by a provider or through a
          subcontractor. Extermination may be requested exclusively or along with other chore
          services such as moderate or heavy cleaning. Extermination service consists of several
          categories of treatment identified as follows:

          a.     Assessment/Estimate: An overall estimate and assessment of the pest infestation, to
                 be completed prior to any authorized extermination service. An assessment
                 report (form) must be completed, identifying the problem, the proposed plan of
                 treatment, the expected duration of treatment, and outcomes leading to the problem’s
                 resolution.

          b.     Initial Extermination - Authorized intervention based on the plan of treatment
                 proposed as a result of the assessment that can include:




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          c.    Baseboard / Crack and Crevise Treatment – spray application of liquid type, low
                odor insecticide, usually of a non-petroleum base, in all rooms in household.

          d.    Gel Application - Consists of thick brown gel, with a sweet odor that roaches find
                appetizing. Gel bait advantages:

                -      Food and dishes do not have to be removed from cabinets.
                -      Odorless application is used so that consumer does not need to leave
                       premises.
                -      Gel has a longer residual effect than a liquid application.

          e.    Rodents

                (1.)   Treatment to place baits and glue traps in rodent pathways.
                (2.)   Seal rodent entry holes with a foam sealant, mesh, or plugs.

          f.    Baiting – Baiting for roaches, water bugs, ants, etc, used when a consumer cannot
                leave the house for a fogging/bombing, or has a respiratory problem.

          g.    Gnats and flies – require special catcher traps and different surface applications.

                PCA expects extermination providers to treat the entire home in order to
                maximize effectiveness of the intervention.

          h.    Follow up Extermination: An authorized repeat of the extermination treatment, on a
                pattern basis, until the problem is resolved.

          i.    Special Extermination: Special extermination is a prior approved intervention to be
                used when a severe infestation of the types of pests identified under the Initial
                Extermination (B. above) is present. Note: a Special extermination service is
                defined as an intervention that requires a completion time of between three (3)
                and eight (8) hours. The provider will document the start and stop time of this
                service through the use of time-slips or work logs. Special extermination is
                authorized only after the completion of an assessment, which identifies the problem,
                the proposed plan of treatment, and is subject to LTC’s policy and procedures
                regarding the ordering of the service. Special extermination services should consist
                of a different form of treatment and/or a different type of application.

                Special Extermination Problems and Treatments

                (1.)   Fogging/bombing – Fogging and bombing treatments, used especially in
                       such instances of severe infestation of roaches, fleas, mites, etc. The fogging
                       chemical is used to saturate and cover the area being treated. Consumer
                       precautions with this intervention include:

                       (a.)    Removal of foods and dishes from cabinets and cupboards.
                       (b.)    Close all windows and extinguish all pilot flames.
                       (c.)    Cover any fish tanks; remove all pets and clear baseboards for


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                               application.
                       (d.)    Remain out of premises for three (3) to four (4) hours.
                       (e.)    Upon entering, ventilate household before re-entering.
                       (f.)    In the treatment of fleas, the following additional actions must be
                               taken:
                               (i.)     All floors must be swept or vacuumed.
                               (ii.)    All carpets and furniture must be sprayed.
                               (iii.) For maximum results, two treatments, seven to ten days apart,
                                        are recommended.
                       Note: treatment for flea infestation also requires the consumer and/or
                       caregiver to make arrangements for “dipping” all household pets, however
                       this would not be the responsibility of the extermination provider.

          2.    Termites: Wood destroying insects require putting a chemical barrier around the
                premises, both interior and exterior. This process involves both drilling and
                trenching, and any other intervention as deemed appropriate in the industry’s
                certification standards. Provider must detail all proposed activity of the
                intervention/treatment.

          j.    LTCO Policy and Procedures for Special Extermination

                (1.)   In all cases Care Managers are to seek supervisory approval prior to
                       ordering/authorizing special exterminations (CHXS & CHXT). If the Care
                       Manager Supervisor or Registered Nurse Consultant is not immediately
                       available, the Care Manager must secure approval from the Assistant Director
                       prior to ordering/authorizing the service.

                (2.)   Prior to ordering this service, Care Managers are to verbally verify with the
                       provider that the procedure will, in fact, take 3 – 8 hours to complete, per
                       contractual agreement.

                (3.)   If unable to verify this required timeframe, Care Managers are not to order the
                       service. This outcome is to be reported to the immediate supervisor, who is
                       to communicate this via e-mail to the Assistant Director with a copy to the
                       Director. The Director is to e-mail all such reported instances to the Business
                       Administration Department, with a copy to the Deputy Director.

                (4.)   Care Managers are to document all activity related to the above in the contact
                log.

                (5.)   To monitor compliance with this policy, billing information is to be
                       distributed to the supervisory/management personnel on a monthly basis.

   5.     REPORTING REQUIREMENTS

          a.    Service Activity Reports

                (1.)   A consumer-by-consumer listing of all cases referred for service, estimated


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                       for service, or completed during the week, shall be completed by the provider.

                (2.)   The report is to be kept on file at the agency for review by PCA during
                       regular monitoring, or it may be reviewed as a separate audit. Should there
                       be a concern or specific issue observed at the consumer’s home, it may be
                       indicated on the service report, and the provider may forward it to the LTC
                       Care Manager.

                (3.)   Issues requiring immediate follow up should be communicated to the PCA
                       Care Manager. In their absence, the Care Manager Supervisor, the Nurse
                       Consultant or the Supervisor on call should be contacted. It is expected that
                       reporting requirements will be strictly adhered to.

                (4.)   Service Activity Reports shall be the basis for invoicing submitted by the
                       provider agency. Figures on the Chore Service Activity Report are to be
                       based on dated time slips signed by the consumers and workers, which show
                       actual hours of work provided to each consumer, as indicated on the service
                       order. Appropriate information, including time slips, is to be maintained in
                       the provider agency’s records for justification of the reports submitted, and is
                       subject to periodic review by PCA staff.

          b.    The provider shall obtain the consumer’s signature (or that of other authorized
                representative) on a time slip or other standardized form each time a service is
                delivered to a PCA consumer. Consumers must be given a copy of the signed
                form as a confirmation of delivery of service. It is recommended that providers
                utilize multi-part forms so that the consumer can receive their copy as an
                acknowledgement of the receipt of service on the given day.

   6.     STAFF QUALIFICATIONS

          a.    Exterminators:

                (1.)   All Exterminators must pass the required state exam, possess a state license
                       with the category identified, i.e. commercial, pest control and/or termite, and
                       possess State registration. Exterminators must maintain Environmental
                       Protection Agency (EPA) tickets on file for all work done.

                (2.)   Good physical and mental health, sensitivity to feelings and needs of others,
                       and maturity of attitude toward work assignment.

                (3.)   Ability to work under supervision as an employee of the agency.

                (4.)   Ability to communicate orally with the consumer.

                (5.)   Honesty and good personal grooming habits.

                (6.)   Assurance that there is no communicable disease.



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          b.     Administrative Staff:

                 (1.)   All of the above qualifications for Exterminators.

                 (2.)   Ability to complete required assessment forms, estimates and ancillary forms
                        accurately.

                 (3.)   Ability to give direction and training to assure compliance with PCA
                        standards, procedures, etc.

                 (4.)   Ability to organize and track the scheduling and completion of work.

   7.     TRAINING

          The extermination provider is expected to provide orientation for new workers before
          assignment to a PCA case. This may be done on a one-to-one basis, or in a group session.
          The orientation must include a description of the policies of the provider agency, and an
          introduction to the LTCO Program. Particular emphasis must be provided on the role of the
          Care Manager in developing the care plan and managing the consumer’s services. Ongoing
          communication with the Care Manager must also be highlighted.

   8.     ADMINISTRATIVE CHANGES

          When changes occur on the administrative level, the PCA Contract Manager is to be notified
          in writing, in advance, if known, or immediately upon such change.

   9.     COMMUNICABLE DISEASES

          a.     When caring for consumers with communicable diseases, PCA expects providers to
                 follow procedures recommended in the Center for Disease Control (CDC) guidelines
                 and OSHA Regulations. Agencies are responsible to provide appropriate in-services
                 regarding universal precautions. (A training tape is available from CDC upon
                 request. The CDC toll-free number is 1-800-232-4636.)

                 Provider is also required to provide appropriate protective articles such as, but not
                 limited to aprons, gloves, masks, and gowns as needed.

          b.     Based on CDC guidelines, the provider shall develop a written policy regarding
                 communicable diseases. That policy must meet State/Federal requirements.

          c.     The provider shall notify the PCA Nurse Consultant or Care Manager upon
                 determining or learning from another source, that a consumer has a communicable
                 disease.

          d.     Before being assigned to a case, and annually, all consumer-contact employees shall
                 have a Mantoux Intracutaneous PPD test according to CDC recommendations, and
                 if the results are positive, it will be followed by the appropriate Physician directed
                 treatment.


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                In order to continue employment, the employee must be free of active TB.
                Verification by a Physician that the employee is free of TB must be in the personnel
                file and updated annually. Chest X-rays are required based on Physician advice.

          e.    All employees must be offered and/or receive the Hepatitis B Vaccine as designated
                by OSHA Regulations.




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M.      HOME SUPPORT FINANCIAL MANAGEMENT: SERVICE SPECIFIC OPERATIONAL
        PROCEDURES

These Operational Procedures are in addition to the Home Support Service Standards as they relate
to financial management tasks. They delineate further expectations for providers serving
Philadelphia Corporation for Aging (PCA) consumers, of the Long Term Care (LTC) Program
which encompass the Options and the Aging Waiver payment sources. For other home support
tasks, refer to the Personal Care, Respite and Home Support Specific Operational Procedures along
with Home Support-Chore and Extermination Services.

        1.     SERVICE DEFINITION

               Home Support financial management service provides consumers with professional
               assistance in money management. Consumers will authorize Social Security and/or other
               income checks to be deposited directly into a financial institution via Durable Power of
               Attorney or Representative Payee relationship. Through this relationship, the service
               provider will facilitate the day-to-day money management and accurate bill paying. (NOTE:
               the scope of this service is not to be mistaken with that of the Financial Management
               Services (FMS), which was added to the Aging Waiver as part of the approved
               reapplication to CMS).

               The need for financial management services may be identified initially during the assessment
               process, through interviews between the care manager and the consumer/caregiver, or
               through observation by another service already in the consumer’s home. Consumers must
               have “capacity” to designate a Durable Power of Attorney. If a consumer’s capacity is
               uncertain, a psychiatric evaluation must be secured to assess capacity.

        2.     INTAKE

               a.     The care manager will request the consumer to select a provider from the Certified
                      Provider list.

               b.     The care manager will contact the chosen agency and make a financial management
                      service referral, detailing the consumer’s circumstances, needs resources, etc. After
                      reviewing the referral, the service provider will schedule and initial
                      assessment/enrollment interview in the consumer’s home.

               c.     Upon confirmation of Initial Evaluation visit, the care manager will generate a
                      service order, which will indicate the authorization for an initial visit. Note: Initial
                      Evaluations are not required for consumer transferred from Options to Aging Waiver,
                      who may be already receiving financial management services from the provider.

               d.     With the consumer’s acceptance of the service, the provider will proceed with
                      completion of the required authorization forms and/or documents needed for
                      enrollment. While all efforts will be made by the provider to complete the
                      enrollment during the initial assessment visit, additional contacts or visits may be
                      needed. Authorization for these additional visits is not required since they are


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                factored into the initial assessment.

          e.    Upon the development and finalization of a financial management plan for the
                consumer, the care manager will authorize a monthly management fee for the length
                (or remaining months) of the six (6) month care plan. The care plan will be updated
                and a service order generated.

   3.     SERVICE DELIVERY AND INVOICING

          a.    The provider will schedule the initial assessment authorized by the care manager and
                develop a financial management plan. The initial assessment interview is to be
                conducted at the consumer’s residence, within ten working days of the receipt of the
                service order. The provider will forward to the care manager a copy of the proposed
                financial management plan, within ten working days of the initial assessment visit.
                Bill paying activity cannot begin until the direct deposit of the various sources of
                income begins.

          b.    The provider will reconcile the individual consumer’s monthly statements from the
                financial institution with the various activities delineated in the financial
                management plan. A copy of the monthly statements will be forwarded to the
                consumer.

          c.    The provider will furnish the care manager with semi-annual updates or progress
                reports. Progress notes should include complete reassessment materials, care plans,
                and projected budget of finances being managed. The Provider will forward a copy
                of the Reassessment to the care manager within ten days after the Reassessment visit.

          d.    The provider will keep a case record on each consumer being served. It should
                contain ongoing, chronological, dated record of all contact about or with the
                consumer. The contact logs will document telephone calls, interviews, mail receipt,
                and all contact with and/or about the consumer. The consumer file will include:

                (1.)   Referral information;
                (2.)   Initial assessment information, including: financial institution account
                       documents, consent and release forms, direct deposit arrangement records,
                       etc.;
                (3.)   Financial institution material, including: monthly statements, payment
                       instructions, and automatic payment authorization;
                (4.)   Copies of all bills;
                (5.)   Fax documentation, correspondence, and contact logs;
                (6.)   Account charges.

          e.    The provider should make monthly contact, by telephone, with the consumer or
                consumer’s designee to assess any problems and/or respond to any questions.

          f.    The provider will invoice DPW (Aging Waiver) or PCA (Options) for an initial
                assessment and management fee for the subsequent months.




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          g.    Providers are required to verbally report all incidents and follow up with a written
                incident report; copies must be maintained in the consumer’s file.




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N.      PERSONAL CARE: STANDARDS

        1.     ACTIVITIES

               Personal Care is the provision in a consumer’s home of “hands-on” care related to a personal
               hygiene or functional activity of daily living that an individual cannot meet independently.
               Personal Care may only be provided in accordance with the care plan developed. The
               following list of activities can be considered in provision of this service:

               a.     Bathing - assistance to the consumer with bathing in the tub, shower or bed. (Totally
                      dependent, bedridden consumers who are unable to direct the bathing activity by the
                      Personal Care worker, and/or are unable to provide any assistance in washing
                      themselves or are unable to move independently in bed are not appropriate for
                      bathing by a Personal Care worker. However, when care is under nurse management,
                      a Personal Care worker can augment the medically supervised care as long as the
                      Personal Care tasks are limited to those allowed under the Personal Care definition.)

               b.     Skin Care - the routine application of lotion to unbroken, uninfected, undiseased skin
                      surface.

               c.     Mouth Care - assistance in care of teeth and mouth including care of dentures.

               d.     Dressing - includes assistance with clothing as well as application of previously self-
                      applied prostheses.

               e.     Grooming - includes hair care, shaving, cleaning and filing of nails. (The diabetic
                      consumer’s toe nails may not be cared for by the Personal Care workers.)

               f.     Toileting - includes assistance with transfers on and off commode or toilet, emptying
                      commodes and catheter bags.

               g.     Ambulation and Transfer - includes steady support and supervision to assist a
                      consumer with walking and transferring.

               h.     Change of Position or Turning Consumer - does not include range of motion
                      exercises, except when such care is under nurse management.

               i.     Feeding - which may also include mashing of food for easier management and/or
                      assistance in preparation and serving a meal.

               j.     Medication - assistance with self-administered medication. Assistance is limited to
                      reminding the consumer to take medications, placing medication within consumer’s
                      reach, obtaining the necessary equipment, pouring water for oral medication, opening
                      bottle caps, checking dosage, storing the medication and reassuring the consumer
                      that he/she has obtained and taken the correct dosage.

               k.     Observation - reporting of changes in consumer conditions and needs as observed
                      during performance of personal care.


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          l.     Instruction to Informal Caregivers - in the delivery of the above-listed activities.

                 Personal Care service may also include provision of supplemental housekeeping
                 service as long as the primary service rendered is for personal care. These activities
                 may include:

                 (1.)   washing dishes and clean-up after meal preparation,
                 (2.)   making beds and linen change for the consumer,
                 (3.)   shopping for the consumer,
                 (4.)   washing the consumer’s personal laundry,
                 (5.)   light housekeeping essential to maintaining a healthful living environment for
                        the consumer,
                 (6.)   preparing and serving nutritious meals,
                 (7.)   assistance with home and simple money management.

   2.     STANDARDS FOR PERSONAL CARE PROVIDERS

          Persons providing Personal Care services are usually Personal Care Aides, but can be Home
          Support Workers, who have been properly trained, Home Health Aides or Licensed Practical
          Nurses.

          a.     Qualifications and selection of Personal Care workers shall follow personnel policies
                 that include:

                 (1.)   A personal interview and required follow-up of personal and employment
                        references must be completed.

                 (2.)   Recruited workers must provide appropriate references:

                        a.      one verifiable work reference indicating a minimal length of
                                employment of two years;

                        b.      one verifiable work reference if employed less than two years plus one
                                verifiable personal reference;

                        c.      two references from instructors and/or supervisors from an acceptable
                                homemaker training program;

                        d.      two verifiable personal references.

                 (3.)   There must be assurance of compliance with Title VI of the Civil Rights Act
                        of 1964, as amended, in recruiting.

                 (4.)   There must be assurance of applicant’s ability to read, write and follow
                        simple instructions.




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                 (5.)    In order to make available a variety of competencies, efforts should be made
                         to recruit Personal Care workers with knowledge of language and/or skills
                         which address the special needs of older chronically ill individuals.

                 (6.)    Agencies that provide Personal Care services must assure that Personal Care
                         workers comply with federal, state and local health requirements related to
                         communicable diseases. All field staff must receive a PPD test - the results
                         of which are maintained in their files.

                 (7.)    Personal Care workers shall receive a copy of a job description, personnel
                         policies and wage scale for workers at the time of their employment and when
                         there is a revision or change in these policies.

                 (8.)    Wage scale shall be in conformity with applicable minimum wage laws.
                         Compensation for overtime work shall be provided in accordance with
                         current federal and state law.

                 (9.)    The AAA is responsible for assuring that provider agencies will schedule and
                         serve all consumers authorized for service without regard to race, religion,
                         national origin, age, physical condition, functional limitations or medical
                         diagnosis.

   3.     TRAINING STANDARDS

          Each person providing Personal Care service shall be trained for all services to be
          performed.

          a.     Such training shall be given in an organized course and include content related to:

                 (1.)    orientation to the service,
                 (2.)    interpersonal skills and understanding family relationships,
                 (3.)    working with older persons,
                 (4.)    personal care and rehabilitative care skills,
                 (5.)    care of the home and personal belongings,
                 (6.)    safety and accident prevention,
                 (7.)    home, time and money management,
                 (8.)    food nutrition and meal planning.

          b.     For each broad area of the training and appropriate professional shall provide
                 instructions. A registered nurse (RN) must provide the skills training in personal
                 care techniques.

          c.     Evidence of proficiency in skills and completion of training course shall be
                 documented in the Personal Care worker’s personnel file.

          d.     No Personal Care service may be rendered by a Personal Care worker prior to
                 demonstration of his/her competency in performing the specific service assigned.




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          e.     The requirement for completion of the 40-hour training requirement may be waived
                 if the Personal Care worker:

                 (1.)    Provides documentation of completion of related training that includes
                         demonstrated competency in all skill areas.

                 (2.)    Is able to demonstrate to the provider agency competency in all skill areas
                         included in the basic training and that observation of the competency is
                         documented.

          f.     AAA shall ensure that each individual Personal Care worker is in compliance with
                 basic training, competency and in-service requirements. Methods may include:

                 (1.)    Required submission by the trainer of documentation for each worker
                         attesting to proficiency in required skills.

                 (2.)    Required submission by Personal Care worker of a certificate of course
                         completion.

                 (3.)    Periodic review of personnel records of contracted agencies to verify
                         documentation of training and/or skill proficiency.

   4.     SUPERVISION STANDARDS

          A Registered Nurse must be included in the supervision of all Personal Care workers. A
          nurse supervisory review visit is made to the consumer’s home, on assignment of the
          Personal Care Aide to the consumer, then every ninety days thereafter. If the Case Manager
          determines that the consumer needs more frequent nurse supervisory review visits because
          of a fragile or unpredictable medical or functional condition, the Case Manager has the
          flexibility to require that the visits occur more often than the 90 day interval. This decision
          must be reflected in the consumer’s care plan.

          The purpose of the on-site, in-person nursing supervisory review visit is to review the status
          of the consumer, to review the services recommended by the site, to identify special care
          instructions or training requirements for the aide assigned to the case, to be able to establish
          schedules and give assignments to the aide, to monitor aide performance, to provide for
          continuity of care with other involved caregivers and to review specific consumer needs with
          service implications. Although not required, it is encouraged that if convenient and feasible,
          Registered Nurse supervisory review visits be made to the consumer’s home with the
          Personal Care Aide present.

          As part of the nurse supervisory review visit, the R.N. is responsible for identifying changes
          in the consumer’s status and/or needs and a review of the Provider's plan of service to
          include a professional recommendation on the appropriateness of the service rendered. This
          portion of the report should be shared with the Care Manager and the physician of record.
          The report should also include a Personal Care worker daily log of service which indicates
          arrival and departure time, specific services provided and tasks performed and comments




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          and observations about the consumer’s response to service. This portion of the report should
          also be shared with the Care Manager.

          When there is more than one agency involved in providing care to the consumer, combined
          supervisory visits with the Home Health Agency Registered Nurse may be made with the
          aide(s) to provide for coordination of care.

   5.     RECORDS AND DOCUMENTATION

          Records shall be maintained for each individual for whom the service is provided and shall
          be maintained in a confidential manner. All entries by the Personal Care worker and the
          supervisor shall be signed and dated. Individual time slips must be signed by the consumer
          or family member/caregiver and the personal care worker to document each unit of service
          billed.

          a.     The record should contain:

                 (1.)    data that identify the consumer,

                 (2.)    current care plan,

                 (3.)    the written assignment to the worker,

                 (4.)    Personal Care worker daily log of service which indicates arrival and
                         departure time and specific services provided,

                 (5.)    worker's comments and observations concerning the consumer’s condition
                         and his/her response to service including the reporting of changes and/or
                         problems to the supervisor,

                 (6.)    a record of supervisory visits,

                 (7.)    statements of any change in consumer’s condition as observed and reported
                         by the Personal Care Workers and acknowledged by the supervisor;

                  (8.)   statements of follow up taken by the supervisor, including reporting to the
                         Care Management Unit of the AAA.

   6.     SERVICE REPORTING

          Persons providing Personal Care services must comply with all reporting requirements as
          specified by the Area Agency on Aging.

   7.     SCHEDULING

          Days and times scheduled for Personal Care services must be consistent with the Care Plan
          provided by the AAA.




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    8.    INSURANCE

          Agencies who wish to provide Personal Care services will be required to attest to having the
          following types of insurance in amounts consistent in the industry:

          a.     General liability;
          b.     Professional liability;
          c.     Automobile liability covering owned, non-owned and hired vehicles;
          d.     Workman Compensation as required by law;
          e.     Employer’s liability of accident and disease.

   9.     CONFIDENTIALITY

          All agencies who provide Personal Care services must comply with all federal, state and
          local laws relating to research on human subjects and consumer confidentiality.

          Agencies must provide all Care Managers with consent forms and approval from all
          appropriate review boards for those consumers who wish to be part of a research study.




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O.      PERSONAL CARE, RESPITE, COMPANION, AND HOME SUPPORT: SERVICE
        SPECIFIC OPERATIONAL PROCEDURES


These Operational Procedures are a supplement to the Personal Care, Respite, Companion and
Home Support Standards. They delineate further expectations for providers administering care to
Philadelphia Corporation for Aging (PCA) consumers, of the Long Term Care (LTC) Program
which encompass the Options and Aging Waiver payment sources. When there is a difference
between Personal Care, Respite, Companion or Home Support Standards and the PCA’s Service
Specific Operational Procedures, the more stringent requirement prevails. (For consistency, the
providers’ Personal Care, Respite, Companion and Home Support workers are herein referred to as
“aides”).

Personal Care Agencies must be licensed/registered by the Pennsylvania Department of Health under
Act 69 of 2006 and Title 28 Pa. Code Chapter 51.

        1.     INTAKE

               a.    The Care Manager contacts the provider, selected by the consumer, to make the
                     initial referral. The request for service will be based on a plan of care developed by
                     the LTC Care Manager in conjunction with the consumer and/or caregiver. The plan
                     will identify tasks to be performed and specific days and times for service. Once a
                     referral is made, provider must contact the Care Manager within two (2)
                     business days if unable to meet the request. If a Community Choice referral
                     requires immediate service start-up, the provider is to be able to give the Care
                     Manager a response within that day.

                     NOTE: Providers must keep the PCA Contract Manager current on their
                     capacity to provide services. They must notify the PCA Contract Manager
                     immediately when having difficulty providing service in their designated service
                     area(s), experiencing staffing problems, or when experiencing any other
                     problems that impact their ability to accept referrals and/or deliver service to
                     PCA consumers.

               b.    LTC staff will telephone personal care providers to make the initial referral. A
                     service authorization – Service Order, will be forwarded to the provider upon
                     acceptance of the referral.

               c.    A copy of the LTC Personal and Home Management Care Plan will be left in the
                     consumer’s home, and a copy will be forwarded to the provider electronically, with
                     the service order, via the PCA website. This plan includes the tasks to be performed
                     and the specific days and times for the visit. Any errors or questions regarding the
                     information on both the Service Order and the Personal and Home Management Care
                     Plan must be immediately brought to the attention of the PCA care manager. Please
                     note: care plans will only be sent with the initial or modified Service Orders. Also,
                     Personal care services cannot be provided at the same time as Personal Assistance
                     Service, Home Support Service, Home Health Aide Service, or Companion Service.


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          d.    PCA will order service for specific blocks of time, i.e. number of hours and number
                of days per week, to provide specific personal care tasks. Generally, it is expected
                that service will be provided in one, two, three, or four hours blocks of time,
                depending on the actual needs of the consumer. Service will usually be requested
                between the hours of 8:00 a.m. and 6:00 p.m.; however, on occasion, service will be
                requested before or after the latter times, and PCA expects the provider agency to
                have the capacity to meet this need.

          e.    For consumers who are authorized to receive Home Support only, the frequency for
                the ongoing support activities should not (in most cases) be more than once or twice
                per month.

   2.     SCHEDULING

          a.    If the provider cannot meet the service request within 5 working days from receipt of
                the service order or earlier for those Community Choice cases that require service to
                start within 24 to 72 hours, the Care Manager will refer the consumer to another
                personal care or home support agency of the consumer’s choice.

          b.    It is expected that service will be provided on Saturdays, Sundays, holidays, and
                evenings if requested. Reimbursement is at the same rate as daily service. Service
                must be rendered to consumers in accordance with the care plan and service order.

          c.    The initial visit must occur within a maximum of five working days from receipt of
                the service order. The provider agency will notify the Care Manager of the start date
                and the name of the worker. In cases where the initial visit will be delayed,
                notification of the delay shall be reported to PCA immediately. Providers must
                check eligibility for all newly assigned Aging Waiver consumers prior to the
                initiation of service. Any problems with eligibility must be communicated to the
                PCA Care Manager and service should not begin until the issue is resolved. Should
                PCA become aware of a change in the consumer’s eligibility, it will be
                communicated to the provider.

          d.    Aides must continue on the same case at the days and times ordered. Should the aide
                fail to provide service at the assigned time, the provider agency is expected to
                provide a substitute worker on the day, and at the approximate time scheduled.
                When changes are made, both the consumer and the Care Manager must be
                notified.

          e.    Should additional time be needed than what is authorized, the provider must call the
                Care Manager for authorization and an updated service order. Provider will only be
                reimbursed for authorized delivered service. Providers may not invoice for
                staff travel time to and from a consumer’s home.

          f.    Aides must not be assigned to relatives and friends in the provision of service to
                PCA consumers. Service cannot be provided by a legally responsible person,
                relative, or legal guardian.



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          g.    No scheduling arrangements are to be negotiated between aides and
                consumers/caregivers. It is expected that all modifications to the schedule be
                done by the appropriate administrative personnel.

   3.     IDENTIFICATION AND CONDUCT OF STAFF

          a.    All field staff is required to wear professional attire, and be given provider
                issued photo identification cards. Photo identification must be shown prior to
                entry into consumers’ homes.

          b.    Aides are not permitted to bring family members or friends to the consumer’s home.

          c.    Aides are not permitted to disseminate neither the consumer’s telephone number nor
                any other personal information.

          d.    Aides are not permitted to eat consumers’ food, use toiletries, or use other personal
                items. Use of consumers’ phones must be restricted to business use only, with
                permission from consumer, and used sparingly. No personal calls are allowed.

          e.    Aides are not permitted, under any circumstances, to reside with PCA consumers.

          f.    Transportation: aides are not permitted to transport a consumer in either the worker's
                car or a consumer's car. When it is necessary for an aide to use public transportation
                or her/his own car to perform required duties, and it is agreed upon by the consumer,
                the consumer is responsible for paying the transportation costs, if additional expense
                is incurred. (Those costs shall not exceed SEPTA's current round trip bus fare, and
                the trip must be within a 10-block radius.)

   4.     SUPERVISION

          a.    Supervision of the aides shall be performed directly by a Registered Nurse (RN)
                Field Supervisor, who is capable of demonstrating and teaching all personal care,
                respite, companion or home support activities, as ordered on the care plan. The RN
                must have two years of professional work experience in a health care related
                capacity. If less than two years, the RN must provide one work reference and one
                personal reference.

                Note: in those instances where the consumer is receiving Home Support Services
                only, field supervision can be provided by a designated person with appropriate
                training and work experience related to the service being provided.

          b.    The RN or designated Field Supervisor is required to visit each new consumer’s
                home on the first day of service to review the care plan and to observe the
                worker providing care. A new consumer is one who is new to the provider agency,
                and/or to the aide.

                PCA requires supervision of the aide, with the worker present during
                supervision, at a minimum of every 90 days; this is also applicable for those


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                receiving Respite, Companion or Home Support Services only. The RN Field
                Supervisor or designated field supervisory staff visits each consumer to determine
                the effectiveness of service given, including:

                (1.)   Assuring the worker arrives at and leaves the consumer’s home as scheduled;
                (2.)   Making sure the worker satisfactorily accomplishes the tasks outlined in the
                       care plan;
                (3.)   Being aware of changes in the consumer’s needs/and or circumstances, and
                       reporting these changes promptly to the provider agency and the Care
                       Manager.

                       (a.)    In instances where the RN or designated Field Supervisor is
                               unavailable to supervise the aide on the first day of service, and
                               the aide is available to staff the case, the provider may accept the
                               referral. However, the RN or designated Field Supervisor must be
                               present during one of the first three visits to supervise the aide.
                               Both the aide and the RN or designated Field Supervisor must be
                               present during that supervisory visit.

                       (b.)    Supervisory requirements are waived for cases receiving escort
                               service only.

          c.    Home Health providers involved in the provision of personal care service are
                expected to continue supervising aides in a manner consistent with the Centers for
                Medicare and Medicaid Service guidelines, as well as any other regulatory guidelines
                governing Home Health agencies. In such instances, supervision of ides is expected
                every 60 days.

                A report must be completed by the RN or designated Field Supervisor for each
                consumer, on the effectiveness of activities carried out by the personal care worker
                (aide). The report includes changes noted by the aide and observed by the Field
                Supervisor in the consumer’s home. It is expected that the consumer or caregiver,
                the RN and the aide sign the report. This report will be used to ascertain provider
                agency compliance with each care plan, monitor consumer progress, and document
                that the Supervisor visited each consumer. The report must be kept on file at the
                agency for review by PCA during regular monitoring, or it may be reviewed as a
                separate audit. Should there be a concern or specific issue observed at the
                consumer’s home, it may be indicated on a Personal Care Supervisory Report, and
                the provider may forward it to the PCA Nurse Consultant. Items requiring
                immediate follow up should be communicated to the PCA Care Manager. In
                their absence, the Care Manager Supervisor, the Nurse Consultant or the Supervisor
                on call should be contacted. The Supervisor on call is available from 8:30 a.m. -
                5:00 p.m. Monday through Friday, to address any concerns that may arise in the Care
                Manager's absence.

          d.    Collaboration between the RN or designated Field Supervisor and PCA Care
                Manager is expected, to assure quality care. Communication is expected when there
                is a significant change in the consumer’s condition, as well as in the following


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                 conditions:

                 (1.)    When there are complaints;
                 (2.)    When other services such as meals, transportation, etc. are not received;
                 (3.)    When the consumer is hospitalized; or
                 (4.)    When there is an incident.

          e.     PCA requires supervision of Home Support and Respite workers at a minimum of
                 every 90 days, with the worker present, as indicated above for aides.

          f.     Care Management staff reserves the right to request that a provider conduct more
                 frequent supervision of staff, on a case by case basis, as needed.

          g.     Each provider is expected to have established clear policies related to the supervision
                 of staff. The above supervisory requirements are in no way intended to waive a
                 provider’s responsibility for supervision of staff and being accountable for its staff.

   5.     PERSONAL CARE TASKS (Activities of Daily Living - ADLS)

          a.     Before assigning an aide to perform tasks, their competency and judgment to perform
                 the tasks safely, effectively, and completely must be evaluated and affirmed by their
                 RN Field Supervisor. An RN evaluation of an aide’s competency and judgment prior
                 to assignment is not necessary for licensed CNS staff.

          b.     For a detailed listing of allowable tasks, please refer to the Personal Care, Respite,
                 Companion and Home Support Standards.

   6.     HOME SUPPORT TASKS

          Personal Care or Home Support service may also include provision of supplemental
          housekeeping service, as long as the primary service rendered is for personal care. These
          tasks are provided to persons who are unable to perform some or all of the tasks needed to
          manage their home, where no resource (or only partial help) in the family or community
          exists, or where respite is needed. As with personal care tasks, these tasks will vary from
          case to case, as indicated on the care plan, and can include:

          a.     Meal preparation and serving;
          b.     Housekeeping - maintenance of areas used by consumer, to keep the environment in
                 state of cleanliness and safety;
          c.     Damp-mopping floors;
          d.     Dusting and sweeping;
          e.     Vacuuming;
          f.     Changing bed linens;
          g.     Day-to-day cleaning of the refrigerator (including routine defrosting and assisting the
                 consumer in discarding spoiled food), stove, oven and other appliances;
          h.     Cleaning of kitchen and bathroom (including portable commodes);
          i.     Trash and garbage disposal;




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          j.    Personal laundry, including bed linens and towels, washed in the most efficient way,
                at the closest suitable location for the aide, if there is no washer/dryer;
          k.    Marketing, in the most suitable location with consideration to economy and
                efficiency;
          l.    Local errands and/or assistance with food shopping within the neighborhood;
          m.    PCA does not expect the worker to assist consumers with financial management.
                Aides are not permitted to cash, write, or deposit checks for consumers,
                purchase money orders, use consumer credit/debit cards for purchases, or be
                given more than $50.00 at one time to market or assist with local errands. Receipts
                must be presented to consumers for any purchase made.
          n.    Escort, as identified and/or arranged by the Care Manager. Note: aides are not
                permitted to transport a consumer in either the worker's car or a consumer's
                car.

   7.     SERVICE VERIFICATION

          a.    PCA requires that subcontractors obtain a sample, for verification purposes, using a
                staff member other than the person providing service, of each consumer’s signature
                at the time service is initiated. If the consumer cannot sign, the signature of a person
                authorized to sign is to be obtained. The authorized person must sign their own
                name each time and indicate they are signing for the consumer. An aide signing the
                consumer’s name to a slip will be considered fraud and is strictly prohibited.

          b.    The provider shall obtain the consumer’s signature (or that of other authorized
                representative) on a time slip or other standardized form each time a service is
                delivered to a PCA consumer. Consumers must be given a copy of the signed
                time slip or form as a confirmation of delivery of service. It is recommended
                that providers utilize multi-part forms so that the consumer can receive their
                copy as an acknowledgement of the receipt of service on the given day.

                Note: provider use of electronic / telephony systems in place of the consumer
                signature process, described throughout this section, is possible only with PCA
                prior written approval.

          c.    These signed receipts are to be cross-checked with the sample signature and be kept
                in consumer files or with the billing documents at the subcontractor’s office as this
                requirement will be audited by PCA’s internal and external auditors. No payment
                claim is to be submitted to PCA or MA without a signed receipt for each individual
                item or service. Any questionable or missing signatures during an audit by PCA or
                other authorized agent will result in a deduction in the amount billed from the next
                invoicing period.

          d.    The time slip must clearly identify the consumer served, the worker providing the
                service, the time service started and ended, including whether A.M. or P.M., the
                dates of service, and consumer’s signature each time service was rendered. Time
                slips for consumers receiving multiple services must clearly indicate service time for
                the specific service provided; e.g. personal care hours versus companion hours, etc.



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          e.    Providers are required to use a scheduling system for each aide visiting PCA
                consumers. That schedule shall identify the aide’s name, each consumer to be
                visited, date, starting and ending time, travel time between visits and break
                time. Each aide’s schedule, combined with the daily time sheets, must back-up
                that worker’s payroll records and hours billed to PCA and/or MA.

   8.     STAFF QUALIFICATIONS AND TRAINING

          a.    All aides must have good physical and mental health, as evidenced by a Statement of
                Good Health, from a Physician, which will be made part of the personnel file; and
                they must demonstrate maturity of attitude toward work assignment.

          b.    Orientation: Personal Care workers (aides) assigned to PCA consumers must
                meet State standards of certification and have experience with the elderly. The
                provider agency is expected to provide orientation for new aides before
                assignment to a case. This may be done on a one-to-one basis, or in a group
                session. The orientation must include a description of policies of the provider
                agency, and an introduction to the PCA LTC Program, with particular
                emphasis on the care plan and the need for strict adherence to
                tasks/days/hours/and role of the Care Manager.

                Please note: training requirements are subject to, and superseded by, those
                regulatory requirements stipulated in Act 69 for Home Care Agencies.

          c.    Certificate Training

                (1.)   To assure the highest quality of service possible, prior to assignment to PCA
                       cases, all aides must:

                       (a.)   Receive a certified training of at least forty (40) hours from the
                              provider agency; or
                       (b.)   Possess a training certificate comparable to the training content
                              outlined; or
                       (c.)   Be listed in good standing on the Nursing Home Aide Registry.

                (2.)   On- the-job training is not to be included in meeting the forty (40) hours
                       requirement, but specific practice in performing tasks is to be included. In
                       order to assure the validity and consistency of the training, PCA has elected
                       to require that “National Home Care Aide Certification Program", developed
                       by the National Association of Homecare be used by all provider agencies.
                       The curriculum can be obtained by contacting the Home Care University, 228
                       Seventh Street SE, Washington, DC 20003. As an alternative, provider
                       agencies who provide Home Health Aides to Medicare certified Home Health
                       Agencies may substitute a training program, approved by the Home Health
                       Agency, that meets the “Personnel Qualifications" specified in the Medicare
                       Regulations for Home Health Agencies, Federal Register/Vol. 56, No. 138,
                       section 484.4 and the “Conditions of Participation: Home Health Aides
                       Services" specified in the Medicare Regulations for Home Health Agencies,


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                       Federal Register/Vol.54, No. 153, section 484.36 (a).

                       Please note: training requirements are subject to, and superseded by,
                       those regulatory requirements stipulated in Act 69 for Home Care
                       Agencies

                (3.)   Agency records must include documentation of the certificate training
                       program, which the aide has completed.

                (4.)   Current Employees -In order to be allowed to continue to serve PCA
                       consumers, all aides, currently employed by the provider agency, who do not
                       possess a training certificate consistent with c. above, must be enrolled in and
                       complete no later than 6 months following signing of a contract with PCA for
                       the then current fiscal year, a certified training course consistent with the
                       requirements in this section. Until such training is completed, aides cannot
                       care for PCA consumers.

                (5.)   In-Service Training

                       (a.)    In-service training sessions must be offered to all aides at least
                               quarterly. The training curriculum should be kept on file and will be
                               reviewed by PCA during regular monitoring.

                       (b.)    In-service training should include:

                               (i.)     Follow-up in content areas introduced in certificate training;
                               (ii.)    Relevant trends in service delivery;
                               (iii.)   Content areas based on identified problems of aides in
                                        providing service;
                               (iv.)    Programs on agency policies and procedures are necessary but
                                        should not constitute the majority of the sessions.

                       (c.)    In-service sessions may be conducted by the agency or may
                               include attendance at outside seminars.

   9.     ADMINISTRATIVE STAFF QUALIFICATIONS

          a.    Sufficient administrative staff shall be employed to insure the efficient and effective
                provision of service. Experience has shown that a ratio of 100 to 125 consumers per
                Office Coordinator (and Field Supervisor) allows for provision of adequate service.

          b.    Coordinators and Field Supervisors are expected to be familiar with the aged and
                chronically ill, and be sensitive to consumer needs and living situations; thus
                assuring awareness and ability to match aide with consumer needs. Specific
                requirements for the RN Field Supervisor are listed under “Supervision” on page 3.




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   10.    STAFFING

          a.    When a change occurs on the administrative level, the PCA Contract Manager is to
                be notified in writing, in advance if known, or immediately upon such change. When
                the change involves a change in administrative or supervisory personnel, curriculum
                vitae for the new employee shall be included with the written notification.

          b.    The provider agency shall maintain sound personnel policies to minimize personnel
                turnover, which would adversely affect the delivery of service. Experience has
                shown that turnover may be minimized by providing competitive wages
                commensurate with the required job skills, as well as incentives (in the form of
                bonuses and/or fringe benefits) for workers who have given continuous and
                satisfactory performance.

          c.    Providers must submit any exceptions to PCA staff requirements to the
                Contract Manager in the Business Administration Department for review.
                Submissions may be done by mail, e-mail, or fax. Staff is not to be assigned to
                provide services to PCA consumers until an exception has been reviewed and
                approved.

          d.    RN Field Nurses and administrative staff with contract oversight responsibility
                must attend a PCA Orientation. While the nurse is encouraged to attend the
                orientation before serving a PCA consumer, some flexibility is permitted. If provider
                can demonstrate that the nurse will be closely supervised while waiting to attend the
                orientation, the nurse may serve PCA consumers and attend the next scheduled PCA
                training. Their resume must be submitted to the PCA Contract Manager and/or the
                Program Review Nurse prior to attending the Orientation.

          e.    PCA reserves the right to request the provider to remove individual staff from
                providing care to specific consumers, or from seeing any PCA consumers.

   11.    RECRUITMENT OF STAFF

          a.    Providers shall establish an effective ongoing program of staff recruitment
                procedures. Experience has shown that face-to-face involvement between the
                Scheduling Coordinator and aide, during the recruitment process, facilitates the best
                provision of service.

          b.    When recruiting staff, applicants who meet the following requirements, shall be
                given priority: public assistance recipients and individuals of minority groups,
                including men and elderly persons.

          c.    Aides may be recruited for either full or part-time service in accordance with the
                demands of the agency, and the ability of the aide to meet full or part-time
                assignments.

          d.    Individuals with special knowledge, such as different cultural backgrounds,
                languages, or experience with various groups of older or chronically ill persons, shall


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                be sought by the provider in order to make available a variety of competencies to
                meet special situations.

   12.    COMMUNICABLE DISEASES

          a.    When caring for consumers with communicable diseases, PCA expects provider
                agencies follow procedures recommended in the Center for Disease Control (CDC)
                guidelines and OSHA regulations. Agencies are responsible to provide appropriate
                In-services regarding universal precautions. (A training tape is available from CDC
                upon request. The CDC toll-free number is 1-800-232-4636.)

                Provider agencies are also required to provide appropriate protective articles such as,
                but not limited to, aprons, gloves, masks, and gowns as needed.

          b.    Based on CDC Guidelines, the provider shall develop a written policy regarding
                communicable diseases. That policy must meet State/Federal requirements.

          c.    The provider shall notify the PCA Nurse Consultant or Care Manager upon
                determining or learning from another source, that a consumer has a communicable
                disease.

          d.    The provider must follow CDC and OSHA Guidelines regarding the disposal of
                contaminated needles.

          e.    Before being assigned to a case, and annually, all consumer-contact employees shall
                have a Mantoux Intracutaneous PPD test according to CDC recommendations.
                If the results are positive, it must be followed by appropriate physician directed
                treatment.

                In order to continue employment, the employee must be free of active TB.
                Verification by a Physician that the employee is free of TB must be in the personnel
                file and updated annually. Chest X-rays are required based on physician's advice.

          f.    All employees must be offered and/or receive the Hepatitis B Vaccine as designated
                by OSHA Regulations.




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P.      PERSONAL ASSISTANCE SERVICE (PAS): SERVICE SPECIFICATIONS


        1.     Definition

               Personal Assistance Service (PAS) is in-home personal care and other approved support
               activities for consumers with functional disabilities who need assistance to accomplish daily
               living tasks. The service consists of those basic and ancillary services, which enable eligible
               consumers to live in their own homes and communities rather than institutions and to carry-
               out functions of daily living, self-care, and mobility. Primarily, the consumer if he/she were
               physically able, or family/friends, if available, would carry out these activities.

               Personal Assistance Service is available for eligible consumers in both the Aging Waiver
               and Options programs.

        2.     Aging Waiver PAS Standards

               An individual with an assessed need for PAS shall have a choice of directing a portion of
               his/her care or having an agency direct the care.

               Individuals who are assessed as being cognitively able to direct a portion of their own care
               and are willing to do so may manage certain aspects of their care or choose to have a
               caregiver direct the care. The caregiver may not be a paid personal assistance worker.

               An individual who is assessed as being cognitively impaired must not direct his/her own
               care. Such an individual may have a caregiver or legally authorized surrogate who is willing
               to direct the care. The caregiver or legally authorized surrogate may not be a paid personal
               assistant.

               a.     Services

                      Personal assistance services shall include primarily “hands-on” personal care
                      assistance with one or more of the following basic activities in order to maintain the
                      personal care of one’s self, regardless of who provides the assistance:

                      (1.)    Getting in and out of bed, wheelchair, or motor vehicle;
                      (2.)    Ambulating, with or without mechanical aids, inside the home;
                      (3.)    Routine bodily functions, including eating or feeding (including meal
                              preparation and clean-up) and toileting;
                      (4.)    Bathing, dressing, personal hygiene and grooming; and
                      (5.)    Health maintenance activities (i.e. insulin injections, medication
                              administration -and skin care).

               b.     Health maintenance activities are activities that are necessary to maintain the
                      consumer’s optimum health, as directed by the physician responsible for the
                      consumer’s medical/health plan of care.

                      Unless determined otherwise by the assessment and agreed to in the care plan, the


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                consumer will direct and supervise the PAS worker in the specified health
                maintenance activities under the following conditions:

                (1.)   The consumer has indicated that he/she has been adequately instructed by the
                       appropriate health professionals and is thereby qualified and able to instruct
                       and supervise his/her PAS worker in health maintenance activities. A
                       statement to this effect is included in the care plan.

                (2.)   At the consumer’s request, the PAS worker will be instructed in health
                       maintenance activities by health professionals as arranged by the provider
                       agency or PCA.

                (3.)   The PAS worker is instructed and monitored in health maintenance activities
                       by the consumer, the consumer’s physician, and/or health professional as
                       appropriate.

                (4.)   The provider or PCA, as appropriate, will monitor the PAS worker’s
                       performance of health maintenance activities during monitoring visits and
                       through consultation and input from the consumer regarding his/her
                       satisfaction with the service.

                (5.)   The consumer has appropriate arrangements in place to respond to health
                       emergencies and back-up services; a statement to this effect is included in the
                       care plan. Information on the arrangements for health emergencies is also
                       made available to the PAS worker(s) either by the consumer, provider, or
                       PCA, as appropriate.

                (6.)   The consumer, the PAS worker(s) and others who have committed to provide
                       health maintenance activities must sign the care plan. Copies of the care plan
                       should be given to all persons providing health maintenance activities.

                (7.)   If at any time there is an indication that the health maintenance activities are
                       not being carried out adequately by the PAS worker or not being adequately
                       supervised by the consumer, the provider or PCA has the right and
                       responsibility to intervene and recommend appropriate corrective measures.

          c.    Supplemental Services

                Home support services, including but not limited to, shopping, laundry, cleaning and
                seasonal chores.

                Companion-type services including, but not limited to, assistance with transportation,
                reading, and letter writing.

          d.    Backup Services

                For those consumers who choose to direct their care and not opt for the agency model
                (see Service Delivery Options below), PCA shall require the consumer to take


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                primary responsibility for arranging backup services. The use of family, friends and
                neighbors shall be encouraged since these sources are dependable and usually
                available on short notice. In the event the consumer is unable to arrange for backup
                services, PCA or its subcontractor will be responsible to provide basic services, as
                defined in the definitions section of this policy, to the consumer until the regular
                personal assistance worker returns. A written statement describing the consumer's
                arrangement of backup services must be included in the care plan.

                The consumer shall take primary responsibility for arranging back-up services,
                especially in priority-care situations/conditions. (Priority care is defined as care
                needed by consumers to fulfill their basic service needs. Priority care does not
                include supplemental services.) The use of family, friends and neighbors shall be
                encouraged since these sources are dependable and usually available on short notice.

                The provider remains ultimately responsible for ensuring that basic services are
                provided when a consumer’s back up fails. Consumers are responsible for notifying
                the provider promptly when back-up and priority situations arise or when the
                consumer’s back-up system changes. Provider response to these situations should be
                within a reasonable time frame (one to three hours).

                The scheduling of PAS will be responsive to the special needs of consumers as
                appropriate and is to be made available on weekends and after normal working hours.

          e.    Personal Assistance Worker Specifications

                PAS workers are usually neither licensed nor registered nurses. A PAS worker is
                someone chosen by the consumer or legally authorized surrogate to meet his or her
                individualized service needs. PAS workers may be friends and/or relatives of the
                consumer, but may not be spouses (including common-law spouse), minor children,
                legal guardian, or power of attorney. All PAS workers, including friends and
                relatives, must meet the following qualifications:

                (1.)   Be 18 years of age or older;
                (2.)   Have the required skills to perform personal assistance services as specified
                       in the consumer’s service plan;
                (3.)   Possess basic math, reading, and writing skills;
                (4.)   Possess a valid Social Security number; and,
                (5.)   Be willing to submit to and pass a criminal record check.
                (6.)   When required by the consumer, the personal assistance (attendant care)
                       worker must be able to demonstrate the capability to perform health
                       maintenance activities specified in the consumer’s service plan or be willing
                       to receive training.

          f.    Service Delivery Options

                Based upon their assessed ability and competency, consumers should be given the
                option of choosing a service delivery model which best meets their needs. At a
                minimum, PCA is required to offer consumers one of the PAS service delivery


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                models described below and are encouraged to develop the capacity to implement the
                combination model. The service delivery option must be described in the consumer’s
                care plan.

                (1.)   Combination Model

                       (a.)   The consumer chooses to manage certain aspects of his/her PAS,
                              including:

                              (i.)     Recruiting, hiring and training personal assistance workers.
                              (ii.)    Defining personal assistance workers’ duties and work
                                       schedules.
                              (iii.)   Supervising personal assistance workers regarding how and
                                       when specific tasks are to be completed.
                              (iv.)    Disciplining and discharging personal assistance workers.

                       (b.)   Support Coordination

                              The provider agency or PCA will be responsible for managing all
                              aspects of the PAS not assumed by the consumer.

                              When requested by a personal assistance consumer and determined
                              appropriate through the assessment process, PCA will be responsible
                              for making available (either directly or arranged through another
                              source) the elements necessary to support a consumer who chooses
                              the combination service delivery model. These elements include but
                              are not limited to assistance with the following: recruiting and
                              screening attendants; training consumers and PAS workers;
                              supervising PAS workers. If requested by the consumer, PCA or a
                              subcontractor will also be responsible to assist those consumers who
                              choose the combination model service delivery model for a period of
                              time until the consumer acquires the skill necessary to perform the
                              requisite employer functions independently.

                              NOTE: The Aging Waiver Program does not allow consumers to be
                              paid directly. This should in no way diminish the ability of the
                              consumer to direct his/her care.

                              Example: A consumer choosing this model has previously secured or
                              will secure a PAS worker who meets all definitions and qualifications
                              and will assume some or all responsibility for employee management
                              related tasks. The payroll management and disbursement activities
                              will be completed by an MA certified fiscal agent (see below). The
                              fiscal agency may be a private payroll company, PCA, an MA service
                              provider, or a DPW Attendant Care provider currently providing this
                              service to DPW Attendant Care Waiver consumers.




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                       (c.)   Financial Management Services (FMS)

                              Financial Management Services (FMS) are supportive services
                              provided only to participants (consumers) who use Combination
                              Model services for some or all of their individual service plan hours.
                              When FMS is provided, the participant is the common law employer
                              of the direct care worker employed under the consumer-employer
                              model. FMS agencies reduce the employer-related burden of
                              participants using the consumer-employer model of services through
                              the provision of appropriate fiscal and supportive services. FMS
                              agencies must have a separate Employer Identification Number (EIN)
                              for FMS.

                              FMS includes performing the following tasks with the participant’s
                              authorization:

                              (i.)    On behalf of the participant employer, enrollment of the
                                      participant into all applicable taxing authorities;
                              (ii.)   Assisting participant to understand their responsibilities as an
                                      employer;
                              (iii.) On behalf of the participant employer, processing employment
                                      application package and documentation for prospective
                                      individual to be employed (including verifying their workers’
                                      qualifications and clearances);
                              (iv,) On behalf of the participant employer, establishing and
                                      maintaining a record for each individual employed and process
                                      all employment records;
                              (v.)    On behalf of the participant employer, preparing and
                                      disbursing payroll;
                              (vi.) On behalf of the participant employer, securing workers’
                                      compensation or other forms of insurance and managing the
                                      claims;
                              (vii.) On behalf of the participant employer, withholding, filing,
                                      reporting and depositing federal, state, and local income taxes
                                      in accordance with federal IRS, state Department of Revenue
                                      Services, and local tax bureaus rules and regulations;
                              (viii.) On behalf of the participant employer, withholding, filing,
                                      reporting, depositing and maintaining compliance with the
                                      claims and appeals with the Pennsylvania and Federal
                                      Unemployment Compensation Bureaus rules and regulations;
                              (ix.) On behalf of the participant employer, generating and
                                      distributing IRS W-2’s, wage and tax statements and related
                                      documentation annually to all member-employed caregivers
                                      who meet the statutory threshold earnings amounts during the
                                      tax year by January 31st;
                              (x.)    On behalf of the participant employer, acting on behalf of the
                                      participant receiving supports and services for the purpose of
                                      payroll reporting;


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                              (xi.)    On behalf of the participant employer, distributing, collecting
                                       and processing provider time sheets and attendance data as
                                       summarized on payroll summary sheets completed by the
                                       participants;
                              (xii.) On behalf of the participant employer, securing business
                                       agreements with any individual or entity that will be
                                       reimbursed with waiver funding;
                              (xiii.) On behalf of the participant employer, establishing and
                                       maintaining all FMS related participant records with
                                       confidentiality, accuracy, and appropriate safeguards;
                              (xiv.) Participating in the Commonwealth of Pennsylvania’s quality
                                       management strategy;
                              (xv.) On behalf of the participant employer, purchasing other forms
                                       of insurance, including healthcare, as appropriate;
                                       On behalf of the participant employer, verifying weekly
                                       service hours in relationship to payroll in order to ensure
                                       correct billing, problem resolution, and alternate billing
                                       procedures;
                              (xvi.) On behalf of the participant employer, processing judgments
                                       and wage garnishments and requests for employee wage
                                       information;
                              (xvii.) Rescinding or revoking all authorizations when a participant
                                       leaves the program;
                              (xviii.) Maintaining compliance with all applicable regulations and
                                       statutes, such as the Bureau of Program Integrity’s (BPI) fraud
                                       and abuse policies; and
                              (xix.) Providing reports and documentation to the Department as
                                       requested.

                              The following DPW Attendant Care forms can be used/modified for
                              these and other PAS related activities: Fiscal Agent Function, Fiscal
                              Agent and Employment Related Forms, Consumer Selection
                              Option, Service Agreement Between Consumer and
                              Contractor/Provider, Consumer Designation of Primary
                              Responsibility, Consumer/Employer Appointment of Agent, List
                              of Services Agreed to be Provided by Fiscal Agent, Application
                              for Employment, Criminal Record Check Policy for
                              Consumers/Employers, Agreement Between Consumer and
                              Attendant, Time Sheet, Payroll Form, Status Form, Notice of
                              Discontinued Employment, Taxing Agency Forms.

                              NOTE: The Fiscal Agent duties described above are currently
                              included in the Monthly Coordination fee for those in the consumer
                              directed Combination Model of service.

                (2.)   Agency Model - The consumer is not responsible for managing any aspect of
                       his/her PAS. The provider agency will employ the PAS worker, or through a
                       subcontractor, and manage all aspects of the consumer’s PAS.


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                       Supervision and oversight of the PAS worker is required and must be
                       provided as outlined in the standards for Aging Waiver Personal Care
                       Services, hereby included by reference. In addition, providers and their
                       subcontractors will adhere to those additional supervisory requirements as
                       outlined in PCA’s Service Specific Operational Requirements for Personal
                       Care, Respite, Companion and Home Support, hereby included by reference.

                       In both service delivery options, a registered nurse, on staff of the provider or
                       its subcontractor, or in a consultant role, must be available as needed by
                       consumers and/or by PCA or provider agency responsible for delivering the
                       PAS and for ensuring the health and safety of the consumer.

                       Appropriate professional staff must be available to provider staff and to
                       consumers to assist in training and to provide consultative support in PAS
                       service delivery.

          g.    Supervision

                Supervision of PAS workers in the Combination Model is to be performed directly
                by the consumer. It shall be the responsibility of the consumer to supervise the PAS
                worker in regards to the specified tasks. That responsibility also extends to decisions
                to discharge the PAS worker, when deemed appropriate.

                Note: in those instances where the consumer lacks the necessary skills to properly
                supervise the PAS worker, PCA or the contract provider will be responsible until the
                consumer can perform the requisite employer functions independently.

                Supervision of the PAS worker in the Agency Model is not the responsibility of the
                consumer. The contract provider or their designated subcontractor will employ the
                PAS worker and manage all aspects of the consumer’s PAS service. Supervision of
                the PAS worker must be provided as outlined in the standards for Aging Waiver
                Personal Care Services, hereby included by reference. In addition, providers and their
                subcontractors will adhere to those additional supervisory requirements as outlined in
                PCA’s Service Specific Operational Requirements for Personal Care, Respite,
                Companion and Home Support, hereby included by reference.

          h.    Provider Agency Requirements

                In order to serve Aging Waiver consumers, each provider agency will have a
                provider agreement directly with the Department of Public Welfare (DPW) Office of
                Medical Assistance Programs.

                Under the terms of the DPW provider agreement, all full-time and part-time
                employees of the provider agency or individuals delivering services through personal
                assistance services agreements with a provider agency, including subcontractors,
                must meet the qualifications for safeguarding the health and welfare of the recipients,
                specified in the provider requirements for Aging Waiver personal assistance


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                services.

                (1.)   For Aging Waiver consumers, provider agencies must be certified Medicaid
                       Providers of Service as documented by a completed Provider of Service
                       agreement with the Commonwealth of Pennsylvania, Department of Public
                       Welfare and must meet all stipulated fiscal, Medical Assistance Program, and
                       AGING Waiver personal assistance service requirements.

                (2.)   Provider agencies can have subcontracting arrangements in place.

                (3.)   Provider agencies must provide, either directly or by sub-contract, the full
                       range of personal assistance services. Personal assistance service provider
                       agencies under the waiver and subcontractors must be capable of providing a
                       continuum of services that enable the consumer to choose the level of
                       consumer control most suitable to individual needs. The consumer always
                       has the choice of directing his or her own care. In addition, provider agencies
                       must be capable of providing 24-hour service availability. The range of
                       options must be made available to each consumer. The option chosen is in
                       conformance with the consumer’s care plan.

                (4.)   The provider agency must agree to assist the consumer in all employer-related
                       activities that are needed.

                (5.)   For Aging Waiver consumers, provider agencies must be willing to accept the
                       Department of Public Welfare’s reimbursement rate for provision of personal
                       assistance services as payment in full. Reimbursement is for personal
                       assistance services provided, including the direct provision of personal
                       assistance services to consumers, service coordination, support activities,
                       program monitoring activities, and administrative requirements stipulated by
                       the Department of Public Welfare. Provider agencies may not balance bill
                       consumers or seek any additional reimbursement other than any minimal co-
                       payment stipulated by the Department of Public Welfare.

                (6.)   Provider agencies must meet the following staffing requirements:

                       (a.)   The agency must have sufficient professional staff to perform the
                              needed service coordination and support activities as required by
                              AGING Waiver personal assistance services requirements.

                       (b.)   The Medicaid Waiver and PCA provider agency must have registered
                              nurse (RN) consulting services available, either by a staffing
                              arrangement or through a contracted consulting arrangement to
                              provide support as needed to ensure the health, welfare and safety of
                              consumers. The responsibilities of the provider agency RN consultant
                              include the following:

                              (i.)    Provide training, as needed, to consumers, personal assistance
                                      workers, and provider agency staff, on issues related to health


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                                       maintenance activities and/or other health, welfare and safety
                                       issues.

                              (ii.)    Provide consultation, as needed, on service delivery problem
                                       solving related to health maintenance activities and/or to the
                                       health, welfare, and safety of consumers including
                                       consultation services to consumers and to provider agency
                                       staff on issues related to supervision of personal assistance
                                       worker basic services and ancillary activities.

                              (iii.)   To the extent specified in the consumer’s care (service) plan,
                                       supervision of personal assistance workers’ basic and ancillary
                                       service activities is by the consumer. Provider RN consulting
                                       services shall be available as needed by consumers and/or by
                                       the provider agency staff supervising personal assistance
                                       service delivery.

                (7.)   Qualified provider agencies will provide personal assistance services
                       consistent with the following requirements:

                       (a.)   Provider agencies will have the capability to provide, either directly or
                              under purchase arrangements, an array of support activities that will
                              assist consumers in managing their personal assistance service and in
                              other aspects of independent living. These activities include: payroll
                              services related to personal assistance service, management and
                              assistance in linking consumers to services such as transportation,
                              income maintenance, housing, medical and related services, and
                              general assistance with the direct provision of personal assistance
                              service.

                       (b.)   Provider agencies will also coordinate with the Office of Vocational
                              Rehabilitation, county governments and other sources of support
                              services, including family and friends, who are available to provide
                              back-up services according to the consumer’s care plan to avoid
                              duplication and to integrate service.

                       (c.)   Provider agencies will offer consumers a continuum of consumer
                              control options, ranging from consumer management of the personal
                              assistance service, to provider agency management. Provider agencies
                              will offer consumers the option of recruiting, managing, training,
                              hiring, and approving time sheets of their personal assistance workers.
                               Consumers have the right to choose and perform any or all of these
                              tasks in conformance with their own needs and requirements. The
                              consumers will determine which level of control is desired.

                       (d.)   Provider agencies that provide services through a subcontract or any
                              other purchase arrangement are responsible for ensuring that services
                              rendered under these contractual or purchase arrangements are in


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                                 compliance with the Medical Assistance and AGING Waiver
                                 Programs and quality of care requirements to the same extent that
                                 services are provided by direct employees of the provider agency.

                 (8.)    All providers of services to PCA consumers are to comply with federal, state
                         and local health requirements related to communicable disease and to follow
                         procedures recommended in the Centers for Disease Control (CDC)
                         Guidelines and OSHA regulations, including provision of protective articles
                         to staff and in-service on universal precautions.

   3.     Options Program PAS Standards

          Personal Assistance Service is in-home personal care and other approved support activities
          for consumers with functional disabilities who need assistance to accomplish daily living
          tasks. The service consists of those basic and ancillary services, which enable eligible
          consumers to live in their own homes and communities rather than in institutions and to
          carry out functions of daily living, self-care and mobility. Primarily, the consumer if he/she
          were physically able, or family/friends, if available, would carry out these activities.

          Personal assistance service is consumer directed care, in which a consumer chooses a service
          delivery model and is given the opportunity to control the delivery of service prescribed in
          the care plan.

          a.     Standards:

                 (1.)    An individual with an assessed need for personal assistance service shall have
                         a choice of directing a portion of his or her care or having an agency direct his
                         or her care.

                 (2.)    Individuals who are assessed as being cognitively capable to direct a portion
                         of their own care, and are willing to do so, may manage certain aspects of
                         their care or choose to have a caregiver direct their care.

                 (3.)    An individual who is assessed as being cognitively impaired must not direct
                         his or her care. Such an individual who is assessed as being cognitively
                         impaired may have a caregiver who is willing and able to direct his or her
                         care. Consumers who have objections to being assessed as cognitively
                         impaired shall have immediate and full access to the PCA and PDA hearings
                         and appeals process.

                 (4.)    An individual consumer, or legally authorized surrogate, may direct the care.
                         “Legally authorized surrogate” is defined as an individual legally appointed to
                         speak, act, and make decisions for the consumer; i.e., power of attorney and
                         /or guardian. The legally-authorized surrogate may not be a paid personal
                         assistance worker.




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         b.     Services

                (1.)   The individual must currently experience functional disabilities, which result
                       in a substantial loss of capability to perform one or more of the following
                       basic activities associated with the personal care of one's self, and require
                       "hands-on" assistance to fulfill these needs:

                       (a.)    Getting in and out of bed, wheelchair, or motor vehicle;
                       (b.)    Ambulating, with or without mechanical aids, inside the home;
                       (c.)    Routine bodily functions, including eating or feeding (including meal
                               preparation and clean-up) and toileting;
                       (d.)    Bathing, dressing, personal hygiene and grooming; and
                       (e.)    Health maintenance activities.

                NOTE: The need for "hands-on" assistance in completing these basic activities must
                be the individual's primary need for formal services in order for personal assistance
                to be the appropriate service response.

                The individual must reside in a private home or apartment or be able to reside in a
                private home or apartment if personal assistance is provided.

                (2.)   In addition, personal assistance services may include the following activities,
                       if these activities are ancillary to the above "hands-on" activities which
                       establish the primary need for personal assistance service:

                       (a.)    Home Support services including, but not limited to, shopping,
                               laundry, cleaning and seasonal chores.
                       (b.)    Companion-type services including, but not limited to, assistance with
                               transportation, letter writing, reading mail and escort.
                       (c.)    At the direction of the consumer, assistance with household
                               management tasks.

                (3.)   Backup Services - For those consumers who choose to direct their care and
                       not opt for the Agency Employed Model, PCA shall require the consumer to
                       take primary responsibility for arranging backup services. The use of family,
                       friends, and neighbors shall be encouraged since these sources are dependable
                       and usually available on short notice. In the event the consumer is unable to
                       arrange for backup services, PCA or its subcontractor will only be responsible
                       to provide basic services, as defined earlier in the definitions section of this
                       policy, to the consumer until the regular attendant returns. A written
                       statement describing the consumer's arrangement of backup services must be
                       included in the care plan.

                (4.)   Supplemental Services - Supplemental services necessary to support personal
                       assistance assessments and service delivery may be appropriate in specific
                       situations. When the services listed below are not otherwise available, PCA
                       may provide them as follows:



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                       (a.)    Home Health Services, other than those performed by a PAS worker
                               pursuant to the definition of Health Maintenance Activities in this
                               document.

                       (b.)    Rehabilitative Therapy for disabled persons, when medically
                               prescribed for a specific consumer's needs, if PCA has have
                               exhausted all possibilities for obtaining such therapy under other
                               community or third party resources.

                (5.)   In addition to being made available during normal weekday working hours,
                       services will be made available to meet individual needs on weekends and
                       before or after normal working hours.

                (6.)   The scheduling of personal assistance services shall, to the extent feasible,
                       respond to the special needs of the individual for personal assistance at
                       specific times.

          c.    PAS Worker Specifications

                Personal assistance workers are usually neither licensed nor registered nurses. A
                personal assistance worker is someone chosen by the consumer or appropriate
                caregiver to meet his/her individualized service needs. Personal assistance workers
                may be friends and/or relatives of the consumer, but may not be spouses (including
                common-law spouse), minor children, legal guardian, or power of attorney. All
                personal assistance workers, including friends and relatives, must meet the
                qualifications outlined below:

                (1.)   Be 18 years of age or older;
                (2.)   Have the required skills to perform personal assistance (attendant care)
                       services as specified in the consumer’s service plan;
                (3.)   Possess a valid Social Security number;
                (4.)   Be willing to submit to and pass a criminal record check; and
                (5.)   When required by the consumer, must be able to demonstrate the capability to
                       perform health maintenance activities specified in the consumer’s service
                       plan or be willing to receive training.

          d.    Service Delivery Options

                Based upon their assessed ability and competency, personal assistance consumers
                should be given the option of choosing a service delivery model which best meets
                their needs.

                (1.)   Combination Model:

                       (a.)    The consumer chooses certain aspects of his/her personal assistance
                               service to manage and PCA or a subcontractor of PCA is responsible
                               for providing the consumer with the remaining aspects of care.



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                       (b.)   Support Coordination:

                              When requested by a personal assistance consumer and determined
                              appropriate through the assessment process, PCA will be responsible
                              for making available (either directly or arranged through another
                              source) the elements necessary to support a consumer who chooses
                              the combination service delivery model. These elements include but
                              are not limited to assistance in performing the following: recruiting
                              and screening attendants; training consumers and personal assistance
                              workers; managing and supervising personal assistance workers. If
                              requested by the consumer, PCA or a subcontractor of PCA will also
                              be responsible to assist those consumers who choose the combination
                              service delivery model for a period of time until the consumer
                              acquires the skills necessary to perform the requisite employer
                              functions independently.

                       (c.)   Financial Management Services (FMS)

                              Financial Management Services (FMS) are supportive services
                              provided only to participants (consumers) who use Combination
                              Model services for some or all of their individual service plan hours.
                              When FMS is provided, the participant is the common law employer
                              of the direct care worker employed under the consumer-employer
                              model. FMS agencies reduce the employer-related burden of
                              participants using the consumer-employer model of services through
                              the provision of appropriate fiscal and supportive services. FMS
                              agencies must have a separate Employer Identification Number (EIN)
                              for FMS.

                              FMS includes performing the following tasks with the participant’s
                              authorization:

                              (1.)   On behalf of the participant employer, enrollment of the
                                     participant into all applicable taxing authorities;
                              (2.)   Assisting participant to understand their responsibilities as an
                                     employer;
                              (3.)   On behalf of the participant employer, processing employment
                                     application package and documentation for prospective
                                     individual to be employed (including verifying their workers’
                                     qualifications and clearances);
                              (4.)   On behalf of the participant employer, establishing and
                                     maintaining a record for each individual employed and process
                                     all employment records;
                              (5.)   On behalf of the participant employer, preparing and
                                     disbursing payroll;
                              (6.)   On behalf of the participant employer, securing workers’
                                     compensation or other forms of insurance and managing the
                                     claims;


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                              (7.)   On behalf of the participant employer, withholding, filing,
                                     reporting and depositing federal, state, and local income taxes
                                     in accordance with federal IRS, state Department of Revenue
                                     Services, and local tax bureaus rules and regulations;
                              (8.)   On behalf of the participant employer, withholding, filing,
                                     reporting, depositing and maintaining compliance with the
                                     claims and appeals with the Pennsylvania and Federal
                                     Unemployment Compensation Bureaus rules and regulations;
                              (9.)   On behalf of the participant employer, generating and
                                     distributing IRS W-2’s, wage and tax statements and related
                                     documentation annually to all member-employed caregivers
                                     who meet the statutory threshold earnings amounts during the
                                     tax year by January 31st;
                              (10.) On behalf of the participant employer, acting on behalf of the
                                     participant receiving supports and services for the purpose of
                                     payroll reporting;
                              (11.) On behalf of the participant employer, distributing, collecting
                                     and processing provider time sheets and attendance data as
                                     summarized on payroll summary sheets completed by the
                                     participants;
                              (12.) On behalf of the participant employer, securing business
                                     agreements with any individual or entity that will be
                                     reimbursed with waiver funding;
                              (13.) On behalf of the participant employer, establishing and
                                     maintaining all FMS related participant records with
                                     confidentiality, accuracy, and appropriate safeguards;
                              (14.) Participating in the Commonwealth of Pennsylvania’s quality
                                     management strategy;
                              (15.) On behalf of the participant employer, purchasing other forms
                                     of insurance, including healthcare, as appropriate;
                                     On behalf of the participant employer, verifying weekly
                                     service hours In relationship to payroll in order to ensure
                                     correct billing, problem resolution, and alternate billing
                                     procedures;
                              (16.) On behalf of the participant employer, processing judgments
                                     and wage garnishments and requests for employee wage
                                     information;
                              (17.) Rescinding or revoking all authorizations when a participant
                                     leaves the program;
                              (18.) Maintaining compliance with all applicable regulations and
                                     statutes, such as the Bureau of Program Integrity’s (BPI) fraud
                                     and abuse policies; and
                              (19.) Providing reports and documentation to the Department as
                              requested.

                       The following DPW Attendant Care Program forms can be used/modified for
                       these and other related PAS activities: Fiscal Agent Function, Fiscal Agent
                       and Employment Related Forms, Consumer Selection Option, Service


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                       Agreement Between Consumer and Contractor/Provider, Consumer
                       Designation of Primary Responsibility, Consumer/Employer
                       Appointment of Agent, List of Services Agreed to be Provided by Fiscal
                       Agent, Application for Employment, Criminal Record Check Policy for
                       Consumers/Employers, Agreement Between Consumer and Attendant,
                       Time Sheet, Payroll Form, Status Form, Notice of Discontinued
                       Employment, Taxing Agency Forms.

                       NOTE: The Fiscal Agent duties described above are currently included in the
                       Monthly Coordination fee for those in the consumer directed Combination
                       Model of service.

                (2.)   Agency Model - The consumer is not responsible for managing any aspects
                       of his or her personal assistance service. PCA or a subcontractor of PCA
                       would employ the attendant and manage all aspects of the consumer's
                       personal assistance service.

                       Supervisory visits must be made to the consumer's home to monitor the
                       performance of the PAS worker. This includes the requirement for the
                       frequency of supervisory visits to be made at a minimum of 90-day intervals.
                       In addition, providers and their subcontractors will adhere to those additional
                       supervisory requirements as outlined in PCA’s Service Specific Operational
                       Requirements for Personal Care, Respite, Companion and Home Support,
                       hereby included by reference.

                       The selected service delivery option will be described in the consumer’s plan
                       of care. Supervision of personal assistance worker basic and ancillary
                       activities is controlled by the consumer to the extent specified in the
                       consumer’s plan of care. A registered nurse, on staff or in a consultant
                       arrangement with a provider agency, must be available as needed by
                       consumers and/or by the provider agency responsible for delivering the
                       personal assistance service and for ensuring the health and safety of the
                       consumer. Appropriate professional staff must be available to provider
                       agency staff and to consumers to assist in training and to provide consultative
                       support in personal assistance service delivery as needed to ensure the health,
                       welfare, and safety of consumers.

                       The personal assistance service is necessary to prevent institutionalization
                       and to provide optimum conditions for participating consumers to live as
                       integrated members of society.

          e.    Health Maintenance Activities

                Health Maintenance Activities are those activities which are necessary to maintain
                the consumer's optimum health, as directed by the physician responsible for the
                consumer's medical/health plan of care. These activities would be carried out
                primarily by the consumer if he/she were physically able, or family members if
                available. These activities include, but are not limited to:


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                (1.)   Catheter irrigations;
                (2.)   Administration of medication, enemas, and suppositories; and
                (3.)   Wound Care.

          f.    Supervision

                Supervision of PAS workers in the Combination Model is to be performed directly
                by the consumer. It shall be the responsibility of the consumer to supervise the PAS
                worker in regards to the specified tasks. That responsibility also extends to decisions
                to discharge the PAS worker, when deemed appropriate.

                Note: in those instances where the consumer lacks the necessary skills to properly
                supervise the PAS worker, PCA or the contract provider will be responsible until the
                consumer can perform the requisite employer functions independently.

                Supervision of the PAS worker in the Agency Model is not the responsibility of the
                consumer. The contract provider or their designated subcontractor will employ the
                PAS worker and manage all aspects of the consumer’s PAS service. Supervision of
                the PAS worker must be provided as outlined in the standards for Aging Waiver
                Personal Care Services, hereby included by reference. In addition, providers and their
                subcontractors will adhere to those additional supervisory requirements as outlined in
                PCA’s Service Specific Operational Requirements for Personal Care, Respite,
                Companion and Home Support, hereby included by reference.

          g.    Special Program and Cost Concerns

                Health Maintenance Activities - In cases where the personal assistance service (PAS)
                worker will be assisting the consumer with health maintenance activities, it is
                required that the consumer have a "medical home"; i.e., that the consumer is enrolled
                and being seen regularly by a primary care physician in a clinic, HMO or a primary
                care center responsible for the consumer's medical/health plan of care.

                If the consumer chooses to direct his/her health maintenance activities and his/her
                primary care physician makes a determination that the consumer is capable of
                directing his/her health maintenance activities, then the PAS worker may perform
                health maintenance activities under the conditions listed below:

                (1.)   The consumer has indicated that he/she has been adequately instructed by the
                       appropriate health professionals and is thereby qualified and able to instruct
                       and supervise his/her attendant in Health Maintenance Activities. A written
                       statement to this effect must be included in the care plan. This statement
                       must be signed by the appropriate health professional (preferably the
                       consumer's physician).

                (2.)   The PAS worker is instructed and monitored in Health Maintenance
                       Activities by the consumer, the consumer's physician and/or a health
                       professional (usually a nurse or therapist) as appropriate.


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                (3.)   The PCA care manager will monitor Health Maintenance Activities which are
                       part of the care plan to assure that the services are being provided as ordered
                       by the physician. The care manager will also monitor the consumer's
                       satisfaction with the PAS worker’s performance of Health Maintenance
                       Activities, either through routine monitoring visits or through periodic
                       consultation and input from the consumer regarding his/her satisfaction with
                       the service. The PCA care manager will not monitor the PAS worker’s
                       performance of the health maintenance activity. This is the consumer's,
                       consumer's physician and/or health professional's responsibility as
                       appropriate.

                (4.)   Disposable items or devices are used in caring for the consumer whenever
                       they are obtainable.

                (5.)   The PAS worker’s prior experience and work history do not indicate unsafe
                       performance of such activities.

                (6.)   The consumer has appropriate arrangements in place to respond to health
                       emergencies; a statement to this effect is included in the care plan.
                       Information on the arrangements for health emergencies is also made
                       available to the PAS worker(s) either by PCA, its delegate or by the
                       consumer.

                (7.)   PCA and consumer must document in the Care Plan who is responsible for
                       providing Health Maintenance Activities and that these persons, if PAS
                       workers, have been trained in the performance of these activities as approved
                       by the consumer's physician.

                (8.)   When there is an indication that the Health Maintenance Activities are not
                       being carried out as ordered by the physician, PCA has the right and
                       responsibility to intervene and provide appropriate corrective measures.
                       Corrective measures could involve contacting the physician to make him or
                       her aware of the problem and requesting additional training and/or direction.

          h.    Care Management

                Consumers receiving personal assistance service must receive care management in
                accordance with the program instructions contained in the Options Program policy.




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Q.      PERSONAL EMERGENCY RESPONSE SYSTEM: STANDARDS

        1.     SERVICES TO BE PURCHASED

               PCA’s Options and Aging Waiver Program will lease Personal Emergency Response System
               (PERS) from an emergency medical response system manufacturer (herein called vendor).
               Units leased will be maintained and guaranteed by the vendor, and will be updated, at no
               cost to the Options or Aging Waiver Program, as technology improves performance.

               Each PERS shall include:

               a.     Installation, in the consumer’s home, including any needed phone jack modifications
                      and devices;
               b.     Two way voice communication;
               c.     Fire and smoke detector;
               d.     Inactivity timer;
               e.     Average range, water proof, portable help button, with a five year battery;
               f.     Ability to self-test on-line status of all functions;
               g.     UL listed/certified.

               Included as a part of the monthly charge, the vendor shall, either directly or through
               subcontract, provide for ongoing provision of on-line emergency response center services for
               each consumer authorized. This shall include response to consumer self-testing, as well as
               daily provider testing, self auditing and quality control, repair, replacement, and staff
               training.

               The vendor will insure 24-hour staffing, by trained operators, of the emergency response
               center, 365 days per day.

        2.     CERTIFICATION, STANDARDS AND SAFETY

               All PERS installed, shall be certified as meeting standards for safety and use, as may be
               promulgated by any governing body, including any electrical, communications, consumer or
               other standards, rules or regulations that may apply.

        3.     INSTALLATION

               It shall be the vendor's responsibility to deliver and install each Personal Emergency
               Response System unit that is leased. The vendor agrees to complete installation within five
               working days of receipt of the service order. Services will be billed in the month that PERS
               units are ordered and installed.

               a.     The PCA Care Manager will notify the vendor by phone of a request for installation.
                      The vendor shall arrange with the consumer for a mutually convenient appointment
                      within five working days of the vendor's notification by the Care Manager.

               b.     The vendor shall notify the Care Manager of the installation appointment and shall
                      notify the Care Manager to confirm that installation has been completed.


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          c.    The vendor immediately shall notify the Care Manager if it is unable to schedule or
                complete an installation within the required time frame.

          d.    The vendor shall provide all parts and equipment necessary for installing an
                emergency medical response system unit, whether purchased or leased, into a
                functioning telephone system.

          e.    The vendor shall instruct the consumer in the use and maintenance of the PERS and
                shall provide the consumer with simple written instructions, including how to report
                a malfunction of the PERS.

          f.    The vendor shall, upon request of the consumer or Care Manager, provide additional
                follow-up instructions to the consumer on operating and maintaining the PERS.

          g.    The vendor shall forward to the Care Manager, within five working days of the
                installation either by mail or by facsimile, a form signed by a vendor representative
                or employee and by the consumer or consumer’s representative confirming the date
                of the installation and the consumer’s understanding of the use and maintenance of
                the PERS.

          h.    The vendor shall provide the Care Manager, consumers, and other persons (as needed
                to assure care), instructional materials and orientation in the operation of the PERS,
                stated in simple and understandable language.

          i.    If any applicable regulatory, industry, or manufacturer standards are changed,
                resulting in improvements or updating of equipment, the Care Manager shall be
                notified and each on-line consumer with leased equipment immediately shall be
                provided with said new equipment.

   4.     MAINTENANCE OF EQUIPMENT AND SERVICE

          a.    Vendor shall maintain all installed PERS in proper working order.

                (1.)   The vendor shall make provision to insure that each installed PERS is
                       operating properly at least once every 24 hours.

                (2.)   Provision for the daily testing will preferable be automated and cause the
                       least possible inconvenience for the consumer.

                (3.)   The vendor shall follow up with the consumer and notify the Care Manager
                       within 24 hours, or the next business day of any PERS that is not operating
                       properly. Malfunctioning equipment shall be repaired or replaced within 24
                       hours of notification or identification.




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   5.     PROVISION OF SERVICE

          Vendor shall maintain, either directly or through subcontract, a 24-hour Emergency
          Response Center staffed with trained emergency response operators. The Emergency
          Response Center shall perform the activities that follow:

          a.     Receive, acknowledge, and establish immediate two-way communication in
                 responding to emergency signals from consumers. The vendor immediately upon
                 receiving a signal from a consumer’s PERS, will retrieve the consumer’s automated
                 data records, establish immediate two-way voice contact directly with the consumer
                 via the incoming signal, and contact the consumer’s representative, or take other
                 emergency action as prescribed in the consumer’s record.

          b.     Be capable of responding to multiple emergency signals simultaneously.

          c.     Respond immediately to any and all signals from consumer’s PERS and maintain
                 appropriate contact until termination of the emergency situation.

          d.     Notify a third party, consumer-designated representative, (e.g. neighbor, police,
                 Emergency Medical System (EMS), etc.), to respond to an emergency via immediate
                 telephone contact and without interrupting or terminating direct voice contact with
                 the consumer.

          e.     The Emergency Response Operator will monitor the provision of emergency service
                 to verify that it has been provided and that the emergency situation no longer exists at
                 the consumer’s residence.

          f.     Verify resolution of the emergency situation, document the incident, as below, for
                 future reference, and notify the Care Manager of the incident within 24 hours or the
                 next business day.

   6.     SUSPENSION AND TERMINATION OF SERVICE

          The decision to remove a PERS is at the sole discretion of the Care Manager. For all PERS
          removals, notification will be by telephone from the authorized Care Manager. Written
          authorization to terminate PERS service will be sent to the vendor on the same day as the
          telephone notification. If the vendor is notified directly by a consumer’s family or other
          representative to remove the PERS, authorization must first be obtained from the Care
          Manager.

          a.     When a consumer with a PERS no longer requires such services, regardless of the
                 reason, the Care Manager will discuss with appropriate staff, as needed, and contact
                 the vendor, so that the PERS may be transferred or removed.

          b.     When a consumer’s services are suspended because of the consumer’s admission to
                 the hospital, the Care Manager will notify and/or authorize the vendor to take the unit
                 off line. Services will be resumed to the consumer, only after the Care Manager




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                 notifies the vendor. Payment for leased equipment will be made at the standard unit
                 price as long as a unit remains in the home of a consumer.

          c.     The vendor shall disconnect/remove a PERS from a consumer’s residence within five
                 working days of notification by the Care Manager.

   7.     SUPERVISION

          The vendor shall supervise all staff providing services covered by this contract, at a
          minimum of once a month. It is expected that there will be a supervisor available during
          working hours.

   8.     STAFFING AND QUALIFICATIONS

          a.     Line Staff Employees Shall Possess:

                 (1.)   Ability to work under supervision as an employee of the agency;

                 (2.)   Ability to communicate orally with the consumer and resource personnel with
                        whom they must work, and both orally and in writing with their supervisor;

                 (3.)   Ability to read, write, follow written instructions, and to converse easily on
                        the telephone;

                 (4.)   Training and/or paid or volunteer experience of one year or more, specifically
                        related to the skills required to perform as an Emergency Response Center
                        employee;

                 (5.)   Ability to provide references as follows:

                        (a.)    Two verifiable work references, or

                        (b.)    One verifiable work reference indicating a minimum length of
                                employment of one year, or

                        (c.)    Two references, total, from a supervisor and/or instructors from an
                                acceptable training program.

                 (6.)   A written test shall be administered to all consumer contact employees, by the
                        vendor, pertaining to proper operation of the system and response to
                        emergencies, or installation and repair of equipment, prior to being assigned
                        on the job.

          b.     Supervisors

                 (1.)   Supervisors shall be capable of demonstrating and teaching all job skills
                        needed to perform all aspects of the jobs of their employees.




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                 (2.)   Supervisors shall receive regular supervision by a designated administrative
                        staff person.

          c.     Administrative Staff

                 Sufficient administrative staff shall be employed to insure the efficient and effective
                 provision of service under the contract.

          d.     Consultant Staff

                 Appropriate other staff shall be available for consultation regarding response,
                 operation, training, or other matters requiring professional input

          e.     General

                 The vendor will maintain sound personnel policies to minimize personnel turnover
                 which would adversely affect the delivery of service.

   9.     TRAINING

          a.     In-service training sessions must be offered to all direct consumer contact employees.
                  Subject areas covered should relate to relevant aspects of service delivery, trends or
                 advances in the field, or identified problems or gaps in knowledge. Programs on
                 vendor policies and procedures are necessary but should not constitute the majority
                 of any session.

          b.     The vendor will use and have on file, written training materials and procedures.

          c.     For staff with demonstrated personal characteristics and abilities, training in how to
                 work with consumers having special mental health or other complex needs, is
                 encouraged.

   10.    SERVICE REPORTING

          Persons providing Personal Emergency Response services must comply with all reporting
          requirements as specified by the AAA.

   11.    SCHEDULING

          Days and times schedules for Personal Emergency Response services must be consistent
          with the care plan provided by the AAA.

   12.    INSURANCE

          Agencies who wish to provide Personal Emergency Response services will be required to
          attest to having the following types of insurance in amounts consistent in the industry:




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          a.     General liability;
          b.     Professional liability;
          c.     Automobile liability covering owned, non-owned and hired vehicles;
          d.     Workman Compensation as required by law;
          e.     Employer’s liability of accident and disease.

   13.    CONFIDENTIALITY

          All agencies who provide Personal Emergency Response services must comply with all
          federal, state, and local laws relating to research on human subjects and consumer
          confidentiality.

          Agencies must provide all Care Managers with consent forms and approval from all
          appropriate review boards for those consumers who wish to be part of a research study.




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R.      TELECARE SERVICES

        1.     GENERAL INFORMATION

               a.    TeleCare is a model of care, which integrates social and healthcare services that are
                     supported by innovative technologies to sustain and promote independence, quality
                     of life and reduce the need for nursing home placement. By utilizing in-home
                     technology, Pennsylvania will have more options to assist and support individuals so
                     that they can remain in their own homes. TeleCare complements home and
                     community based services by facilitating timely visits based on patient needs and
                     enables healthcare providers to allocate resources by allowing nurses and other
                     homecare professionals to work more efficiently.

               b.    Types of TeleCare Services:

                     (1.)   Health Status Measuring and Monitoring
                     (2.)   Activity and Sensor Monitoring
                     (3.)   Medication Monitoring System

                     Note: All other medical equipment and supplies that will be of value to the
                     individual to maintain them safely in the home can be purchased using medical
                     equipment and supplies in the Aging Waiver. (Examples include but are not limited
                     to: blood pressure cuff, weigh scale, light movement sensors, etc.)

               c.    TeleCare Services will be utilized for participants where there is a demonstrated
                     medical need for the services and it has been determined that the services are not
                     covered under Medicare, State Plan or other third party resources. In instances where
                     Medicare or other third party payer services are in place TeleCare services will not be
                     approved by the care manager and AAA nursing staff. TeleCare Services are
                     provided in an efficient manner, preventing duplication of services, unnecessary
                     costs and unnecessary administrative tasks. TeleCare Services attempt to use
                     resources efficiently to maximize the benefits and services available to all individuals
                     enrolled in the AGING 60+ Waiver Program.

               d.    The participant’s home must be evaluated to ensure that there is an adequate living
                     environment with sufficient utilities to meet the manufacturers’ specifications for
                     equipment, which allows for the adaptation of the TeleCare equipment. TeleCare
                     Services which are web based services must be HIPAA compliant. The
                     documentation collected from the use of TeleCare services must be available upon
                     request. All reports and data must be maintained and made available for at least 1
                     year past removal of the equipment. All TeleCare service providers must be enrolled
                     in the Medical Assistance program and are required to comply with other applicable
                     statutes, state and federal regulations and policies and procedures. Providers shall
                     ensures that individuals providing services meet service qualifications and standards
                     and equipment meet all manufacturers’ qualifications and standards for the
                     appropriate type of TeleCare Services.




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          e.    Participant care plans including TeleCare Services must adhere to PDA policies for
                Care Plan review as outlined in APD #06-01-03. TeleCare Services are not to be
                used as a onetime emergency service.

          f.    Special Eligibility Criteria for All TeleCare Services

                (1.)   The participant must be assessed and determined to be clinically eligible for
                       nursing facility level of care (NFCE); as defined in the approved Waiver and
                       Aging Program Directive #07-01-01 (Chapter 1 of the Home and
                       Community-Based Services Manual).

                (2.)   The participants must have at least three of the following
                       conditions/situations:

                       (a.)   Three (3) or more hospitalizations in the past year.
                       (b.)   Frequent, recurrent, repeated or regular use of the emergency room.
                       (c.)   Poor adherence with physician orders or medication.
                       (d.)   Formal or informal support systems are limited or absent.
                       (e.)   Documented history of falls within the last six months that results in
                              an injury that required medical or emergent care.
                       (f.)   Lives alone or is at home for extended periods of time or care access
                              challenges (for example, RN shortage, rural access issues, etc.)

                (3.)   The participant must be sufficiently cognitively intact and be able to
                       physically operate the equipment (i.e. able to see the monitor or put on the
                       blood pressure cuff) or has a caregiver willing and able to assist with the
                       equipment, unless the service does not require active participation of the
                       participant.

                (4.)   The participant’s home must be evaluated to ensure that the TeleCare
                       equipment can work. Adequate utilities to meet the manufacturer’s
                       specifications for equipment, if applicable and the living
                       situation/environment must allow for adequate adaptation of the TeleCare
                       equipment.

                (5.)   A determination has been made that the participant’s needs are not covered
                       under third party resources, Medicare, or the Medicaid State Plan.




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   2.     HEALTH STATUS MEASURING AND MONITORING SERVICE

          a.    Health Status Measuring and Monitoring Service is beneficial to participants with
                chronic medical conditions such as congestive heart failure, diabetes or pulmonary
                disease that could benefit from frequent monitoring and evaluation. Examples of
                Health Status Measuring and Monitoring Service may include but are not limited to
                weight, pulse oximetry, and vital sign monitoring. Providers of health Status
                Measuring and Monitoring Services must be Medicare certified Home health Agency
                (HHA) enrolled in the Medical Assistance program. Any peripheral equipment must
                be capable of interfacing with Health Status Measuring and Monitoring Service
                equipment. All equipment and any peripheral equipment for Health Status
                Measuring and Monitoring Services must be certified by the FDA and be UL
                listed/certified.

          b.    Reimbursement for Health Status Measuring and Monitoring Service includes an RN
                visit as part of the service fee. When additional services are required due to changes
                in participant’s condition the care manager must be informed and services approved
                in consultation with the AAA RN. When the change in condition requires a skilled
                level of care the HHA should access Medicare and other third party payers for those
                services. If the participant is receiving an approved skilled Medicare 60 day episode
                TeleCare cannot be authorized.

          c.    The use of Health Status Measuring and Monitoring Services will be authorized
                when all other care methods such as informal care givers, RN availability, physician
                monitoring, and other technology have been demonstrated to be ineffective or
                unavailability, physician monitoring, and other technology have been demonstrated
                to be infective or unavailable for the individual’s safety and monitoring.

          d.    The reimbursement fee for this service will include:

                (1.)   The installation, removal of equipment and monthly equipment rental.

                (2.)   The training of the participant and/or their representative in the use of the
                       equipment and health status monitoring.

                (3.)   Health Status Measuring and Monitoring Service by the home health agency
                       and all data collected.

                (4.)   One monthly face to face visit by the Medicare certified Home Health
                       Agency and includes any other contact with the participant (such as telephone
                       contact).

          e.    Roles and Responsibilities of the Area Agency on Aging (AAA)

                (1.)   Determine the need for Health Status Measuring and Monitoring service
                       based on the completion of the Care Management Instrument (CMI) and
                       applying the special eligibility criteria for TeleCare Services.



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                (2.)    The need for Health Status Measuring and Monitoring service must be
                        approved by consultation with the AAA nurse and the care manager
                        Supervisor.

                (3.)    The AAA nurse will review the Care Management Instrument and all other
                        pertinent information, including but not limited to information obtained by
                        contacting health care providers who have cared for the client, to assure the
                        appropriateness of the service.

                (4.)    If there is a question regarding the need for health status measuring and
                        monitoring, the AAA nurse should perform a nursing evaluation, which could
                        include examining the client to assess a particular problem. However, the
                        AAA RN may not carry out any treatments or clinical interventions.

                (5.)    The AAA nurse assists in the development of the care plan.

                (6.)    Care Manager Supervisor must concur and approve with the recommendation
                        for TeleCare Services.

                (7.)    Health Status Measuring and Monitoring service must be ordered by a
                        primary physician.

                (8.)    The AAA must follow PDA requirements for Care Plan Review as outlined
                        in APD # 06-01-03.

                (9.)    Notify PDA and DPW of critical events related to the Health Status
                        Measuring and Monitoring Services.

                (10.)   On a monthly basis provide a face to face assessment to evaluate the
                        participant’s FDA certified, UL Listed/certified of the technology in the home
                        and assess whether the continued use of the TeleCare services is warranted.

                (11.)   The AAA must provide the HHA with a copy of the participants current care
                        plan (which includes the care plan worksheet and service plan.)

          f.    Roles and Responsibilities for Health Status Measuring and Monitoring Service
                Providers:

                (1.)    Must be Medicare Certified, Medicaid enrolled HHA provider and meet all
                        the standards in the approved waiver.

                (2.)    Must document Health Status Measuring and Monitoring Services including
                        the type, mode, and frequency in the participants care plan.

                (3.)    Must provide teaching and training of the peripheral, video or non-video
                        equipment.




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                (4.)    Must review all data collection of peripheral devices (blood pressure, weight,
                        glucometer readings, etc.) and follow-up with appropriate interventions.

                (5.)    Must assure that all equipment meet service standards.

                (6.)    Must ensure that the Health Status Measuring and Monitoring service is
                        ordered by a primary physician.

                        (a.)   The order must be obtained by the HHA prior to service authorization.

                        (b.)   The order must include the specific nursing and/or therapeutic service
                               required.

                        (c.)   The order must reflect the client’s medical condition as it relates to
                               the special medical eligibility requirements.

                        (d.)   The order must be obtained every sixty days for continuation of
                               service.

                (7.)    HHA must inform the care manager and contact the physician for approval of
                        additional services and obtain new medical orders when additional services
                        are required due to changes in participant’s condition. When the change in
                        condition requires a skilled level of care the HHA should access Medicare
                        and other third party payers for those services.

                (8.)    Must maintain clinical documentation of all Home Health activities, Health
                        Status Measuring and Monitoring Service data and all participant contacts.
                        Documentation must be available upon request

                (9.)    HHA must submit to the AAA the care plan and recommendation for service
                        when plan of care is updated or modified or at least every 60 days prior to
                        service authorization.

                (10.)   The HHA must provide the AAA with a copy of the participants current care
                        plan.

          g.    Health Status Measuring and Monitoring Service Standards

                (1.)    Persons providing and evaluating Health Status Measuring and Monitoring
                        Services must be licensed Registered Nurses.

                (2.)    The reimbursement fee for Health Status Measuring and Monitoring Services
                        includes one monthly face to face visit by the RN from the Medicare Certified
                        Home Health Agency and any other contact with the participant (such as
                        telephone contact).

                (3.)    Providers of Health Status Measuring and Monitoring Service must be
                        Medicare certified Medicaid enrolled HHA.


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                (4.)   Providers are required to comply with other applicable statutes, state and
                       federal regulations and policies and procedures.

                (5.)   Providers shall assure that individuals providing Health Status Measuring and
                       Monitoring Services meet service qualifications.

                (6.)   All equipment and any peripheral equipment for Health Status Measuring and
                       Monitoring Services must be FDA certified and/or UL listed/certified.

                (7.)   All web based services must be HIPAA compliant.

          h.    Health Status Measuring and Monitoring Service Reporting:

                (1.)   Reporting for Health Status Measuring and Monitoring Services includes:
                       documentation and care plan requirements, data analysis with tracking and
                       trending and any other state and federal requirements (e.g. communicable
                       diseases, abuse and neglect, incident reporting, etc.)

          i.    Health Status Measuring and Monitoring Service confidentiality:

                (1.)   All information must be kept confidential and HIPAA compliant.




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   3.     ACTIVITY AND SENSOR MONITORING SERVICE

          a.    A service that employs sensor based technology on a 24 hr./7 day basis by remotely
                tracking the participant’s activities of daily living. These activities may include but
                are not limited to total activity in the house and environmental temperature
                monitoring. Data is then transmitted to the caregiver and/or healthcare provider
                depending on the activity and sensor monitoring system employed. Activity and
                Sensor Monitoring Service equipment must be UL listed/certified. Activity and
                Sensor Monitoring Services can be provided by a Home Health Agencies, DME
                providers or MA enrolled provider of Activity and Sensor Monitoring Services.

          b.    The use of Activity and Sensor Monitoring Services will be authorized by the AAA
                when all other methods such as informal care givers, PERS systems, infant
                monitoring systems, and other less restrictive technology have been demonstrated
                and documented to be ineffective or unavailable for individual safety and monitoring.

          c.    The reimbursement fee for this service will include:

                (1.)   The installation and removal of the equipment and any additional
                       repositioning of sensor equipment,

                (2.)   Training of the participant and/or their caregivers,

                (3.)   Monthly rental of equipment,

                (4.)   Appropriate monitoring and documentation of the activities to maximize
                       technology capability,

                (5.)   The repair or replacement of malfunctioning equipment,

                (6.)   The provider shall provide ongoing provision of web based data collection for
                       each individual, as appropriate. This shall include response to participant
                       self-testing, as well as manufacture’s specified provider testing, self-auditing
                       and quality control.

          d.    As appropriate, included as part of the monthly charge, the provider shall, either
                directly or through subcontractor provide for ongoing provision of on-line emergency
                response services for each individual authorized. This shall include response to
                participant self testing as well as daily provider testing, self auditing and quality
                control.

          e.    Roles and Responsibilities of the Area Agency on Aging (AAA):

                (1.)   Determine the need for Activity and Sensor Monitoring Service based on the
                       completion of the Care Management Instrument (CMI) and applying the
                       special eligibility criteria for TeleCare Services.




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                (2.)    The AAA nurse will review the Care Management Instrument and all other
                        pertinent information, including but not limited to information obtained by
                        contacting health care providers who have cared for the client, to assure the
                        appropriateness of the service.

                (3.)    If there is a question of need for Activity and Sensor Monitoring Services, the
                        nurse should perform elements of a nursing evaluation, including examining
                        the client to assess a particular problem however, the AAA nurse may not
                        carry out any treatments or clinical interventions.

                (4.)    Care Manager Supervisor must concur and approve with the recommendation
                        for TeleCare services.

                (5.)    The AAA must follow PDA requirements for Care Plan Review as outlined
                        in APD # 06-01-03.

                (6.)    Activity and Sensor Monitoring Service must be ordered by a primary
                        physician.

                (7.)    The AAA must provide the Activity and Sensor Monitoring Service provider
                        with a copy of the participants current care plan (which includes the care plan
                        worksheet and service plan).

                (8.)    Notify PDA and DPW of critical events related to the Activity and Sensor
                        and Monitoring Services.

                (9.)    The decision to remove an Activity and Sensor Monitoring Service is at the
                        sole discretion of the participant/representative and the Care Manager. The
                        Care Manager will provide written documentation to terminate Activity and
                        Sensor Monitoring Services.

                (10.)   On a monthly basis provide a face to face assessment to evaluate the
                        participant’s UL Listed/certified of the technology in the home and assess
                        whether the continued use of the TeleCare services is warranted.

                (11.)   The Care manager will investigate the damage or misuse of the Activity and
                        Sensor Monitoring Service equipment with the participant/representative and
                        provider to determine the continued use 9of the Activity and Sensor
                        Monitoring Service.

          f.    Roles and Responsibilities for Activity and Sensor Monitoring Providers:

                (1.)    Must be MA enrolled provider and meet all the Medicaid enrolled provider
                        requirements as defined in the approved waiver.

                (2.)    Must ensure that the Activity and Sensor Monitoring Service is ordered by a
                        primary physician.



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                (3.)    The order must be obtained by service provider prior to service authorization.

                        (a.)   The order must include the specific service required.

                        (b.)   The order must reflect the client’s medical condition as it relates to
                               the need for the Activity and Sensor Monitoring Services.

                (4.)    Must develop and implement a service plan indicating the type, mode and
                        frequency for Activity and Sensor.

                (5.)    Must provide the AAA with a copy of the participant’s current service plan
                        documenting the individual who will provide the Activity and Sensor
                        Monitoring.

                (6.)    Must provide training for the Activity and Sensor Monitoring Services to the
                        individual and representatives.

                (7.)    Must review the data collected and monitor activity with follow-up and
                        appropriate interventions as applicable to the type of technology in the home.

                (8.)    Must ensure that Activity and Sensor Monitoring Service equipment is UL
                        listed/certified.

                (9.)    Must inform the care manager and contact the physician for approval of
                        additional services and obtain new medical orders due to changes in
                        participant’s condition prior to additional service authorization.

                (10.)   Must maintain all Activity and Sensor Monitoring Service date and all
                        documented participant contacts. As data is collected utilizing technology
                        and the Activity and Sensor Monitoring service provider will provide tracking
                        and trending reports on participant’s activity.

                (11.)   Must disconnect/remove an Activity and Sensor Monitoring Service
                        equipment from a participant’s residence within 5 working days of
                        notification by the Care Manager.

          g.    Provider Standards for Activity and Sensor Monitoring Service

                (1.)    Activity and Sensor Monitoring Service providers must be enrolled in the
                        Medical Assistance program and are required to comply with other applicable
                        statutes, state and federal regulations and policies and procedures.

                (2.)    Activity and Sensor Monitoring Service must install and maintain services in
                        proper working order and guaranteed by the provider.

                (3.)    Activity and Sensor Monitoring Service provider must deliver and install
                        Activity and Sensor Monitoring Services within 5 working days of receipt of
                        the service order.


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                (4.)    Activity and Sensor Monitoring Service providers must notify the Care
                        Manager of the installation of Activity and Sensor Monitoring Service
                        equipment.

                (5.)    Activity and Sensor Monitoring Services provider must instruct the
                        participant/representative in the use, maintenance and safety of the Activity
                        and Sensor Monitoring Service.

                (6.)    Activity and Sensor Monitoring Service provider must have a system in place
                        for notification of emergency events to designated individuals.

                (7.)    Activity and Sensor Monitoring Service provider must update equipment
                        when necessary, at no cost to the Aging Waiver Program, as technology
                        improves performance.

                (8.)    The Activity and Sensor Monitoring Service provider must assure that
                        Activity and Sensor Monitoring Service equipment is UL listed/certified.

                (9.)    The Activity and Sensor Monitoring Service provider must repair or replace
                        malfunctioning Activity and Sensor Monitoring Service equipment within 24
                        hours or next business day of notification or identification.

                (10.)   Activity and Sensor Monitoring Service provider’s data collected must be
                        available at least 90% of the time to designated individuals when web based
                        systems are used.

                (11.)   Activity and Sensor Monitoring Services provider must offer to all direct
                        participant contact employees training. The provider must verify that all
                        employees completing installation are adequately trained.

                (12.)   Activity and Sensor Monitoring Service provider must use, and have on file,
                        written training materials and procedures for Activity and Sensor Monitoring
                        Services.

                (13.)   Activity and Sensor Monitoring Service provider must be HIPAA compliant.

          h.    Activity and Sensor Monitoring Services Confidentiality:

                (1.)    All information must be kept confidential and HIPAA compliant.




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   4.     MEDICATION DISPENSING AND MONITORING SERVICES

          a.     A remote Medication Dispensing and Monitoring Service is pre-programmed based
                 on the needs of the participant to dispense and monitor medication compliance. A
                 system will be in place to notify the provider or caregiver of missed does or non-
                 compliance with medication administration. This service may be used with
                 individuals that demonstrate a cognitive deficit, need assistance with medication, and
                 have demonstrated and documented past non-compliance with medication
                 administration.

          b.     Medication Dispensing and Monitoring service equipment must be UL
                 listed/certified. The provider agency shall assure that all equipment meet service
                 standards. Medication Dispensing and Monitoring Services can be obtained from
                 MA enrolled providers which may include any MA enrolled provider that meets the
                 standards of Medication Dispensing and Monitoring Services.

          c.     The reimbursement fee will include:

                 (1.)   The installation, removal, repair or replacement of equipment;
                 (2.)   Rental of the equipment;
                 (3.)   Training of the participant and/or their caregivers;
                 (4.)   Monitoring of the Medication Dispensing service activities by a trained
                        professional with appropriate and documented interventions.

          NOTE: included as part of the monthly charge, the provider shall, either directly or
          through subcontractor, provide for ongoing provision of on-line emergency response
          services for each individual authorized. This shall include response to participant self
          testing, as well as daily provider testing, self auditing and quality control.

          d.     Roles and Responsibilities of the Area Agency on Aging (AAA):

                 (1.)   Determine the need for Medication Dispensing and Monitoring Service based
                        on the completion of the Care Management Instrument (CMI) and applying
                        the special criteria for TeleCare Services.

                 (2.)   The need for Medication Dispensing and Monitoring Service must be
                        approved by consultation with the AAA.

                 (3.)   The AAA nurse will review the Care Management Assessment and other
                        pertinent medical information, including information obtained by contacting
                        health care providers who have cared for the client, to assure the
                        appropriateness of the service.

                 (4.)   The Care Manager Supervisor must concur and approve with the
                        recommendation for Medication Dispensing and Monitoring Services.

                 (5.)   The AAA must follow PDA requirements for Care Plan Review as outlined
                        in APD#06-01-03.


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                (6.)    Medication Dispensing and Monitoring Service must be ordered by a primary
                        physician.

                (7.)    The AAA must provide the service provider with a copy of the participants
                        current care plan (which includes the care plan worksheet and service plan).

                (8.)    The decision to remove the Medication Dispensing and Monitoring Service is
                        at the sole discretion of the participant/representative and the Care Manager.
                        The Care Manager will provide written documentation to terminate.

                (9.)    Notify PDA and DPW of critical events related to the Medication Dispensing
                        and Monitoring Service.

                (10.)   The Care Manager will investigate the damage or misuse of the Medication
                        Dispensing and Monitoring Service with the participant/representative and
                        provider to determine the continued use of the Medication Dispensing and
                        Monitoring Service.

          e.    Roles and Responsibilities for Medication Dispensing and Monitoring Service
                Providers:

                (1.)    Must be MA enrolled provider and meet all the Medicaid enrolled provider
                        requirements as defined in the approved waiver.

                (2.)    Medication Dispensing and Monitoring Service must be ordered by a primary
                        physician.

                        (a.)   The order must be obtained by the service provider prior to service
                               authorization.

                        (b.)   The order must reflect the client’s medical condition as it related to
                               the need for the Medication Dispensing and Monitoring System.

                (3.)    Must provide training to the participant/representative on the Medication
                        Dispensing and Monitoring Services.

                (4.)    Must review the data collected and monitor activity with follow-up and
                        appropriate intervention as applicable to the type of technology in the home.
                        Documentation must be available upon request.

                (5.)    The provider must maintain an up to date event notification system. Notify
                        the Care Manager of critical events that occur in the home related to the use
                        of Medication Dispensing and Monitoring Services.

                (6.)    The provider must disconnect/remove Medication Dispensing and Monitoring
                        Service equipment from a participant’s residence within 5 working days of
                        notification by the Care Manager.


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                (7.)    The provider must update the Medication Dispensing and Monitoring Service
                        equipment when necessary, at no cost to the AGING Waiver Program, as
                        technology improves performance.

          f.    Provider Standards for Medication Dispensing and Monitoring Services:

                (1.)    Medication Dispensing and Monitoring Service providers must be enrolled in
                        the Medical Assistance program and are required to comply with other
                        applicable statutes, state and federal regulations, and policies and procedures.

                (2.)    Medication Dispensing and Monitoring Service equipment must be UL
                        listed/certified and shall assure that all equipment meet manufacturer service
                        standards.

                (3.)    It shall be the provider’s responsibility to deliver and install each Medication
                        Dispensing and Monitoring Service. The provider agrees to complete
                        installation within 5 working days of receipt of service order.

                (4.)    The provider shall notify the Care Manager of the installation of Medication
                        Dispensing and Monitoring Services.

                (5.)    The provider shall instruct the participant/representative in the use,
                        maintenance and safety of the Medication Dispensing and Monitoring
                        Services.

                (6.)    Medication Dispensing and Monitoring Service provider must have a system
                        in place for notification of emergency events to designated individuals.

                (7.)    The repair or replacement of malfunctioning Medication Dispensing and
                        Monitoring Service equipment shall be completed within 24 hours or next
                        business day of notification or identification.

                (8.)    Data collection from Medication Dispensing and Monitoring Service must be
                        available to designated individuals, participant representative, care managers,
                        PDA staff or State Medicaid staff.

                (9.)    Medication Dispensing and Monitoring Service reports which provide an
                        analysis of the medication monitoring activities must be made available to
                        designated individuals.

                (10.)   Training sessions must be offered to all direct participant contact employees.
                        The provider must verify that all employees completing installation are
                        adequately trained.

                (11.)   The provider will use, and have on file, written training materials and
                        procedures.



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                (12.)   Units will be maintained and guaranteed by the provider, updated at no cost
                        to the Aging Waiver Program as technology improves performance.

          g.    Medication Dispensing and Monitoring Service Confidentiality:

                (1.)    All information must be kept confidential and HIPAA compliant.




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S.      RESPITE SERVICE: STANDARDS

        1.     GENERAL INFORMATION

               a.     Respite services consist of temporary and emergency residential services offered to
                      recipients to relieve family members or primary caregivers who normally provide
                      care.

               b.     Respite services may be provided in the recipient's home or in other approved
                      settings.

               c.     Eligible residents may receive two categories of Respite Service: Twenty-four hour
                      overnight Respite and temporary or emergency Respite. Twenty-four hour overnight
                      Respite is provided in segments of 24 hours and includes overnight care. Temporary
                      or emergency assistance means Respite Services which are provided less than 24
                      hours.

               d.     All Respite Service providers are trained in the following areas prior to rendering
                      services:

                      (1.)    Consumer Rights
                      (2.)    Respite Service Provider Responsibilities
                      (3.)    Fire and Safety
                      (4.)    First Aid
                      (5.)    Basic Nutrition/Medication Training
                      (6.)    Program Philosophy/Mission

        2.     STAFF QUALIFICATION

               Agencies that provide Respite Care services must assure that Respite Care workers comply
               with federal, state and local health requirements related to communicable diseases. All field
               staff must receive a PPD test, the results of which are maintained in their files.

        3.     RECORDS AND DOCUMENTATION

               Individual time slips must be signed by the consumer or family member/caregiver and the
               Respite Care worker to document each unit of service.

        4.     SERVICE REPORTING

               Persons providing Respite Care services must comply with all reporting requirements as
               specified by the Area Agency on Aging.

        5.     SCHEDULING

               Days and times scheduled for Respite Care must be consistent with the care plan provided by
               the AAA.



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   6.     INSURANCE

          Agencies who wish to provide Respite Care services will be required to attest to having the
          following types of insurance in amounts consistent in the industry:

          a.     General liability;
          b.     Professional liability;
          c.     Automobile liability covering owned, non-owned and hired vehicles;
          d.     Workman Compensation as required by law;
          e.     Employer’s liability of accident and disease.

   7.     CONFIDENTIALITY

          All agencies who provide Respite Care services must comply with all federal, state and local
          laws relating to research on human subjects and consumer confidentiality.

          Agencies must provide all Care Managers with consent forms and approval from all
          appropriate review boards for those consumers who wish to be part of a research study.

   8.     EXCLUSIONS FROM FFP

          Room and Board

          (1.)   Pursuant to 42 CFR 441.10 (a) (3), the department shall only reimburse service
                 providers for room and board costs when Respite Services are provided in the
                 following facilities:

                 (a.)    Medicaid Certified Hospitals and Nursing Facilities;

                 (b.)    Foster Homes and Community and Residential Facilities that meet
                         appropriate state standards;

          (2.)   Reimbursement for room and board costs when Respite Services are provided in
                 private residences shall be excluded under the Waiver.




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S.      TEMPORARY SHELTER: SERVICE SPECIFIC OPERATIONAL PROCEDURES

These Operational Procedures delineate further expectations for providers delivering services to
Philadelphia Corporation for Aging (PCA) consumers of the Long Term Care Program (LTC) which
encompass the Options and Aging Waiver payment sources. Where there are differences between these
procedures and Pennsylvania Department of Health license and/or Department of Public Welfare provider
enrollment requirements and regulations, the more stringent requirement prevails.

        1      Temporary Shelter / Respite - Defined

               a.     Temporary Shelter is the intermittent provision of room, board, supervisory and
                      supportive care in a protective setting outside of the consumer’s usual place of
                      residence which is necessary to maintain the health and safety of the individual when
                      the primary caregiver needs respite from the responsibility of caring and/or is not
                      available to provide such care, or when a temporary emergency living
                      arrangement is necessary to maintain the health and safety of the consumer.

               b      Such care may be provided in an institutional - Nursing Facility (NF) or a
                      non-institutional setting, reflecting the needs of the individual and the regulatory
                      requirements of the setting.

               c.     The availability of temporary shelter arrangements are based on individual
                      agreements with service providers, based on a contracted daily rate. While every
                      effort should be made to utilize existing reimbursement sources, such as Medical
                      Assistance, Medicare, and third party payors, PCA can authorize private payment for
                      such stays up to a maximum of 2 weeks (14 days).

        2.     Service Authorization

               The need for temporary shelter arrangements may be identified on a planned basis or
               precipitated by an emergency; such circumstances can include:

               a.     The provision of respite for a primary caregiver who will be absent for at least eight
                      (8) hours a day, due to health needs of the caregiver and/or pre-scheduled relief;

               b.     The need for a temporary living arrangement, on an emergency basis, to maintain the
                      health and safety of the consumer;

               c.     The need to identify permanent housing.

                      The LTC Care Manager or Protective Services Investigator can facilitate placement
                      of a consumer in a temporary shelter arrangement based on the availability of beds at
                      a given facility. Placement can occur during regular work hours, at night, or on
                      weekends. The care manager will remain actively involved with the consumer, the
                      family, and the facility throughout the placement so as to assure a timely transfer out
                      of the placement and appropriate resolution of the consumer’s circumstances.
                      Supervisory approval is required for use of this service, and can be provided up to a
                      total of fourteen days per fiscal year per client. Individual consumer exceptions may


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                 be made on a case by case basis.

   3.     Facility Specifications

          a.     License - PCA will seek temporary shelter arrangements only with those facilities
                 which are fully licensed by their respective licensing authority:

                 (1.)   Nursing Homes - such facilities must have current license from the
                        Commonwealth of Pennsylvania Department of Health (DOH),

          b.     Standards of Care

                 PCA expects that facilities make available to consumers in temporary shelter
                 arrangements the same type and quality of services offered to permanent residents
                 consistent with Federal and State regulatory requirements.

                 * Subject to a facility's regulatory requirements, the placement of a stable consumer
                 into a temporary shelter arrangement - under 14 days, may not require the extensive
                 care planning of a regular admission. The evaluation of nursing, medical, social
                 work, dietary, activities, therapies, etc. can be facilitated with and in collaboration
                 with the referring care manager. It is expected that third party reimbursement will be
                 secured for eligible services and individuals.

          c.     Admission Agreements

                 (1.)   PCA - Facility

                        PCA's intent is to establish admission agreements with any and all licensed
                        facilities that are willing to provide temporary shelter arrangements, based of
                        course on the availability of beds, for appropriate LTC consumers. In order
                        to facilitate appropriate referrals, facilities will need to clearly indicate
                        admission criteria, limitations, ability to accept placements during normal
                        business hours and week-ends, and any other limitations.

                        In instances where the temporary shelter arrangement requires nursing home
                        care, PCA will attempt whenever possible to assure that all individuals
                        referred will have been examined and diagnosed free of an acute mental
                        health disorder, as a primary diagnosis, and be free of tuberculosis or other
                        communicable diseases. Moreover, in all instances, PCA will attempt
                        whenever possible to assure individuals needing psychiatric interventions or
                        care will have been directed into appropriate mental health facilities.
                        Whenever possible individuals will also be screened by health care providers
                        and certified that they are not in need of admission to an acute care facility.

                 PLEASE NOTE: There may be occasions where the Older Adults Protective
                 Services (OAPS) will not have immediate or complete consumer assessment
                 information as described above, e.g. emergency interventions to alleviate immediate
                 risk to a consumer. In such instances, these departments will work with the facility


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                 where the placement is being requested to secure appropriate and timely consumer
                 assessment/diagnostic information.

          (2.)   Facility - Consumer

                 PCA recognizes that every facility has its own admission procedure, which may
                 include a formal admission agreement. Such admission agreements should stipulate
                 the terms of the stay in the facility, and contain a list of those services included in the
                 daily rate and those services for which there are additional charges. Unless informed
                 otherwise by the PCA care manager at the time of a consumer placement, facilities
                 are not to seek "Financial Guarantee" agreements with consumers, families or
                 caregivers.

                 ** There may be occasions when the consumer and/or family/caregiver will be
                 sharing in the cost of the Temporary Shelter placement. In such instances, the PCA
                 care manager will advise the facility at the time of placement and identify those costs
                 that are to be assumed by each party; e.g. PCA could be responsible for specific
                 number of days of service and the remainder to be borne by the consumer and/or
                 family. When such a placement is requested, the facility can seek "Financial
                 Guarantee" agreements with the client and/or family/caregiver.

   3.     Payment Provisions/Invoicing

          It is anticipated that most temporary shelter arrangements will be private pay. However,
          PCA will request the cooperation of facilities to make every effort to utilize existing
          reimbursement sources such as, Medicare, Medical Assistance, and other third party payors.

          a.     Service Orders

                 When a client has been placed in a facility, PCA will forward to that facility a
                 Service Order which represents a written authorization for payment for the
                 anticipated number of days of service. For those Medical Assistance or Medicare
                 eligible consumers, it is expected that the facility or its providers will bill Medicare
                 or MA for any covered services.

          b.     Invoices

                 Units of service are invoiced on a monthly basis. Claims for Options consumers will
                 be submitted to PCA via the Automated Billing System (ABS).The invoice will
                 indicate units of service delivered. The daily reimbursement is an all-inclusive rate;
                 no miscellaneous or ancillary charges will paid without prior approval by the care
                 manager. Any such approved charges must be supported by appropriate
                 documentation, e.g. receipts, vendor invoices, etc. NOTE: all co-pay billing of
                 services reimbursable by Medicare or Medical Assistance or other insurances must
                 be done through the monthly invoice, unless otherwise noted by the care manager.
                 Service for AGING Waiver consumers will be billed directly to MA at the
                 established rate for that facility.



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   4.     Financial Statement

          Providers entering into contracts with PCA must be financially solvent and able to
          demonstrate an ability to meet daily operational expenses. Should a provider enter into
          bankruptcy proceedings, the Contract Manager must be notified immediately.




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U.      SPECIALIZED MEDICAL EQUIPMENT AND SUPPLIES: STANDARDS

        1.     Conditions

               The equipment and/or supply provided is above and beyond those already supplied under the
               approved state plan.

        2.     Fiscal Management

               Procurement of durable medical equipment, medical supplies and adaptive devices must be
               achieved by the Care Manager in the most cost effective manner available. The decision to
               rent or purchase equipment from an enrolled provider may vary greatly, depending on types
               of equipment and consumers.




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V.      DURABLE AND CONSUMABLE MEDICAL EQUIPMENT (DME): SERVICE SPECIFIC
        OPERATIONAL PROCEDURES

The following procedures are a supplement to the Durable Medical Equipment and Supplies (DME) service
standards. They delineate further general expectations for providers serving consumers in PCA’s Long
Term Care (LTC) Program which encompass the Options and Aging Waiver payment sources.

        1.     Provider Eligibility

               a.     The Philadelphia Corporation for Aging (PCA) will certify and contract with only
                      DME providers who are enrolled providers in both the Medicare and Medical
                      Assistance programs. Participation as a service provider is contingent on the
                      following:

               b.     Willingness to provide MA/Medicare covered items at the lower of either the
                      provider’s charge to the self-paying public or the respective MA or Medicare fee
                      schedule prices and, when applicable, to use the MA/Medicare prior approval
                      process.

               c.     Willingness to provide several non-MA or Medicare covered items at the established
                      prices on the PCA DME list.

        2.     DME List

               a.     Selected items, only, from the Medical Assistance (MA) Program, Medical Supplier
                      Fee Schedule product list will be utilized by PCA’s LTC program. Consumers,
                      independent of the PCA care manager, may wish to purchase, on their own or
                      covered by MA, Medicare, or a third party payment source, items needed as part
                      of their care by a skilled provider or to increase their safety.

               b.     The Philadelphia Corporation for Aging’s DME List establishes a limited range of
                      non-MA/Medicare covered equipment (hand held showers, grab bars, air
                      conditioners, a microwave, a fan) that may be ordered for consumers to enable them
                      to remain in their homes. The items on the list are identified by their PCA item
                      number, manufacturer code - where applicable, the item description, and designated
                      price. The list also includes those commonly used MA Fee Schedule items,
                      identified by their PCA number, HCPCS code, and MA rate.

               c.     Occasionally a consumer may wish to privately pay for items not on the PCA DME
                      list. In such instance, providers are requested to provide the item at the MA rate or a
                      fair market price and to install it for the same price as indicated in our DME price
                      list. Items not on the PCA DME price list may not be billed to PCA.

        3.     Service Orders

               a.     All orders on the PCA DME list will be placed through PCA personnel, only, subject
                      to an established medical necessity and will have been prescribed or ordered by the
                      consumer’s primary physician or other health professional designated by PCA,


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                within the scope of their practice.

          b.    If the consumer is eligible to receive the item under Medical Assistance or Medicare,
                the provider must bill that third party source, using the designated prior approval
                process – when applicable.

          c.    The provider must have the service order before a delivery can be made or, if
                applicable, the required authorization under the prior approval process. In the
                event the service order is unclear or erroneous, the care manager must be contacted
                immediately to discuss the problem. The care manager will make any needed
                corrections in the care plan and generate a new service order.

   4.     Third Party Billing

          a.    PCA is mandated by the Pennsylvania Department of Aging to pursue all other
                payment sources for consumers such as Medicare, Medical Assistance, and other
                third party payers. Therefore, providers must be knowledgeable about third
                party billing requirements and are expected to process the necessary forms,
                including the prior approval process for items whose individual cost is over
                $100.00, and contacting the consumer’s physician, as needed.

                (1.)   Upon the initial contact by the PCA care manager, the provider must inform
                       them if the item requested can be billed to a third party such as Medicare or
                       Medical Assistance.

                (2.)   Care managers will provide the necessary insurance information and name of
                       the physician, including license number, at the time the order is placed. PCA
                       will not retroactively reimburse a provider if the claim is rejected by such
                       third party payers.

                (3.)   If an item is needed in amounts greater than those allowed or covered by third
                       party, (e.g., MA fee schedule), the excess amount may be ordered by the PCA
                       care manager and billed to PCA or Aging Waiver, at the established
                       MA/Medicare fee schedule rate.

          b.    It is expected that providers will accept third party reimbursement as full payment for
                the item delivered, except as mandated for copayment requirements.

   5.     Delivery

          a.    The provider must have the capacity to deliver, within 3 business days, to the homes
                of PCA consumers citywide after receiving prior approval and/or the service order
                from the Options or Aging Waiver Program. The Options or Aging Waiver Program
                may request next day delivery on a regular basis for certain items, such as
                incontinence products. PCA requires that subcontractors receive a signed receipt
                for every item delivered to a PCA consumer. No payment will be made without a
                signed receipt for each individual item. Delivery charges are included in the prices
                for all items on the LTC - DME SUPPLY LISTS.


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          b.     If a provider is temporarily out of stock of a particular item, the PCA staff person
                 ordering the item(s) must be notified by the provider within 2 hours of receipt of the
                 request or service order issued from PCA. The provider may substitute a comparable
                 item of the same or higher quality for the same price, but must discuss this first with
                 the PCA staff person placing the order. If the item ordered is covered by Medical
                 Assistance or Medicare, the substituted item may NOT be billed to PCA.

          c.     PCA requires that providers make NO partial deliveries. Since a follow up visit for
                 medical equipment is often made to instruct the consumers in the use of the
                 equipment, the entire order must be delivered at the same time. If this requirement
                 cannot be met for any reason, the care manager needs to be contacted immediately to
                 weigh the consequences of the delay, make any changes needed in the order, make
                 any necessary changes in the consumer’s care plan, and issue a new service order.

          d.     Delivery of the item shall be inside delivery to the client's home and to a specific
                 location inside the home if warranted (for instance assemblage of toilet seat onto
                 toilet).

          e.     If the equipment is delivered and the consumer refuses it, PCA needs to know why
                 the equipment was refused (for instance cosmetic reason, consumer no longer wants
                 item, etc.).

          f.     Certain items from List C (Incontinence items like diapers or chux) may be delivered
                 by UPS where indicated. The provider must get the care manager’s approval in
                 all cases where UPS delivery is considered.

   6.     Installation and Assembly of Equipment

          All providers must agree to install and assemble medical equipment, when necessary, in
          consumers’ homes throughout the city of Philadelphia. The Philadelphia Corporation for
          Aging (PCA) defines installation and assembly as follows:

          a.     Installation - This refers to the installing of air conditioners, microwaves, and wall
                 mounted grab bars and hand held shower hoses. Separate fixed prices for installation
                 of the grab bars and shower hoses are included on page 1, List A. Non-Consumable
                 Medical Supplies..

                 (1.)   Air Conditioners and Microwaves:

                        (a.)    Air conditioners will be securely installed in the consumers window,
                                as identified by the Care Manager. Packing material will be removed
                                from the consumer’s home

                        (b.)    Microwaves will be unpacked, placed in a suitable location – as
                                identified by the consumer or Care Manager. Packing material will be
                                removed from the consumer’s home.


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                (2.)   Grab Bars: The Options and Aging Waiver Programs require installing of
                       grab bars or shower hoses. PCA relies on the judgment of the installer to
                       determine if an installation can safely be made. If the installer feels that it is
                       structurally unsafe to install wall mounted grab bars where marked by a PCA
                       subcontract therapist, the provider must notify the care manager immediately.
                       For safety reasons, PCA asks providers not to install any wall grab bars on
                       encased shower stalls or bathtub enclosures that are made of fiberglass.

                (3.)   Shower Hoses: PCA asks that providers install shower hoses into the wall and
                       not use the adhesive backing. We also ask the provider to carry washers and
                       adapters on the truck at the time of doing such installations. Whenever an
                       order for a shower hose is placed, the provider must also take along the
                       Portable hand held shower which fits over faucet because the ordered hose
                       may not fit or the shower head cannot be removed. Please read the third
                       paragraph under “Assembling” concerning the process for billing such an
                       installation charge.

          b.    Assembly

                (1.)   Assembling of equipment means putting together any parts of an item and
                       placing it in the designated area where it is to be used (e.g. the raised toilet
                       seat is to be assembled and placed over the toilet per the instructions of the
                       specific order).

                (2.)   Assembly of equipment must be provided at no extra charge to PCA or the
                       consumer. If wall mounting of grab bars or shower hoses for consumers is
                       requested, it will be reimbursed according to the LTCO DME Supply List, on
                       page 1 of List A Non-Consumable Medical Supplies (Item A-01-0010 for the
                       first grab bar/shower hose installation at a visit, and item A-01-0020 for each
                       additional grab bar/shower hose installation at the same visit).

                (3.)   In the process of assembling an item, it sometimes turns out that it does not
                       fit. In that case, the assembler is not to leave the item at the consumer's
                       home, but to take it back to the provider. The provider must call the PCA
                       care manager who placed the order, and discuss the nature of the problem and
                       recommend a substitute. In these instances, the consumer’s care plan will
                       need to be changed and a new service order with the new price will be faxed
                       to the provider.
   7.     Invoicing

          a.    Specific billing instructions and information will be provided by PCA.

          b.    All orders must be billed in the month they are delivered to a consumer. No
                payment will be made for any item for which the provider does not have a
                service order. Any back billing beyond the normal invoice period is not allowed.
                The care manager must be notified about any item that was not delivered in the
                month it was ordered, as this must be corrected in the consumer’s care plan. PCA


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                will then generate a new service order to the provider. It is very important that the
                provider notifies the care manager of these changes as they affect invoicing and
                payment to the provider.

          c.    PCA requires that providers receive a signed receipt for every item delivered,
                regardless of payer source, to a PCA consumer. These signed receipts are to be
                kept in consumer files or with the billing documents at the provider’s office as
                this requirement will be audited by PCA’s external auditors. No payment will
                be made without a signed receipt for each individual item. The mailing of copies
                of signed delivery slips to PCA is NOT required; however, they must be
                retained in the provider’s records for audit purposes.

   8.     Warranty and Repairs

          a.    The provider must warrant all equipment for satisfactory performance for the period
                of the manufacturer's warranty, from date of installation. Defective equipment under
                warranty must be replaced and installed at no cost to PCA or the consumer.

          b.    Prior to repair requests, the PCA Care Manager will attempt to identify which DME
                provider supplied the item(s) in question, and direct the repair request accordingly to
                that provider. Whether the repair request is directed to the original DME provider or
                another (because the original provider is not known or available), the PCA Care
                Manager will authorize the evaluation for repairs via an initial Service Order that will
                indicate one unit of the RPAR service code at a cost of $1.00.

                Providers will evaluate the DME item in question for repairs, including a
                confirmation for warranty coverage – when applicable, and will notify the PCA Care
                Manger with the estimate of the repair costs. Third party payor sources for repair
                costs are to be exhausted prior to billing PCA or DPW. The cost of replacement
                parts, not covered under warranty, will be based on MA Fee schedule rates, when
                applicable. As needed, the authorization for the repair cost will be forwarded by the
                PCA Care Manager via a modified Service Order. Labor costs for repairs will be
                based on the rate established by MA Fee schedule.




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W.      HEARING AID SERVICES: SERVICE SPECIFIC OPERATIONAL PROCEDURES

        1.     GENERAL INFORMATION

               a.    These Operational Procedures delineate requirements for agencies providing
                     Hearing Aids to Philadelphia Corporation for Aging (PCA) consumers, of the
                     Long Term Care Options (LTCO) Program which encompass the Options and
                     Aging Waiver payment sources. The following requirements apply:

                     (1.)   The evaluation for a hearing instrument will be conducted as a result of and
                            following a comprehensive diagnostic hearing evaluation to determine the
                            consumer’s hearing ability and possible rehabilitation potential that can be
                            corrected with a hearing device(s). Note: Audiology examinations can be
                            covered by Medicare or managed care insurance plans when prescribed by the
                            primary physician and conducted by an Ear, Nose and Throat (ENT)
                            specialist or a licensed audiologist.

                     (2.)   In making appropriate cost effective treatment recommendations, generic
                            products must be considered first if applicable.

                     (3.)   The provision of hearing aid(s), if required, to the PCA consumer in his/her
                            home or provider’s office. Hearing aids will be fitted by the provider.

        2.     DEFINITION OF SERVICE

               a.    Diagnostic Evaluation - a comprehensive examination by an ENT or licensed clinical
                     audiologist, which will include, but is not limited to the following:

                     (1.)   Determination of hearing threshold;

                     (2.)   Differential testing to provide information regarding medical diagnosis and
                            treatment;

                     (3.)   Assessment of communication and handicapping effects of hearing loss;

                     (4.)   Evaluation of aural rehabilitation.

               * Diagnostic evaluations can be covered by Medicare or managed care insurance plans,
               when prescribed by a physician.

               b.    Aural Rehabilitation (Hearing Aid Evaluation) - Procedure to choose suitable
                     amplification for the consumer, which shall be based upon history, test findings,
                     observations and other considerations.

                     (1.)   Hearing Aid evaluation – selection of behind-the-ear, in-the-ear, or in-the-
                            canal hearing aids.



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                (2.)   Taking a mold of the consumer’s ear.

                (3.)   Initial fitting and adjustment of the hearing aid.

                (4.)   Hearing aid counseling; inclusive of:

                       (a.)    Instructions regarding use and care of the hearing aid.

                       (b.)    Evaluation of the consumer’s hearing aid to ensure appropriate
                               amplification.

                       (c.)    Assisting the consumer to adjust the amplification and develop
                               effective strategies to enhance their communication ability.

   3.     STAFF QUALIFICATIONS

          a.    Providers, enrolled in the Long Term Care Program will use staff that has the
                appropriate credentials as deemed valid by experts in the industry. A copy of their
                resume must be forwarded to the Contract Manager for review.

          b.    At a minimum, a Clinical Audiologist should be used. The Audiologist must hold a
                Master’s Degree from an accredited university and hold a Certification of Clinical
                Competence from the American Speech Language and Hearing Association. The
                staff person must hold a license to practice audiology and dispense hearing aids, and
                have adequate liability insurance. Note: a hearing aid fitter cannot be used in place of
                a Clinical Audiologist. A fitter can only be used in conjunction with a Clinical
                Audiologist for tasks such as: taking a mold of the consumer’s ear, an initial fitting,
                and/or adjustment of the hearing aid.

          c.    All staff servicing PCA consumers must receive an orientation on PCA programming
                and the goals and philosophy of the Long Term Care Program prior to servicing PCA
                consumers.

   4.     DELIVERY OF SERVICE

          a.    When the need for service has been determined as a result of a diagnostic hearing
                evaluation, the LTC Care Manager will make a referral to the provider selected by
                the consumer. The provider will schedule the in-the-home hearing instrument
                examination within five (5) working days of the receipt of the referral.

                The information provided in the referral will include the consumer’s insurance
                information, which the provider will utilize to determine whether there is third party
                coverage – prior to the delivery of service. PCA and/or Aging Waiver shall be the
                payor of last resort. Please note: there will be no care manager authorization of
                partial payments for insurance deductibles and co-payments.

          b.    Within 48 hours of the hearing examination, the results of the exam will be phoned
                to the Care Manager, identifying the type and quantity of hearing aids, if applicable.


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          c.    The Care Manager will authorize hearing aids by forwarding a service order to the
                provider. Note: Unless counter-indicated with clearly documented clinical reasons,
                Care Managers will order the “generic” hearing aids.

          d.    The provider will deliver and properly fit the hearing aid(s) to the consumer.

   5.     REPORTING REQUIREMENTS

          a.    The provider is required to keep records on each consumer. Reporting requirements
                remain the same for all LTC consumers irrespective of reimbursement source.

          b.    The provider is required to keep written documentation on each contact with the
                consumer. The consumer record must include:

                (1.)   Consumer’s name, Care Managers’ name, date and time of visits;
                (2.)   Results of a diagnostic hearing evaluation;
                (3.)   Hearing aid evaluation test results;
                (4.)   Documentation of the hearing aid counseling and instructions in the proper
                       use of the new hearing system;
                (5.)   Contact with the physician, Care Manager or other agencies providing care;
                (6.)   Signed verification by the consumer or caregiver that the visit was made.

    6.    ADMINISTRATIVE REQUIREMENTS

          a.    The provider will notify the Contract Manager in writing if there is a resignation of a
                staff member who administers the program or provides direct service to our
                consumers.

          b.    The provider will assume responsibility for the supervision of their staff to assure the
                delivery of quality care.

    7.    COMMUNICABLE DISEASES

          a.    When caring for consumers with communicable diseases, PCA expects provider
                agencies to follow procedures recommended in the Center for Disease Control
                (CDC) guidelines and OSHA regulations. Agencies are responsible to provide
                appropriate In-services regarding these universal precautions.

          b.    Based on CDC guidelines, the provider shall develop a written policy regarding
                communicable diseases. That policy must meet State/Federal requirements.

          c.    The provider shall notify the PCA nurse consultant or Care Manager upon
                determining or learning from another source, that a consumer has a communicable
                disease.

          d.    The provider must follow CDC and OSHA Guidelines regarding the disposal of
                contaminated needles.


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          e.    Before being assigned to a case, and annually, all consumer-contact employees shall
                have a Mantoux Intracutaneous PPD test according o CDC recommendations and,
                if the results are positive, it will be followed by appropriate physician directed
                treatment.

          f.    In order to continue employment, the employee must be free of active TB.
                Verification by a physician that the employee is free of TB must be in the personnel
                file and updated annually. Chest X-rays are required based on physician’ advice.

          g.    All employees must be offered and/or receive the Hepatitis B Vaccine as designated
                by OSHA Regulations.




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X.       STAIR ELEVATOR: SERVICE SPECIFIC OPERATIONAL PROCEDURES

These Operational Procedures delineate specifications for vendors of stair elevators provided to
Philadelphia Corporation for Aging (PCA) consumers in the Long Term Care (LTC) program which
encompass the Options and Aging Waiver payment sources.

        1.     Services to be Purchased:

               a.     PCA will lease a stair elevator unit from a stair elevator manufacturer or supplier
                      (herein called Vendor). Units leased will be maintained and guaranteed by Vendor.
                      Vendor will provide installation, removal, service and repairs for each leased unit in
                      all areas of Philadelphia.

               b.     Vendor shall service a stair elevator that is reported by a consumer to be non-
                      operating within 24 hours of the earliest call provided such call is received between 8
                      a.m. Monday and 4 p.m. Saturday; calls received between 4 p.m. Saturday and 8 a.m.
                      Monday shall be serviced no later than 12 p.m. Monday. Vendor shall make all other
                      service calls within 48 hours of the call to Vendor.

        2.     Certification Standards and Safety

               All installed stair elevators shall be certified by Vendor as meeting standards for safety and
               use, as may be promulgated by any governing body, including any electrical, manufacturing,
               consumer or other standards, rules or regulations that may apply.

        3.     Service Tasks

               PCA will be responsible for referring all consumers to be served under the contract, and will
               retain complete control of consumer eligibility determination and service authorization. PCA
               will also be responsible for monitoring and evaluating Vendor's performance.

        4.     Consumer Screening and Referral

               a.     PCA is responsible for screening and referring any consumer for leasing a stair
                      elevator. PCA will refer consumers to Vendor who have been determined by PCA to
                      be eligible and who elect to participate in leasing a stair elevator unit for their
                      residence. However, Vendor reserves the right to refuse installation in cases where its
                      own assessment reveals that the consumer and/or caregiver would be at undue risk.

               b.     Before the care manager can make the referral, the supervisor or nurse consultant in
                      LTC must approve the referral based on the consumer information on the “Stair
                      Elevator Order/Removal Form”. PCA will provide Vendor with pertinent data for
                      each consumer who is referred; data shall include the consumer's name, address,
                      telephone number, and other pertinent information that may impact on serving,
                      including medical condition and diagnoses if deemed necessary. After Vendor has
                      completed its evaluation in Subsection 4.c., d., e. below, an Occupational Therapist
                      (OT) will document the assessment for a stair elevator.




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          c.     LTC staff will fax a “Stair Elevator Order/Removal Form” requesting Vendor to
                 evaluate the consumer's home to determine if the home is suitable for a stair elevator.
                 Vendor shall arrange with the consumer for a mutually convenient appointment
                 within five (5) working days of PCA's request to evaluate the home, and if the home
                 is suitable for a stair elevator, Vendor will arrange for an installation date and time
                 with the consumer. Vendor agrees to complete installation within ten days following
                 the home evaluation if the home is suitable for a stair elevator or within ten days
                 following the time the home has been made suitable for a stair elevator.

          d.     Vendor shall notify PCA within three (3) days after the evaluation whether a home is
                 suitable for a stair elevator and whether an installation date has been scheduled. If
                 additional work is recommended in order to make the home suitable for a stair
                 elevator, Vendor will inform PCA of its recommendations for making the home
                 suitable for a stair elevator.

          e.     The eligibility screening by PCA under Section 4.a. above relates only to clinical and
                 fiscal matters, not construction, manufacture, design, installation, and safety and use
                 matters. Without limiting the responsibility of Vendor under Section B above and
                 elsewhere in the agreement between PCA and Vendors as to Vendor’s responsibility
                 for compliance with all applicable law, and without limiting the right of Vendor to
                 refuse an installation under Section 4.a. above, in connection with Vendor’s
                 evaluation of whether a particular home is suitable for a stair elevator as required
                 above in this section 4., Vendor shall not install any stair elevator in any particular
                 home if the installation, following any additional work or modifications
                 recommended by the Vendor, will not meet all standards for construction,
                 manufacture, design, installation, safety and use, whether promulgated by governing
                 authorities or independent bodies, such as but not limited to model building code
                 developers and standards-developing organizations, including but not limited to
                 electrical, mechanical, engineering, manufacturing, consumer and other industry
                 standards, requirements of insurance companies and underwriters, and other
                 reasonable standards. Vendor will not recommend or install a lift if it does not meet
                 such standards. Further, all work performed shall be in good and workmanlike
                 manner, exercising Vendor’s professional expertise, being fully informed by legal
                 requirements, such standards, warranty and manufacturers’ certification
                 requirements. PCA may withdraw any Stair Elevator Order/Removal Form, or fail to
                 issue a Service Order, for any or no reason at any time. However, during the
                 evaluation, installation, and promptly after the installation is completed, and at any
                 time thereafter when Vendor visits the consumer’s home or becomes aware of a
                 problem with the lift or the consumer’s use of it, notwithstanding any evaluation by
                 the OT, care manager, nurse or others at any time, Vendor shall have the
                 responsibility to determine not only whether a particular home is suitable, but
                 whether a particular consumer or other user is able to operate the lift safely and the
                 lift is appropriate for the consumer.

   5.     Installation

          a.     When the home is ready to accept the stair elevator and there is a confirmed
                 installation date, PCA will generate written authorization called a Service Order. The


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                order details the date of installation, the type of stair elevator, and other appropriate
                information. Vendor will receive a service order for each consumer when the service
                is initiated.

          b.    It shall be Vendor's responsibility to deliver and install each stair elevator. Vendor
                agrees to complete installation at the date specified. Vendor will obtain consumer
                signature on Client Lease Agreement form at time of installation.

          c.    Vendor shall immediately notify PCA if it is unable to schedule or complete an
                installation within the required time frame.

          d.    Vendor shall instruct the consumer in the use of the stair elevator and shall provide
                the consumer with simple written instructions, including how to report a malfunction
                of the stair elevator.

          e.    The Client Lease Agreement/Acknowledgement Form is dated and signed by the
                consumer or consumer's representative at time of installation, and a copy shall be left
                with the consumer. The Vendor retains a copy in their files.

   6.     Termination of Service

          a.    The decision to remove a stair elevator is at the discretion of PCA. For all removals,
                notification will be by telephone from authorized PCA staff. Written authorization
                to terminate service will be provided to the Vendor on the same day as the telephone
                notification.

          b.    If the Vendor is notified directly by a consumer's family or other representative to
                remove the stair elevator, the Vendor must contact PCA for approval.

          c.    When an LTC consumer with a stair elevator no longer requires such services,
                regardless of the reason, the designated LTC staff member will discuss the
                circumstances with appropriate staff, as needed, and contact the Vendor, so that the
                stair elevator can be removed.

          d.    The Vendor shall, upon instruction by PCA, arrange with the consumer or
                consumer's representative for a mutually convenient appointment to remove the stair
                elevator within five (5) working days of notification by PCA.

          e.    The Vendor will verify to PCA by telephone and in writing that the stair elevator has
                been removed.

          f.    Upon removal of the equipment, Vendor shall plug or patch the holes made at the
                time the equipment was installed. PCA is aware that this is not intended to restore
                the property to its original condition or color.

   7.     Reimbursement and Billing

          a.    PCA will reimburse Vendor for all authorized service for Options consumers.


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                 Provider will submit claims to DPW for all AGING Waiver consumers.


          b.     No payment will be made for any service for which the Vendor does not have a
                 service order.

          c.     PCA will require Vendor to submit invoices electronically to PCA for Options
                 consumers.

   8.     Financial Statement

          Providers entering into contracts with PCA must be financially solvent and able to
          demonstrate an ability to meet daily operational and payroll expenses. Should a provider
          enter into bankruptcy proceedings, the Contract Manager must be notified immediately.




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Y.      TRANSPORTATION: STANDARDS

The provider of transportation services may be the coordinated transportation system or other transportation
agencies which meet the following criteria:

        1.     AGENCY

               a.     Must have a back-up capacity if a vehicle is unable to or does not show.

               b.     Must have coordinated, consistent, and comprehensive safety and emergency
                      policies.

               c.     Must be licensed by the P.U.C. and/or be a Public Transit Authority, a Community

               d.     Transportation Provider, or a Community Transportation Subcontractor.

               e.     Must have drivers/personnel trained on how to relate to the needs of the elderly.

               f.     Ambulance companies who are enrolled in the Medical Assistance Program may also
                      provide non-emergency transportation services as indicated in the plan of care.

        2.     DRIVERS

               a.     Must be 18 years of age or older.

               b.     Must be properly licensed by the Commonwealth of Pennsylvania.

               c.     Must have training in handling emergency situations and accidents.

               d.     Must receive a physical examination, including a vision test, at the time of hire. In
                      addition, it is strongly encouraged that drivers continue to receive physical exams,
                      including vision tests, at least every two years after the initial exam, at the time of
                      hire.

               e.     Must be trained in passenger assistance techniques.

               f.     Must be willing to provide door-to-door service to consumers as necessary.

        3.     VEHICLES

               a.     Must be able to accommodate people with disabilities and be in compliance with the
                      Americans with Disabilities Act requirements and relevant federal regulations.

               b.     Must have capacity to accommodate attendants and escorts.

               c.     Must be maintained in a safe operating condition through a systematic preventive
                      maintenance program which at a minimum meets the recommendations of the
                      vehicle manufacturer.


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          d.     Procure and maintain adequate fleet, general and property liability insurance.

          e.     Drivers will identify MA waiver riders by their log book and/or MA identification
                 card.

   4.     SERVICE REPORTING

          Persons providing transportation services must comply with all reporting requirements as
          specified by the AAA.

   5.     SCHEDULING

          Days and times scheduled for transportation must be consistent with the care plan provided
          by the AAA.




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Z.      VISION CARE SERVICES: SERVICE SPECIFIC OPERATIONAL PROCEDURES

These Operational Procedures delineate requirements for agencies providing Vision Care Services to
Philadelphia Corporation for Aging (PCA) consumers, of the Long Term Care (LTC) Program
which encompass the Options and Aging Waiver payment sources. The following requirements
apply:

        1.     SERVICES TO BE PURCHASED

               PCA will purchase vision examinations, refraction and eyeglasses. These examinations will
               be performed in the homes of identified PCA consumers. In some instances, consumers may
               choose to travel to the provider for the eye examinations. The LTC care manager will
               identify these consumers and the provider will schedule appointments at their
               location/facility. Transportation will be arranged by the referring care manager. The
               services will include:

               a.     A comprehensive vision examination to determine eye condition and the need for a
                      new or change in prescription.

               b.     Making appropriate cost effective treatment recommendations.

               c.     Documentation and communication of those findings to the referring LTC care
                      manager.

               d.     The provision and fitting of new glasses, if required, to the PCA consumer in his/her
                      home.

               e.     Communication with the consumer’s physician when necessary.

        2.     STAFF QUALIFICATIONS

               a.     The staff optometrist must have a Doctor of Optometry degree from an accredited
                      optometric educational institution, Board certified and be licensed to practice
                      optometry in the Commonwealth of Pennsylvania.

               b.     All providers must receive an orientation on PCA’s Long Term Care Program prior
                      to serving consumers.

        3.     DELIVERY OF SERVICES

               a.     The LTC care manager will make a referral to the provider and relay the following
                      information regarding the home visit:

                      (1.)   Consumer name, address, zip code and telephone number;
                      (2.)   Pertinent history relating to vision problem, e.g. cataract surgery, history of
                             glaucoma, etc.;
                      (3.)   Pertinent information which may affect home visit arrangements (hard of
                             hearing, client’s ability to answer phone); and


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                (4.)   Whether or not a care manager or another formal/informal support needs to
                       be present during the examination.

          b.    The vision care provider will schedule the home visit and, if necessary, notify (by
                phone) the LTC care manager prior to the scheduled visit.

         c.     Coordination of care and conferencing will occur for all PCA consumers irrespective
                of reimbursement source (either Medicare, Medicaid or PCA payment.)

   4.     REPORTING REQUIREMENTS

          a.    The provider is required to keep records on each consumer. Reporting requirements
                remain the same for all LTC consumers irrespective of reimbursement source.

          b.    The provider is required to keep written documentation on each contact with
                the consumer. The consumer record must include:

                (1.)   Consumer’s name, care manager’s name, date and time of visit;
                (2.)   Diagnosis, treatment plan, and recommendation for follow-up;
                (3.)   Services and interventions given, including consumers/family reception and
                       understanding of instruction;
                (4.)   Contact with the consumer’s physician or other providers of care to PCA
                       consumers, when appropriate.

          c.    If the Vision Care provider is unable to arrange a home visit because the consumer
                refuses service or cannot be reached by phone, the LTC care manager must be
                notified.

   5.     INVOICING PROCEDURE

          a.    All service must be billed for the month in which they are provided. No payment
                will be made for any service for which the provider does not have a service order.

          b.    The LTC care manager must be notified of any change in the timing of in service
                delivery, as this must be corrected in the consumers care plan and an updated service
                order generated.

          c.    Service will be invoiced on a Reporting Period basis according to the schedule
                provided by PCA. Invoicing for all LTC consumers must be done via PCA’s
                Automated Billing System.

          d.    PCA will not pay for units of service that were ordered but not delivered due to
                consumer cancellation, no-shows, inclement weather, etc.

          e.    Services must be billed to third party payers first, if the consumer is eligible.
                Therefore, the provider will bill third party payers, including, but not limited to,
                Medicare, Medical Assistance and private insurance. The provider must submit to
                PCA information detailing those services billed to third party payers for PCA


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                consumers. PCA will authorize payment for co-pay and/or unmet deductible when
                applicable.

   6.     ADMINISTRATIVE REQUIREMENTS

          a.    The provider will notify the contract manager in writing if there is a resignation of a
                staff member who administers the program or provides direct service to our
                consumers.

          b.    The provider will assume responsibility for the supervision of their staff to assure the
                delivery of quality care.




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                                     SECTION V.



                  APPLICATION FORMAT AND FORMS




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A.      LETTER TO APPLICANTS




Dear Applicant:

     Thank you for your interest in providing services to PCA’s Long Term Care consumers. Please refer to
the enclosed Uniform Application Procedures and Standards for background information requirements.
Following this cover letter, you will find all the forms necessary to apply for Aging Waiver certification and
to initiate contract material from PCA to become a provider of specific services funded through the LTC
Program for the fiscal year effective July 1, 2009 to June 30, 2010.

        In order to apply for a PCA Options contract and/or certification as an Aging Waiver provider for
any one of the specified services, you must submit a completed application packet that consists of all the
required provider information and in format/order referenced on the check-off list. For additional
information regarding Pennsylvania Department of Public Welfare (DPW) rules and regulations governing
AGING Waiver provider enrollment, please refer to their website:
http://www.dpw.state.pa.us/omap/omapprovmain.asp

        Upon receipt of your completed application package, we will review all of the material submitted.
If your application is incomplete in any way, a PCA Contract Manager will contact you to clarify or work
out plans to obtain any missing information. You may withdraw or modify your application at any time
during this process.

       If you are certified as an Aging Waiver provider, your application will be sent to the Department of
Public Welfare with a recommendation for enrollment.

       If you are not approved for a PCA contract and/or certified to be a provider for the Aging Waiver
program, you will be notified of any appeal options available to you.




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B.      PROVIDER APPLICATION


                               SUBMISSION FORMAT / CHECK LIST

        NOTE: Application must be submitted in the format order listed below:

        SECTION                      REQUIRED INFORMATION

        1. ____       Complete organization description, organizational structure and
                      procedures, service capabilities, internal controls, and fee schedules.

        2. ____       Copy of Personnel Manual detailing agency’s recruitment, hiring, supervision
                      policies/procedures, copy of job descriptions and salary structure.

        3. ____       Copy of all forms that consumers are typically asked to sign, including time-sheets
                      or other comparable formats used to verify delivery of service.

        4. ___        Resumes of Professional staff (e.g. RNs, etc.)

        5. ____       Signed Certification/Agency Profile Form(s)

        6. ____       Operating officers and Board Members

        7. ____       Most recent annual Financial Statement/Report

        8. ____       IRS Tax Label; Articles of Incorporation; Licenses

        9. ____       PROMISE (DPW) Provider Enrollment Base Application

        10. ____      Aging Waiver Addendum

        11.____       DPW Provider Agreement for AGING Waiver Services

        12.____       DPW Provider Agreement

        13.____       Signed Assurances form

        14.____       Signed Price Certification Form(s)

        15.____       Signed Affirmation Form(s) for each service applied for

        16.____       Required Insurance Certificates




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PROMISe™ Provider Enrollment Information and Application
In order for providers to participate with the Department of Public Welfare, they must first enroll. To be
eligible to enroll, practitioners in Pennsylvania must be licensed and currently registered by the appropriate
State agency. Out-of-state practitioners must be licensed and currently registered by the appropriate agency
in their state and they must provide documentation that they participate in that state's Medicaid program.
Other providers must be approved, licensed, issued a permit or certified by the appropriate state agency, and
if applicable certified under Medicare. To enroll, providers must complete a base provider enrollment form
and any applicable addenda documents dependent on the provider type.

The links indicated below are applicable for provider type 55 – Vendor. Please see the following link
www.dpw.state.pa.us/omap/promise/enroll/omappromiseenroll.asp for other PROMISe provider types
enrollment information.

        Enrollment Application / Provider Agreement

        Requirements / Additional Information / FormsRequirements / Additional Information / Forms

        PDA Provider Enrollment Application/Provider Agreement/Requirements/Additional Information/Forms




PROMISe (DPW) Provider Enrollment Service Change Request

PROMISe™ Service Location Change Request and Instructions




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C.       CERTIFICATION FORM/AGENCY PROFILE

                                    (Include one form for each applicant office)

LOCAL OFFICE: (complete Operating Officers & Board Members forms as applicable) Attachments? Y / N
1.  Contact Person Name and Title: ____________________________________________
2.  Telephone Numbers Office: ( )                 Fax: ( ) ______ E-Mail _____________
3.  Local Administrator Name and Title: _________________________________________
4.  Office Name: ___________________________________________________________
5.  Street Address:__________________________________________________________
6.  City State and Zip Code:     _________________________________________________

 7.                                                                    Provider Number                  Date of Action
       IRS Number
       Medicare Certification
       DPW/MA Enrollment, Certification
       AGING Waiver Program Certification
       Joint Commission Accreditation (JCHO)

PARENT COMPANY: (complete Operating Officers & Board Members forms as applicable) Attachments? Y / N

 8.      Company Name:___________________________________________________
 9.      Street Address: ______________________________________________________
10.      City, State and Zip Code:_______________________________________________
11.      Agency Status (circle all that apply)
                 A.     (1) Profit             (2)     Non-Profit   (3) Public
                 B.     (1) Corporation        (2) Privately Owned  (3) Publicly Traded

12.      Agency Type (circle one):
               (1) Educational Institution                     (2) Product Vendor
               (3) Organization/Agency                         (4) Other Institution

13.      Agency Data:                               _________________                      _______________
                           (Company Founded)              (Initiation of this office)       (Number of Offices)

14.      Total Unduplicated Persons served
         by this office during the last calendar year: ____________                        ____________
                                                                           (Year)          (Number for year)
15.      Total Number of Current Staff (This office Only):
         ___________________       ___________ _____________                            ___________
         (Administrative/Supervisory)         (Service)          (Other)                  (Total)

16.      Total IRS Gross Revenue:                              $_________________                   $_______________
         Filing Year: ___________                                     (Total Company)                    (This Office)

17.      _________________________________                ___________________                       __________________
         (Signature of Authorized Representative)              (Title)                                     (Date)


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                        OPERATING OFFICERS (Photocopy, as needed)

A. NAME __________________________________________________________

TITLE _____________________________________________________________

ADDRESS                                        ZIP CODE             PHONE____________

ETHNICITY (CIRCLE)                                    SEX             AGE
1. BLACK                  4. AMERICAN INDIAN          1. MALE        1. UNDER 60
2. HISPANIC               5. WHITE                    2. FEMALE      2. OVER 60
3. ASIAN AMERICAN         6. OTHER

B. NAME_____________________________________________________

TITLE ____________________________________________________________

ADDRESS                                     ZIP CODE            PHONE ___________

ETHNICITY (CIRCLE)                    SEX               AGE
1. BLACK                  4. AMERICAN INDIAN          1. MALE         1. UNDER 60
2. HISPANIC               5. WHITE                    2. FEMALE       2. OVER 60
3. ASIAN AMERICAN         6. OTHER

C. NAME____________________________________________________

TITLE ____________________________________________________________

ADDRESS __________________________ZIP CODE               PHONE_________________

ETHNICITY (CIRCLE)                                     SEX           AGE
1. BLACK                  4. AMERICAN INDIAN           1. MALE      1. UNDER 60
2. HISPANIC               5. WHITE                     2. FEMALE    2. OVER 60
3. ASIAN AMERICAN         6. OTHER

D. NAME _____________________________________________________________

TITLE _______________________________________________________________

ADDRESS                                         ZIP CODE             PHONE_______________

ETHNICITY (CIRCLE)                                    SEX             AGE
1. BLACK                  4. AMERICAN INDIAN          1. MALE   1. UNDER 60
2. HISPANIC               5. WHITE                    2. FEMALE 2. OVER 60
3. ASIAN AMERICAN         6. OTHER




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                          BOARD MEMBERS (Photocopy, as needed)

A. NAME __________________________________________________________

TITLE _____________________________________________________________

ADDRESS                                        ZIP CODE             PHONE ________

ETHNICITY (CIRCLE)                                    SEX             AGE
1. BLACK                  4. AMERICAN INDIAN          1. MALE        1. UNDER 60
2. HISPANIC               5. WHITE                    2. FEMALE      2. OVER 60
3. ASIAN AMERICAN         6. OTHER

B. NAME __________________________________________________________

TITLE _____________________________________________________________

ADDRESS                                        ZIP CODE             PHONE _________

ETHNICITY (CIRCLE)                                    SEX             AGE
1. BLACK                  4. AMERICAN INDIAN          1. MALE        1. UNDER 60
2. HISPANIC               5. WHITE                    2. FEMALE      2. OVER 60
3. ASIAN AMERICAN         6. OTHER

C. NAME __________________________________________________________

TITLE _____________________________________________________________

ADDRESS                                        ZIP CODE             PHONE __________

ETHNICITY (CIRCLE)                                    SEX             AGE
1. BLACK                  4. AMERICAN INDIAN          1. MALE        1. UNDER 60
2. HISPANIC               5. WHITE                    2. FEMALE      2. OVER 60
3. ASIAN AMERICAN         6. OTHER

D. NAME __________________________________________________________

TITLE _____________________________________________________________

ADDRESS                                        ZIP CODE             PHONE _________

ETHNICITY (CIRCLE)                                    SEX             AGE
1. BLACK                  4. AMERICAN INDIAN          1. MALE        1. UNDER 60
2. HISPANIC               5. WHITE                    2. FEMALE      2. OVER 60
3. ASIAN AMERICAN         6. OTHER




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D.      ASSURANCES

        By my initials next to each statement that follows and my signature below, I certify that:

            I have the capacity to deliver all service orders accepted and will commit the resources at my
        disposal to assure provision of all services applied for.

             I understand that PCA does not guarantee any minimum or maximum volume of service and
        that the total amount of actual reimbursement will be based on consumer choice, service orders
        placed by PCA, and actual service delivered and verified by consumer signatures.

              I will carry and keep current insurance and provide evidence of such insurance, upon request.

            I agree to maintain for 4 years and make available, for purposes of PCA monitoring and audit,
        documentation to verify service provision as invoiced and reimbursed.

            I recognize the particular need for sensitivity in serving the elderly, and am committed to
        providing honest, thorough and responsive staff service in order to minimize consumer disruption
        and upset.




NAME: _______________________                               _________________________
              (Signature)                                           (Print name)

TITLE: _______________________________________________________________

Name of organization: ___________________________________________________

Address: _____________________________________________________________

City/State:                          Zip:          Phone:                 Date: _______




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E.      PROVIDER AFFIRMATION, PRICE CERTIFICATION, AND PROFILE FORMS


Following are copies of price certification forms to record the unit price(s) you are requesting for the
services you are seeking to provide. The same prices will apply to both funding sources under LTC:
Options and Aging Waiver. As part of this process, a best and final price quote process may be necessary
depending upon prices offered. An Affirmation and Service Profile form (where included), must be
submitted with each Price Certification Form submitted. Please make sure that your agency/organization is
enrolled in MA as the correct Provider Type for the services/ Procedure Codes you are applying for and
offering prices.

Should you have any questions regarding the price negotiation process, please contact your Contract
Manager in the Business Administration Department.




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1.      ADULT DAY CARE CENTERS: PROVIDER AFFIRMATION

I, the undersigned, affirm that:

        1.     STANDARDS: I will comply with all Pennsylvania Department of Aging licensing
               requirements and the requirements related to the Older Adult Daily Living Centers
               Standards and Service Specific Operational Procedures (SSOP).

        2.     STAFF QUALIFICATIONS: I will assure that all consumer contact staff receives an
               annual PPD test and that documents of the results are maintained in their files along
               with other verification of compliance with federal, state and local health requirements
               related to communicable disease. I will follow procedures recommended in the Center
               for Disease Control (CDC) Guidelines and OSHA regulations, including provision of
               protective articles to staff.

               I will assure that a criminal history record check for compliance with Act 169 will be
               completed on all staff servicing PCA consumers.

        3.     TRAINING: All Older Adult Day Care Staff serving LTC consumers will meet the
               training requirements established by the Pennsylvania Department of Aging.

        4.     SERVICE REPORTING: I will comply with all reporting requirements as specified
               by the AAA.

        5.     SCHEDULING: I understand that the specific days for which service is scheduled shall
               be in conformance with the consumer’s needs and consistent with the Care Plan
               provided by the AAA.

        6.     INSURANCE: I agree to carry, verified by a current certificate of coverage in the
               amounts specified by PCA




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      7.     CONFIDENTIALITY - RESEARCH PROTOCOLS: I will comply with all federal,
             state and local laws relating to research on human subjects; and all federal, state and
             local laws and agreements with AAA’s, regarding consumer confidentiality. I agree and
             warrant that any research in which consumers receiving services under the Aging
             Waiver program will be asked to participate, shall have been reviewed and approved by
             a Department of Health and Human Services (DHHS) or Federal Drug Administration
             (FDA) approved Institutional Review Board (IRB) unless exempt from IRB review. I
             will inform the appropriate (PDA, MA and AAA) staff of research involving said
             consumers and will provide all appropriate parties with copies of IRB approvals and
             consent forms. I, upon request, will provide all parties with any additional information
             and copies of research protocols.


PROVIDER NAME:         ________________________________________

PROVIDER ADDRESS: ___________________________________________

CITY, STATE AND ZIP CODE: ______________________________________

                                                         ______________
(Signature of Authorized Representative)                  (Date)




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2.      PRICE CERTIFICATION FORM: ADULT DAY CARE CENTERS

Provider Name: _______________________________County: _____________________


                                  REIMBURSEMENT RATES
                                       CUSTOMARY AND                    RATE REQUESTED
                                       USUAL CHARGE                     FROM LTC
 PROCEDURE CODE
                                       YEAR: _________                  PROGRAM


 FULL DAY, including meal and 2
 snacks.
  (unit = day)  S5102      DAYC

 FULL DAY, including meal, 2 snacks,
 and bath.
  (unit = day) S5102-32 DAYB

 HALF-DAY, including meal and one
 snack
  (unit = 1/2 day) S5101   DAYH

 HALF-DAY, including meal, one
 Snack, and bath.
 (unit = ½ day) S5101- 32   WATB


 MEAL COST (included above as part
 of daily charge)        DCML


 BATH COST (included above as part
 of daily charge)

                                                           North
                                   South       West        Central       Northwest     Northeast

 Service Areas Requested

I understand the rates above will be used to determine the actual reimbursement rate for the provider
named herein for both LTC funding sources, subject to the price ceiling for each Procedure Code. I
affirm the price information provided above is true, correct, and complete to the best of my knowledge.
 I Understand The Rate Requested From The LTC Program May Not Exceed My Customary
And Usual Rate.
________________________________                     __________________            ___________
Signature of Authorized Representative                       Title                     Date




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3.       ATTENDANT CARE (ACT 150 – Transitional Service): PRICE CERTIFICATION FORM


Provider Name:          ________________________ County: _________________________________


                                          REIMBURSEMENT RATES

                PROCEDURE CODE                       ATTENDANT CARE                   STARTING HOURLY
                                                     FEE SCHEDULE,                      RATE PAID TO
                                                     EFFECTIVE 7/1/08:                    WORKERS


     Combination Model – (unit = hour)                          15.64
     ATCO

     Agency Directed Model – (unit = hour)                      18.84
     ATAO

     Monthly Coordination Fee (unit = 1 month fee)              154.26

     ATMC

     Monthly Financial Management Service – for
     Consumer and Combination Model only–                       75.00
     (unit= 1 monthly fee) ,
     ATFM       (*W7341 - effective 8/1/07)




                                                                 North
                                    South         West          Central          Northwest          Northeast

     Service Areas

I understand the rates above will be used to determine the actual reimbursement rate for the provider named herein
for both LTC funding sources, subject to the price ceiling for each Procedure Code. I affirm the price information
provided above is true, correct, and complete to the best of my knowledge.


                               __                      ______________                  ___________
Signature of Authorized Representative                       Title                         Date




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4.        ATTENDANT CARE / PERSONAL ASSISTANCE SERVICE (PAS) PROFILE

As an adjunct to the enclosed Price Certification Form, the following statistical data is being
requested for informational purposes.

It is expected that data presented will relate to Attendant Care or Personal Assistance Service.

APPLICANT                                                       FISCAL YEAR ________

I. Agency Status

     A.     Are you a Medicare Certified Home Health Agency?

                 Yes            No

     B.     Are you applying for, or intending to obtain Medicare Certification?

                 Yes            No

     C.     Information presented below relates to:     (check one)

                 Personal Assistance Service
                 Attendant Care

II. Agency Information

     A. Training

            Do you currently have the following:
            Certificate Training Yes             No             If yes, hrs./mo.
            In-Service Training Yes              No             If yes, hrs./mo.
            Orientation          Yes             No             If yes, hrs./mo.


     B. Attendant Care / Personal Assistance Service Level; last calendar year: _________

            1.     Average number of consumers served on a weekly basis:           ______
            2.     Average number of hours delivered on a weekly basis:            ______
            3.     Total number of hours delivered last year:                      ______




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C. Attendant Care / Personal Assistance Service Workers

        1. Number of attendant care / personal assistance attendants:


Length of providing service        # Attendants           # of Field Supervisors

24 months & longer

12 through 23 months

6 through 11 months

Less than 6 months

Total number


        2.       What is your current starting salary for attendants?                _________

        3.       What is the current average salary paid to these workers?          _________

        4.       What are the Fringe costs (% basis)?                              __________

        5.       Number of hours per week worked by attendant care / personal assistance workers and
                 field supervisors:


Hours Per Week         Under 9      10-19         20-29            30-39           40-49         50+

  # Attendants


   # of Field
  Supervisors




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5.      COUNSELING: PROVIDER AFFIRMATION


I am applying to provide the Counseling services I have checked below:

         1.            Problem-solving and coping skills
         2.            Drug Dependency
         3.            Alcoholism
         4.            Individual stress
         5.            Marital/family stress
         6.            Family problems involving abuse or neglect
         7.            Detection and treatment of depression and other mental health conditions
         8.            Nutrition education, counseling and/or diet instruction
         9.            Music therapy
        10.            Other (specify):

I, the undersigned, affirm that:

        1.     STANDARDS: I will comply with all the requirements stated in the Long Term Care
               (LTC) Program Counseling Standards and Service Specific Operational Procedures
               (SSOP).

        2.     STAFF QUALIFICATIONS: I will assure that documentation of the credentials of all
               counseling staff is maintained in their files along with other verification of compliance with
               any federal, state and local health requirements related to communicable disease. Where
               they apply, I will follow procedures recommended in the Center for Disease Control (CDC)
               Guidelines and OSHA regulations, including provision of protective articles to staff.

               I will assure that a criminal history record check for compliance with Act 169 will be
               completed on all staff servicing PCA consumers.

        3.     SUPERVISION: All counselors providing service to LTC Program consumers will be
               supervised or have access to consultation.

               Supervision will be provided based on the normal and customary clinical practice in the
               industry. Such supervision will include, but not be limited to, review of assessments and
               other clinical activities, clinical guidance and support regarding therapeutic techniques.

        4.     SERVICE REPORTING: I will comply with all reporting requirements as specified by
               the AAA.

        5.     SCHEDULING: I understand that the specific days and times for which service is
               scheduled shall be in conformance with the consumer’s needs.

        6.     INSURANCE: I agree to carry, verified by a current certificate of coverage in the amounts
               specified by PCA




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      7.     CONFIDENTIALITY - RESEARCH PROTOCOLS: I will comply with all federal,
             state and local laws relating to research on human subjects; and all federal, state and local
             laws and agreements with AAA’s, regarding consumer confidentiality. I agree and warrant
             that any research in which consumers receiving services under the LTO program will be
             asked to participate, shall have been reviewed and approved by a Department of Health and
             Human Services (DHHS) or Federal Drug Administration (FDA) approved Institutional
             Review Board (IRB) unless exempt from IRB review. I will inform the appropriate (PDA,
             MA and AAA) staff of research involving said consumers and will provide all appropriate
             parties with copies of IRB approvals and consent forms. I, upon request, will provide all
             parties with any additional information and copies of research protocols.


PROVIDER NAME:         __________________________________________________

PROVIDER ADDRESS: _________________________________________________

CITY, STATE AND ZIP CODE:__________________________________________

                                                                     _____________
 (Signature of Authorized Representative)                                (Date)




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6.      COUNSELING SERVICE: PRICE CERTIFICATION FORM


Provider Name: _______________________________County: ___________________


                                    REIMBURSEMENT RATES

                                MEDICARE         MA RATE:          CUSTOMARY           RATE
 PROCEDURE CODE                 RATE:            YEAR:             AND USUAL           REQUESTED
                                YEAR:            ______            CHARGE              FROM LTC
                                                                   YEAR:               PROGRAM

 INITIAL
 EVALUATION(unit = visit
  T2025 -HH         CNEV
 PROBLEM SOLVING &
 COPING SKILLS (unit =
 visit)
 T2025 -HH         CNIT
 MUSIC THERAPY(unit =
 visit)
 T2025 -HH        WMUS
 TELEPHONE SUPPORT
 GROUP(unit = session)
 T2025 -HH        CNOG




                                                          North
                                 South       West         Central       Northwest      Northeast

 Service Areas Requested

I understand the rates above will be used to determine the actual reimbursement rate for the provider
named herein for both LTC funding sources, subject to the price ceiling for each Procedure Code. I
affirm the price information provided above is true, correct, and complete to the best of my
knowledge. I Understand The Rate Requested From The LTC Program May Not Exceed My
Customary And Usual Rate.

                                                                                 _________
Signature of Authorized Representative                     Title                     Date




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   7.      PROFESSIONAL EVALUATION SERVICES: PROVIDER AFFIRMATION


I, the undersigned, affirm that:

           1.     STANDARDS: I will comply with all the procedures stated in the Long Term Care (LTC)
                  Program Service Specific Operational Procedures.

           2.     STAFF QUALIFICATIONS: I will assure that all consumer contact staff receive an
                  annual PPD test and that documents of the results are maintained in their files along with
                  other verification of compliance with federal, state and local health requirements related to
                  communicable disease. I will follow procedures recommended in the Center for Disease
                  Control (CDC) Guidelines and OSHA regulations, including provision of protective
                  articles to staff.

                  I will assure that a criminal history record check for compliance with Act 169 will be
                  completed on all staff servicing PCA consumers.

           3.     TRAINING: All staff serving LTC consumers will meet the education and requirements
                  specified and demonstrate competency in the skill areas licensure included in the Service
                  Specific Operational Procedures.

           4.     CARE PLAN COMPLIANCE: I agree that a care plan will be developed jointly
                  between my staff and the LTC care manager and primary physician and will be subject to
                  interdisciplinary review and coordination.

           5.     CARE PLAN COORDINATION: I agree staff will make joint visits, as needed, in the
                  care needed. and will maintain ongoing records and make necessary communication to
                  provide instruction, discuss the consumer’s progress, and review treatment
                  recommendations. I agree staff will assess the consumer and family’s ability to participate

           6.     SERVICE REPORTING: I will comply with all reporting requirements as specified by
                  the AAA.

           7.     SCHEDULING: I understand that the specific days and times for which service is
                  scheduled shall be in conformance with the consumer’s needs.

           8.     INSURANCE: I agree to carry, verified by a current certificate of coverage in
                  the amounts specified by PCA.




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        9.     CONFIDENTIALITY-RESEARCH PROTOCOLS: I will comply with all federal,
               state and local laws relating to research on human subjects; and all federal, state and local
               laws and agreements with AAA’s, regarding consumer confidentiality. I agree and
               warrant that any research in which consumers receiving services under the LTC program
               will be asked to participate, shall have been reviewed and approved by a Department of
               Health and Human Services (DHHS) or Federal Drug Administration (FDA) approved
               Institutional Review Board (IRB) unless exempt from IRB review. I will inform the
               appropriate ( PDA, MA and AAA) staff of research involving said consumers and will
               provide all appropriate parties with copies of IRB approvals and consent forms. I, upon
               request, will provide all parties with any additional information and copies of research
               protocols.



PROVIDER NAME:_____________________________________________________

  PROVIDER ADDRESS: _________________________________________________

  CITY, STATE AND ZIP CODE: _________________________________________

                                                                     ___________________

(Signature of Authorized Representative)                                (Date)




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8.       PROFESSIONAL EVALUATION SERVICES: PRICE CERTIFICATION FORM (1)


Provider name: _____________________________ County: ____________________


                                      REIMBURSEMENT RATES

                                       MEDICARE          MA          CUSTOMARY           RATE
     PROCEDURE CODE                    RATE:             RATE:       AND USUAL           REQUESTED
                                       YEAR:             YEAR:       CHARGE              FROM LTC
                                                                     YEAR:               PROGRAM

     PSYCHIATRIC EVALUATION
     (unit = hour) PSYC

     MEDICAL EVALUATION (unit
     = hour)      PHYS




                                      South     West       North Central     Northwest     Northeast

     Service Areas Requested

I understand the rates above will be used to determine the actual reimbursement rate for the provider
named herein for both LTC funding sources, subject to the price ceiling for each Procedure Code. I
affirm the price information provided above is true, correct, and complete to the best of my
knowledge. I Understand The Rate Requested From The LTC Program May Not Exceed My
Customary And Usual Rate.

                                                                                   ___________
Signature of Authorized Representative                       Title                   Date




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9.       PROFESSIONAL EVALUATION SERVICES: PRICE CERTIFICATION FORM (2)


Provider name: ___________________________ County: ____________________________


                                      REIMBURSEMENT RATES

                                       MEDICARE          MA          CUSTOMARY           RATE
     PROCEDURE CODE                    RATE:             RATE:       AND USUAL           REQUESTED
                                       YEAR:             YEAR:       CHARGE              FROM LTC
                                                                     YEAR:               PROGRAM
     PSYCHOLOGICAL
     EVALUATION
     (unit = hour) PSGY

     OBRA PSYCHOLOGICAL
     EVALUATION
     (unit = hour) OBAS




                                      South     West       North Central     Northwest     Northeast

     Service Areas Requested

I understand the rates above will be used to determine the actual reimbursement rate for the provider
named herein for both LTC funding sources, subject to the price ceiling for each Procedure Code. I
affirm the price information provided above is true, correct, and complete to the best of my
knowledge. I Understand The Rate Requested From The LTC Program May Not Exceed My
Customary And Usual Rate.

                                                                                     ___________
Signature of Authorized Representative                       Title                        Date




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10.      HOME HEALTH CARE: PROVIDER AFFIRMATION



I, the undersigned, affirm that:

         1.     STANDARDS: I will comply with all the requirements stated in the Long Term Care
                (LTC) Program Home Health Care Standards and Service Specific Operational Procedures
                (SSOP).

         2.     STAFF QUALIFICATIONS: I will assure that all consumer contact staff receive an
                annual PPD test and that documents of the results are maintained in their files along with
                other verification of compliance with federal, state and local health requirements related to
                communicable disease. I will follow procedures recommended in the Center for Disease
                Control (CDC) Guidelines and OSHA regulations, including provision of protective
                articles to staff.

                I will assure that a criminal history record check for compliance with Act 169 will be
                completed on all staff servicing PCA consumers.

                All Enterostomal nurses serving LTC consumers will have graduated from an accredited
                Enterostomal Therapy Nurse Education Program approved by the International
                Association for Enterostomal Therapy and be board certified or board eligible. If board
                eligible, the ET nurse shall sit for and pass the board certification examination within one
                year of employment by provider.

         3.     TRAINING: All Home Health Aides serving LTC consumers will demonstrate
                competency in the skill areas included in the Home Health Standards. Observation of
                competency will be documented in each Home Health Aide’s Personnel file.

         4.     CARE PLAN COMPLIANCE: After joint development by the RN, PT, OT, ST, ET,
                Psych Nurse, with the LTC care manager and physician, each home health care plan will
                be maintained in the home of the LTC consumer as well as in the consumer’s file, for
                interdisciplinary review and coordination. The professional involved also will develop a
                care plan for the home health aide to follow in the consumer’s home. The home health
                aide will perform only those tasks approved by AAA staff.

         5.     CARE PLAN COORDINATION: I agree the Enterostomal Nurse and the Registered
                Nurse will make joint visits, as needed, and will maintain ongoing communication to
                provide instruction, discuss the consumer’s progress, and review treatment
                recommendations. I agree the Enterostomal Nurse will assess the consumer and family’s
                ability to participate in the care needed.

         6.     SERVICE REPORTING: I will comply with all reporting requirements as specified by
                the AAA.




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      7.     SCHEDULING: I understand that the specific days and times for which service is
             scheduled shall be in conformance with the consumer’s needs.

      8.     INSURANCE: I agree to carry, verified by a current certificate of coverage in the
             amounts specified by PCA.

      9.     CONFIDENTIALITY-RESEARCH PROTOCOLS: I will comply with all federal, state
             and local laws relating to research on human subjects; and all federal, state and local laws
             and agreements with AAA’s, regarding consumer confidentiality. I agree and warrant that
             any research in which consumers receiving services under the LTC program will be asked
             to participate, shall have been reviewed and approved by a Department of Health and
             Human Services (DHHS) or Federal Drug Administration (FDA) approved Institutional
             Review Board (IRB) unless exempt from IRB review. I will inform the appropriate ( PDA,
             MA and AAA) staff of research involving said consumers and will provide all appropriate
             parties with copies of IRB approvals and consent forms. I, upon request, will provide all
             parties with any additional information and copies of research protocols.


PROVIDER NAME:____________________________________________________

PROVIDER ADDRESS:_________________________________________________

CITY, STATE AND ZIP CODE:__________________________________________

                                                          _________________
(Signature of Authorized Representative)                        (Date)




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   11.      HOME HEALTH SERVICES: PRICE CERTIFICATION FORM

   Provider Name:_______________________________ County: ______________

                                               REIMBURSEMENT RATES

  PROCEDURE CODE                      MEDICARE       MA                     CUSTOMARY AND       RATE
                                      RATE:          RATE:                  USUAL CHARGE        ESTABLISHED
                                      YEAR: ____     YEAR: ____             YEAR:               FOR LTC
                                                                                                PROGRAM
  NURSING (unit = visit)
                                                                                                      88.00
  T2025-TD              NURS
  PHYSICAL THERAPY (unit =
  visit)                                                                                              88.00
  T2025-GP         HHPT
  OCCUPATIONAL THERAPY
  (unit = visit)                                                                                      88.00
  T2025-GO              HHOT
  SPEECH THERAPY
  (unit = visit)                                                                                      88.00
  T2025-GN              HHST
  PSYCHIATRIC NURSING
  (unit = visit                                                                                       88.00
  T2025-TD PSNR
  ENTEROSTOMAL THERAPY
  (unit = visit)                                                                                      88.00
   T2025 - TD           ENST
  HIGH TECH NURSING (unit =
  visit)                                                                                              88.00
  T2025-TD       NRHT
  HOME HEALTH AIDE
  (unit = visit)
                                                                                                      46.00
  T2025 HHHA
  Health Status Measuring and
  Monitoring Service (unit = 1/day)                                                                   10.00
  T2025-GT              HSMM
                                                                   North
                                       South       West           Central        Northwest          Northeast

  Service Areas Requested
I understand the rates above will be used to determine the actual reimbursement rate for the provider named
herein for both LTC funding sources, subject to the price ceiling for each Procedure Code. I affirm the price
information provided above is true, correct, and complete to the best of my knowledge. I Understand The
Rate Requested From The LTC Program May Not Exceed My Customary And Usual Rate.

                                                                                             ___________
Signature of Authorized Representative                    Title                                  Date




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12.      HOME HEALTH SERVICE PROFILE

As an adjunct to the enclosed Price Certification Form, the following statistical data is being
requested for informational purposes.

APPLICANT                                                  YEAR: ________________
Agency Information

  A. Home Health Service Level Last Calendar Year: __________

           1.   Average number of patients served on a weekly basis: _______
           2.   Average number of visits made on a weekly basis: __________
           3.   Total number of visits made last year: __________

  B. Skilled Workers

           1. Number of contracted skilled workers used by you at this time: _________
           2. Number of skilled workers employed by you at this time: ___________
           3. Please break down in the chart below, the total included in 1 and 2: ________


       Length of Employment     Registered     Physical     Occupational   Enterostomal       Psychiatric
             and Status          Nurses       Therapists     Therapists       Nurses            Nurses

      24 months & longer

      12 through 23 months

      6 through 11 months

      Less than 6 months

      Total number

      Employed Full Time

      Employed Part Time

      Contracted




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13.      HOME SUPPORT: PROVIDER AFFIRMATION



Provider may offer one or more of the services that follow:

         1.     Basic housekeeping.
         2.     Labor-intensive, low-cost home repair.
         3.     Chores necessary for reasons of a consumer’s health and safety, which requires availability
                of heavy cleaning in the home, extermination and hauling of debris.
         4.     Grounds Maintenance.
         5.     Extermination
         6.     Dumpster Rental/Hauling
         7.     Home Management necessary to ensure safe and sanitary condition
         8.     Instruction in home management.
         9.     Personal laundry and mending of clothing.
         10.    Meal planning and preparation.
         11.    Financial management.
         12.    The escorting of consumer by a Home Support worker to complete chores or to keep
                medical appointments, through the use of the coordinated transportation system.
         13.    Shopping Assistance with or without the consumer.

I, the undersigned, affirm that:

         1.     STANDARDS: I will comply with all the requirements stated in the Long Term Care
                (LTC) Program Home Support Service Standards and Service Specific Operational
                Procedures (SSOP).

         2.     STAFF QUALIFICATIONS: I will assure that all consumer contact staff receive an
                annual PPD test and that documents of the results are maintained in their files along with
                other verification of compliance with federal, state and local health requirements related to
                communicable disease. I will follow procedures recommended in the Center for Disease
                Control (CDC) Guidelines and OSHA regulations, including provision of protective articles
                to staff.

                I will assure that a criminal history record check for compliance with Act 169 will be
                completed on all staff servicing PCA consumers.

         3.     SERVICE REPORTING: I will comply with all reporting requirements as specified by
                the AAA.

         4.     SCHEDULING: I understand that the specific tasks and days and times for which service
                is scheduled shall be in conformance with the consumer’s needs.

         5.     INSURANCE: I agree to carry, verified by a current certificate of coverage in the amounts
                specified by PCA




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      6.     CONFIDENTIALITY - RESEARCH PROTOCOLS: I will comply with all federal,
             state and local laws relating to research on human subjects, and all federal, state and local
             laws and agreements with AAA’s, regarding consumer confidentiality. I agree and warrant
             that any research in which consumers receiving services under the LTC program will be
             asked to participate, shall have been reviewed and approved by a Department of Health and
             Human Services (DHHS) or Federal Drug Administration (FDA) approved Institutional
             Review Board (IRB) unless exempt from IRB review. I will inform the appropriate (PDA,
             MA and AAA) staff of research involving said consumers and will provide all appropriate
             parties with copies of IRB approvals and consent forms. I, upon request, will provide all
             parties with any additional information and copies of research protocols.


PROVIDER NAME: __________________________________________________

PROVIDER ADDRESS: _______________________________________________

CITY, STATE AND ZIP CODE: __________________________________________

_______________________________________                   __________________
Signature of Authorized Representative)                         (Date)




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14.      HOME SUPPORT: PRICE CERTIFICATION FORM

Provider Name: _____________________________ County: __________________________

                                          REIMBURSEMENT RATES

            PROCEDURE CODE                    CUSTOMARY AND USUAL                    RATE REQUESTED
                                              CHARGE, YEAR:                         FROM LTC PROGRAM


 HEAVY CLEANING
 (unit = 1/4 hour) W1729           CHHC

 INITIAL EXTERMINATION
 (unit = visit) W1732              CHEX

 FOLLOW-UP EXTERMINATION
 (unit = visit) W1733  CHXF

 SPECIAL EXTERMINATION
 (unit = visit) W1733  CHXS

 RENTAL DUMPSTER
 (unit = daily fee) W1758          CHDR
                                                                   North
                                    South          West           Central        Northwest           Northeast

 Service Areas Requested

I understand the rates above will be used to determine the actual reimbursement rate for the provider named herein
for both LTC funding sources, subject to the price ceiling for each Procedure Code. I affirm the price information
provided above is true, correct, and complete to the best of my knowledge. I Understand The Rate Requested
From The LTC Program May Not Exceed My Customary And Usual Rate.

                               __                      ________________                ____________
Signature of Authorized Representative                       Title                         Date

                              HOME SUPPORT/CHORE - VENDOR PROFILE

                              Types of cleaning performed last calendar year
                           Restoration      Domestic
Type                                                      Store     Office   Industrial     Extermination visits
                            (fire, etc)     Services
Enter unduplicated
number cleaned
2008-09




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15.      HOME SUPPORT- FINANCIAL MANAGEMENT: PRICE CERTIFICATION FORM

Provider Name: ___________________________ County: ______________________

                                          REIMBURSEMENT RATES

            PROCEDURE CODE                    CUSTOMARY AND USUAL                    RATE REQUESTED
                                              CHARGE, YEAR:                         FROM LTC PROGRAM


 INITIAL EVALUATION
 (unit = ¼ hour – Aging Waiver;
  unit = hour – Options)
  W1729                      WFIM

 MONTHLY MANAGEMENT
 (unit = ¼ hour – Aging Waiver;
  unit = hour - Options)
 W1729                       WFIM




                                                                 North
                                    South          West         Central          Northwest           Northeast

 Service Areas Requested

I understand the rates above will be used to determine the actual reimbursement rate for the provider named herein
for both LTC funding sources, subject to the price ceiling for each Procedure Code. I affirm the price information
provided above is true, correct, and complete to the best of my knowledge. I Understand The Rate Requested
From The LTC Program May Not Exceed My Customary And Usual Rate.

                               __                      ________________                ____________
Signature of Authorized Representative                       Title                         Date




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16.      PERSONAL CARE: PROVIDER AFFIRMATION

I, the undersigned, affirm that:

         1.     STANDARDS: I will comply with all the requirements stated in the Long Term Care
                (LTC) Program Personal Care Standards and Service Specific Operations Procedures
                (SSOP).

         2.     STAFF QUALIFICATIONS: I will assure that all consumer contact staff receives an
                annual PPD test and that documents of the results are maintained in their files along with
                other verification of compliance with federal, state and local health requirements related to
                communicable disease. I will follow procedures recommended in the Center for Disease
                Control (CDC) Guidelines and OSHA regulations, including provision of protective articles
                to staff.

                I will assure that a criminal history record check for compliance with Act 169 will be
                completed on all staff servicing PCA consumers.

         3.     TRAINING: All personal care workers serving LTC consumers will demonstrate
                competency in the skill areas included in the LTC Program Personal Care Standards and
                SSOP. Observation of competency will be documented in each personal care worker’s
                personnel file.

         4.     SERVICE REPORTING: I will comply with all reporting requirements as specified by the
                AAA.

         5.     SCHEDULING: I understand that the specific days and times for which service is
                scheduled shall be in conformance with the consumer’s needs.

         6.     INSURANCE: I agree to carry, verified by a current certificate of coverage in the amounts
                specified by PCA.

         7.     CONFIDENTIALITY - RESEARCH PROTOCOLS: I will comply with all federal, state
                and local laws relating to research on human subjects, as well as all federal, state and local
                laws and agreements with AAA’s regarding consumer confidentiality. I agree and warrant
                that any research in which consumers receiving services under the LTC program will be
                asked to participate shall have been reviewed and approved by a Department of Health and
                Human Services (DHHS) or Federal Drug Administration (FDA) approved Institutional
                Review Board (IRB), unless exempt from IRB review. I will inform the appropriate (PDA,
                MA and AAA) staff of research involving said consumers and will provide all appropriate
                parties with copies of IRB approvals and consent forms. I, upon request, will provide all
                parties with any additional information and copies of research protocols.




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PROVIDER NAME:_____________________________________________________

PROVIDER ADDRESS: _________________________________________________

CITY, STATE AND ZIP CODE: ___________________________________________

                                                             ___________
 (Signature of Authorized Representative)                      (Date)




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17.      RESPITE CARE: PROVIDER AFFIRMATION

I, the undersigned, affirm that:

         1.     STANDARDS: I will comply with all the requirements stated in the Long Term Care
                (LTC) Program Respite Service Standards and Service Specific Operational Procedures
                (SSOP).

         2.     STAFF QUALIFICATIONS: I will assure that all consumer contact staff will be used
                who have received an annual PPD test that is documented in their files, along with other
                verification of compliance with federal, state and local health requirements related to
                communicable disease. I will follow procedures recommended in the Center for Disease
                Control (CDC) Guidelines and OSHA regulations, including provision of protective articles
                to staff.

                I will assure that a criminal history record check for compliance with Act 169 will be
                completed on all staff servicing PCA consumers.

         3.     TRAINING: All respite workers serving LTC consumers will demonstrate competency,
                that is documented in their files, in the areas for training included in the Long Term Care
                Options Program Respite Standards.

         4.     SERVICE REPORTING: I will comply with all reporting requirements as specified by
                the AAA.

         5.     SCHEDULING: I understand that the specific days and times for which service is
                scheduled shall be in conformance with the consumer’s needs.

         6.     INSURANCE: I agree to carry, verified by a current certificate of coverage in the amounts
                specified by PCA.

         7.     CONFIDENTIALITY - RESEARCH PROTOCOLS: I will comply with all federal,
                state and local laws relating to research on human subjects; and all federal, state and local
                laws, and agreements with AAA’s, regarding consumer confidentiality. I agree and warrant
                that any research in which consumers receiving services under the LTC program will be
                asked to participate, shall have been reviewed and approved by a Department of Health and
                Human Services (DHHS) or Federal Drug Administration (FDA) approved Institutional
                Review Board (IRB), unless exempt from IRB review. I will inform the appropriate (PDA,
                MA and AAA) staff of research involving said consumers and will provide all appropriate
                parties with copies of IRB approvals and consent forms. I, upon request, will provide all
                parties with any additional information and copies of research protocols.




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PROVIDER NAME:_______________________________________________________

PROVIDER ADDRESS: ___________________________________________________

CITY, STATE AND ZIP CODE:______________________________________________

                                                       ______________________
 (Signature of Authorized Representative)                          (Date)




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18.      COMPANION SERVICES: PROVIDER AFFIRMATION

I, the undersigned, affirm that:

         1.     STANDARDS: I will comply with all the requirements stated in the Long Term Care
                (LTC) Program Companion Services Standards and Service Specific Operational Procedures
                (SSOP).

         2.     STAFF QUALIFICATIONS: I will assure that all consumer staff will be used who have
                received an annual PPD test that is documented in their files, along with other verification of
                compliance with federal, state and local health requirements related to communicable
                disease. I will follow procedures recommended in the Center for Disease Control (CDC)
                Guidelines and OSHA regulations, including provision of protective articles to staff.

                I will assure that a criminal history record check for compliance with Act 169 will be
                completed on all staff servicing PCA consumers.

         3.     TRAINING: All Companions serving LTC consumers will demonstrate competency in the
                skill areas included in the LTC Program Companion Standards.

         4.     SERVICE REPORTING: I will comply with all reporting requirements as specified by the
                AAA.

         5.     SCHEDULING: I understand that the specific days and times for which service is
                scheduled shall be in conformance with the consumer’s needs.

         6.     INSURANCE: I agree to carry, verified by a current certificate of coverage the amounts
                specified by PCA.

         7.     CONFIDENTIALITY - RESEARCH PROTOCOLS: I will comply with all federal,
                state and local laws relating to research on human subjects; and all federal, state and local
                laws, and agreements with AAA’s, regarding consumer confidentiality. I agree and warrant
                that any research in which consumers receiving services under the LTC program will be
                asked to participate, shall have been reviewed and approved by a Department of Health and
                Human Services (DHHS) or Federal Drug Administration (FDA) approved Institutional
                Review Board (IRB), unless exempt from IRB review. I will inform the appropriate (PDA,
                MA and AAA) staff of research involving said consumers and will provide all appropriate
                parties with copies of IRB approvals and consent forms. I, upon request, will provide all
                parties with any additional information and copies of research protocols.

PROVIDER NAME: _________________________________________________

PROVIDER ADDRESS:______________________________________________

CITY, STATE AND ZIP CODE: ________________________________________

                                                                     _______________
 (Signature of Authorized Representative)                                  (Date)


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19.      PERSONAL CARE, RESPITE, COMPANION, GENERAL HOME SUPPORT:
         PRICE CERTIFICATION FORM

Provider Name: ___________________________                 County: ____________________


                                       REIMBURSEMENT RATES
                                        CUSTOMARY
                                        AND USUAL     RATE ESTABLISHED                 AVE. HOURLY
PROCEDURE CODE                          CHARGE,       FOR LTC PROGRAM                  RATE PAID TO
                                        YEAR:                                          WORKERS

PERSONAL CARE
(unit = ¼ hour) W1700         PERS                                    3.94

RESPITE CARE – 24 HOURS
( unit = 24 hours of service)                                        222.66
                   W1703      WRSD
COMPANION SERVICE
(unit = ¼ hour) W1723         COMP                                    2.47

ESCORT OF CONSUMER TO
COMPLETE CHORES (ERRANDS) OR
 APPOINTMENT                                                          3.94
(unit = ¼ hr) W1729   WEMV

HOUSEKEEPING & HOME MGT
(unit = ¼ hour) W1729 CHHK                                            3.94

                                                           North
                                     South     West       Central        Northwest       Northeast

  Service Areas Requested

I understand the rates above will be used to determine the actual reimbursement rate for the provider
named herein for both LTC funding sources, subject to the price ceiling for each Procedure Code. I affirm
the price information provided above is true, correct, and complete to the best of my knowledge. I
Understand The Rate Requested From The LTC Program May Not Exceed My Customary And
Usual Rate.

                                                                          ________________
Signature of Authorized Representative                     Title                      Date




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20.      PERSONAL CARE SERVICE PROFILE

As an adjunct to the enclosed Price Certification Form, the following statistical data is being
requested for informational purposes.

It is expected that data presented will relate to Personal Care Service only. If you are a Medicare
Certified Home Health Agency, you may include information for comparable Home Health Aide
services, but not OT, PT, Nursing, etc.

APPLICANT                                                               YEAR:_____________________

I.       Agency Status

         A.       Are you a Medicare Certified Home Health Agency?

                   Yes         No

         B.       Are you applying for, or intending to obtain Medicare Certification?

                   Yes         No

         C.       Information presented below relates to: (check one)

                   Personal Care Service only
                   Personal Care/Home Health Aide Service

II.      Agency Information

         A. Training

              Do you currently have the following:
              Certificate Training       Yes           No               If yes, hrs./mo. ______
              In-Service Training        Yes           No               If yes, hrs./mo. ______
              Orientation                Yes           No               If yes, hrs./mo. ______




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B. Personal Care Service Level Last Calendar Year: ___________

      1. Average number of consumers served on a weekly basis: _____________
      2. Average number of hours delivered on a weekly basis: _____________
      3. Total number of hours delivered last year: ______________
C. Personal Care Workers

      1. Number of personal care/home health aides employed:


Length of Employment       # of Personal Care        # of Home Health            # of Field
                                Workers                    Aides                Supervisors

24 months & longer

12 through 23 months

6 through 11 months

Less than 6 months

Total number

      2.   How many personal care/home health aides currently employed, meet the training
           requirements detailed in the standards?                        ___________

      3.   What is your current starting salary for personal care workers       $___________

      4.   What is the current average salary paid to these workers?            $___________

      5.   If awarded a contract at the price requested, what would your starting salary be for personal
           care workers assigned to PCA cases?                  $___________

      6.   Number of hours per week worked by personal care workers/home health aides and field
           supervisors:

  Hours Per
    Week         Under 9        10-19        20-29         30-39            40-49       50+
# of Personal
  Care/HH
    Aides
  # of Field
    Staff




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21.      PERSONAL ASSISTANCE SERVICE (PAS): PROVIDER AFFIRMATION

I, the undersigned, affirm that:

         1.     STANDARDS: I will comply with all the requirements stated in the Long Term Care
                Options (LTCO) Program Personal Assistance Service (PAS) standards.

         2.     STAFF QUALIFICATIONS: I will comply with federal, state, and local health
                requirements related to communicable disease and to follow procedures recommended in the
                Center for Disease Control (CDC) Guidelines and OSHA regulations, including provision of
                protective articles to staff and in-service on universal precautions.

                I will assure that a criminal history record check for compliance with Act 169 will be
                completed on all staff servicing PCA consumers.

         3.     TRAINING: All personal care workers serving LTCO consumers will demonstrate
                competency in the skill areas included in the LTCO Program Personal Assistance Service
                Standards. Observation of competency will be documented in each personal assistance
                worker’s personnel file.

         4.     SERVICE REPORTING: I will comply with all reporting requirements as specified by the
                AAA.

         5.     SCHEDULING: I understand that the specific days and times for which service is
                scheduled shall be in conformance with the consumer’s needs.

         6.     INSURANCE: I agree to carry, verified by a current certificate of coverage in the amounts
                specified by PCA.

         7.     CONFIDENTIALITY - RESEARCH PROTOCOLS: I will comply with all federal, state
                and local laws relating to research on human subjects, as well as all federal, state and local
                laws and agreements with AAA’s regarding consumer confidentiality. I agree and warrant
                that any research in which consumers receiving services under the LTCO program will be
                asked to participate shall have been reviewed and approved by a Department of Health and
                Human Services (DHHS) or Federal Drug Administration (FDA) approved Institutional
                Review Board (IRB), unless exempt from IRB review. I will inform the appropriate (PDA,
                MA and AAA) staff of research involving said consumers and will provide all appropriate
                parties with copies of IRB approvals and consent forms. I, upon request, will provide all
                parties with any additional information and copies of research protocols.

PROVIDER NAME:_____________________________________________________


PROVIDER ADDRESS: _________________________________________________


CITY, STATE AND ZIP CODE: __________________________________________



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22.      PERSONAL ASSISTANCE SERVICE (PAS): PRICE CERTIFICATION FORM


Provider Name: ______________________________________ County: _______________________


                                          REIMBURSEMENT RATES

               PROCEDURE CODE                        PAS ( +Attendant Care)           AVE. HOURLY RATE
                                                     FEE SCHEDULE,                    PAID TO WORKERS
                                                     EFFECTIVE 7/1/08:


                                                                 3.91
  Combination Model – (unit = ¼ hour)
  W1792           PACO
                                                                (15.64)

                                                                 4.71
  Agency Directed Model – (unit = ¼ hour)
  W1793            PAAO
                                                                (18.84)

  Monthly Coordination Fee                                      154.26
  (unit = 1 month ) , for Combination Model only
  W7341                 PAMC




                                                                 North
                                    South          West         Central          Northwest          Northeast

  Service Areas

I understand the rates above will be used to determine the actual reimbursement rate for the provider named herein
for both LTC funding sources, subject to the price ceiling for each Procedure Code. I affirm the price information
provided above is true, correct, and complete to the best of my knowledge.

                               __                         ________________             ____________
Signature of Authorized Representative                          Title                      Date




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23.      PERSONAL ASSISTANCE SERVICE (PAS) PROFILE

As an adjunct to the enclosed Price Certification Form, the following statistical data is being
requested for informational purposes.

It is expected that data presented will relate to Personal Assistance Service.

APPLICANT                                                              FISCAL YEAR ________


I. Agency Status

  A.       Are you a Medicare Certified Home Health Agency?

                 Yes           No

  B.       Are you applying for, or intending to obtain Medicare Certification?

                 Yes           No

  C.       Information presented below relates to:     (check one)

                 Personal Assistance Service
                 Attendant Care

II. Agency Information

  A. Training

           Do you currently have the following:
           Certificate Training Yes             No             If yes, hrs./mo.
           In-Service Training Yes              No             If yes, hrs./mo.
           Orientation          Yes             No             If yes, hrs./mo.


  B. Personal Assistance Service Level; last calendar year: _________

           1.     Average number of consumers served on a weekly basis:           ______
           2.     Average number of hours delivered on a weekly basis:            ______
           3.     Total number of hours delivered last year:                      ______




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C. Personal Assistance Service Workers

        1. Number of attendant care / personal assistance attendants:


Length of providing service        # Attendants           # of Field Supervisors

24 months & longer

12 through 23 months

6 through 11 months

Less than 6 months

Total number


        2.       What is your current starting salary for attendants?       _________

        3.       What is the current average salary paid to these workers?         __________

        4.       Number of hours per week worked by personal assistance workers and field supervisors:


Hours Per Week         Under 9      10-19         20-29            30-39           40-49        50+

  # Attendants


   # of Field
  Supervisors




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24.      RESPITE/TEMPORARY SHELTER: PRICE CERTIFICATION FORM



Provider name                                           County: ________________________



                                 REIMBURSEMENT RATES

                                          MA / MEDICARE                RATE
 PROCEDURE CODE                           RATE                         ESTABLISHED FOR
                                          YEAR:                        LTC PROGRAM

 Respite/Temporary Shelter – Nursing
 Facility           S5151    WRIN
 (unit = day, all inclusive)




I understand the rates above will be used to determine the actual reimbursement rate for the provider
named herein for both LTC funding sources, subject to the price ceiling for each Procedure Code. I affirm
the price information provided above is true, correct, and complete to the best of my knowledge. I
understand the rate requested from the LTC Program may not exceed my M.A. rate and subject to
quarterly adjustments as issued by DPW.

___________________________________ ____________________                 _________________

Signature of Authorized Representative                     Title                Date




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25.       TRANSPORTATION: PROVIDER AFFIRMATION

I the undersigned, affirm that:

          1.      STANDARDS: I will comply with all the requirements stated in the Long Term Care (LTC)
                  Program Transportation Standards and Service Specific Operational Procedures (SSOP).

          2.      STAFF QUALIFICATIONS: I will assure that all consumer contact staff receives an
                  annual PPD test and that documents of the results are maintained in their files along with
                  other verification of compliance with the Federal, state and local health requirements related
                  to communicable disease. I will follow procedures recommended in the Center for Disease
                  Control (CDC) Guidelines and OSHA regulations, including provision of protective articles
                  to staff.

                  I will assure that a criminal history record check for compliance with Act 169 will be
                  completed on all staff servicing PCA consumers.

          3.      TRAINING: All transportation workers serving LTC consumers will demonstrate
                  competency in the skill areas included in the LTC Program Transportation Standards,
                  documented in each worker’s personnel file.

          4.      SERVICE REPORTING: I will comply with all reporting requirements as specified by the
                  AAA..

          5.      SCHEDULING: I understand that the specific days and times for which service is scheduled
                  shall be in conformance with the consumer’s needs.

          6.      INSURANCE: I agree to carry, verified by a current certificate of coverage in the amounts
                  specified by PCA

          7.      CONFIDENTIALITY: I will comply with all federal, state and local laws relating to
                  research on human subjects; and all federal, state and local laws and agreements with AAA’s,
                  regarding consumer confidentiality. I agree and warrant that any research in which
                  consumers receiving services under the LTC program will be asked to participate, shall have
                  been reviewed and approved by a Department of Health and Human Services (DHHS) or
                  Federal Drug Administration (FDA) approved Institutional Review Board (IRB) unless
                  exempt from IRB review. I will inform the appropriate ( PDA, MA and AAA) staff of
                  research involving said consumers and will provide all appropriate parties with copies of IRB
                  approvals and consent forms. I, upon request, will provide all parties with any additional
                  information and copies of research protocols.




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PROVIDER NAME: _____________________________________________________

PROVIDER ADDRESS:____________________________________________________

CITY, STATE AND ZIP CODE:______________________________________________

                                                                      ______________
  (Signature of Authorized Representative)                              (Date)




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  26.      TRANSPORTATION: PRICE CERTIFICATION FORM


Provider Name:                                             County:     _______________________________



                                       REIMBURSEMENT RATES

                                         CUSTOMARY AND                   RATE ESTABLISHED FOR
 PROCEDURE CODE                          USUAL CHARGE,                   LTC PROGRAM
                                         YEAR:

 AMBULANCE – non emergency
 service, not covered by Medicare or
 MA (unit = one way ride)                                                            120.00
 W1712                     WTRA




                              South        West      North Central       Northwest       Northeast

Service Areas Requested

   I understand the rates above will be used to determine the actual reimbursement rate for the provider
   named herein for both LTC funding sources, subject to the price ceiling for each Procedure Code. I
   affirm the price information provided above is true, correct, and complete to the best of my knowledge. I
   Understand The Rate Requested From The LTC Program May Not Exceed My Customary And
   Usual Rate.

    ________________________________                      ______________            ___________

  Signature of Authorized Representative                      Title                        Date




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   27.      PERSONAL EMERGENCY RESPONSE: PROVIDER AFFIRMATION

I, the undersigned, affirm that:

            1.     STANDARDS: I will comply with all the requirements stated in the Long Term Care
                   (LTC) Program Personal Emergency Response Standards and Service Specific
                   Operational Procedures (SSOP).

            2.     STAFF QUALIFICATIONS: I will assure that all consumer contact staff receives an
                   annual PPD test and that documents of the results are maintained in their files along with
                   other verification of compliance with the Federal, state and local health requirements
                   related to communicable disease. I will follow procedures recommended in the Center for
                   Disease Control (CDC) Guidelines and OSHA regulations, including provision of
                   protective articles to staff.

                   I will assure that a criminal history record check for compliance with Act 169 will be
                   completed on all staff servicing PCA consumers.

            3.     SERVICE REPORTING: I will comply with all reporting requirements as specified by
                   the AAA.

            4.     TRAINING: All employees will demonstrate competency in the skill areas included in
                   the LTC Program Personal Emergency Response Systems Standards, documented in each
                   worker’s personnel file.

            5.     SCHEDULING: I understand that the installation and removal of equipment shall be in
                   conformance with the consumer’s needs.

            6.     INSURANCE: I agree to carry, verified by a current certificate of coverage in the
                   amounts specified by PCA

            7.     CONFIDENTIALITY- RESEARCH PROTOCOLS: I will comply with all federal,
                   state and local laws relating to research on human subjects; and all federal, state and local
                   laws and agreements with AAA’s, regarding consumer confidentiality. I agree and
                   warrant that any research in which consumers receiving services under the LTC program
                   will be asked to participate, shall have been reviewed and approved by a Department of
                   Health and Human Services (DHHS) or Federal Drug Administration (FDA) approved
                   Institutional Review Board (IRB) unless exempt from IRB review. I will inform the
                   appropriate (PDA, MA and AAA) staff of research involving said consumers and will
                   provide all appropriate parties with copies of IRB approvals and consent forms. I, upon
                   request, will provide all parties with any additional information and copies of research
                   protocols.




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PROVIDER NAME:___________________________________________________

PROVIDER ADDRESS:_______________________________________________

CITY, STATE AND ZIP CODE: _________________________________________

                                                             ___________
 (Signature of Authorized Representative)                         (Date)




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28.        PERSONAL EMERGENCY RESPONSE SYSTEM: PRICE CERTIFICATION FORM


   Provider Name: _____________________________________County: ________________________

                                                 REIMBURSEMENT RATES
                                                         CUSTOMARY AND                     ESTABLISHED RATE
                                                         USUAL CHARGE.                     FOR LTC PROGRAM
      PROCEDURE CODE                                     YEAR:
      Personal Emergency Response System; monthly
      monitoring , inclusive of installation and
      repair/replacement cost (unit = monthly fee)

      W1720                            MEMN                                                           30.00




                                                South       West       North Central     Northwest       Northeast

      Service Areas Requested

I understand the rates above will be used to determine the actual reimbursement rate for the provider named herein for
both LTC funding sources, subject to the price ceiling for each Procedure Code. I affirm the price information
provided above is true, correct, and complete to the best of my knowledge. I Understand The Rate Requested From
The LTC Program May Not Exceed My Customary And Usual Rate.

__________________________________                          _________________               ____________
Signature of Authorized Representative                       Title                          Date




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29.        HEALTH STATUS MEASURING AND MONITORING SERVICE:
           PRICE CERTIFICATION FORM


   Provider Name: _____________________________________County: ________________________

                                               REIMBURSEMENT RATES
                                                       CUSTOMARY AND                       ESTABLISHED RATE
                                                       USUAL CHARGE.                       OR MA FEE
      PROCEDURE CODE                                   YEAR:                               SCHEDULE RATE

      Specialized supplies/Health Monitoring equipment
      – not listed on MA fee schedule or in excess of
      state plan limits; (unit = one purchase)
      T2028- GT                      SUHM
      Specialized DME/Health Monitoring equipment –
      not listed on MA fee schedule or in excess of
      state plan limit; (unit = one purchase)
      T2029-GT                       DMHM
      Health Status Measuring and Monitoring of chronic
      conditions; includes equipment installation,
      training, monthly consumer visit, and any other
      contacts. Home Health providers only.
      (unit = 1/day)                                                                                  10.00
      T2025-GT                       HSMM
      Medication Dispenser Monthly Fee, inclusive of
      installation and repair/replacement cost
       (unit = monthly fee)
       S5185 -32                           WMRP                                                       50.00
      Medication Set-Up – by a Pharmacist, for
      consumers not receiving any skilled services. (unit=
      monthly fee)                                                                                    50.00
      S5185                                MEST

                                                 South       West      North Central     Northwest       Northeast

      Service Areas Requested

I understand the rates above will be used to determine the actual reimbursement rate for the provider named herein for
both LTC funding sources, subject to the price ceiling for each Procedure Code. I affirm the price information
provided above is true, correct, and complete to the best of my knowledge. I Understand The Rate Requested From
The LTC Program May Not Exceed My Customary And Usual Rate.

__________________________________                           _________________              ____________
Signature of Authorized Representative                        Title                         Date




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30.        ACTIVITY AND SENSOR MONITORING: PRICE CERTIFICATION FORM


   Provider Name: _____________________________________County: ________________________

                                              REIMBURSEMENT RATES
                                                      CUSTOMARY AND                        RATE ESTABLISHED
                                                      USUAL CHARGE.                        FOR LTC PROGRAM
      PROCEDURE CODE                                  YEAR:
      Activity and Sensor Monitor – installation
      (unit = one time fee)
      W2025                    ASMO                                                                  200.00
      Monthly Monitoring of Activity Sensor equipment
      (unit = monthly fee)
      W9006                   MDMS                                                                    79.95




                                                   South    West       North Central     Northwest       Northeast

      Service Areas Requested

I understand the rates above will be used to determine the actual reimbursement rate for the provider named herein for
both LTC funding sources, subject to the price ceiling for each Procedure Code. I affirm the price information
provided above is true, correct, and complete to the best of my knowledge. I Understand The Rate Requested From
The LTC Program May Not Exceed My Customary And Usual Rate.

__________________________________                          _________________               ____________
Signature of Authorized Representative                       Title                          Date




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31.      DME - HEARING AIDS: PRICE CERTIFICATION FORM


Provider name                                            County: ________________________


                                     REIMBURSEMENT RATES
 PROCEDURE CODE                         CUSTOMARY AND
                                        USUAL CHARGE,                     RATE REQUESTED FROM
                                        YEAR:                             LTC PROGRAM
 Hearing Aid/Behind the ear unit
 (unit = 1 )
  T2029                       ORBE
 Hearing Aid/In the ear unit
 (unit = 1)
  T2029                        ORIE
 Hearing Aid/Canal ear unit
 (unit = 1)
 T2029                        ORCE
 Hearing Aid, Digital, Monaural, CIC,
 ITC, ITE, BTE (unit = 1)
 T2029                        GRDM
 Hearing Aid, Digital, Binaural, CIC,
 ITC, ITE, BTE (unit = 2)
 T2029                        GRDB
 Hearing Aid/ Service or repair of
 unit(unit = variable cost)
  T2029                        ORSR

                                         South       West           North Central   Northwest     Northeast

 Service Areas Requested

I understand the rates above will be used to determine the actual reimbursement rate for the provider
named herein for both LTC funding sources, subject to the price ceiling for each Procedure Code. I affirm
the price information provided above is true, correct, and complete to the best of my knowledge. I
Understand The Rate Requested From The LTC Program May Not Exceed My Customary And
Usual Rate.

_________________________________           ____________________            ____________________

Signature of Authorized Representative                      Title                          Date




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32.      DME – STAIR ELEVATOR: PRICE CERTIFICATION FORM



Provider Name:                                             County: ____________________

                                 REIMBURSEMENT RATES

                                           USUAL AND                   RATE REQUESTED
 SERVICE DESCRIPTION                       CUSTOMARY RATE;             FROM LTC
 (Procedure code)                          YEAR:                       PROGRAM

 Installation – all models
 W1758              SROC
 Front Rider – monthly rent
 T2029              WFRR
 Front Rider – daily rental
 T2029
 Side Rider – fixed seat – monthly rent
 T2029               WFRR
 Side Rider – fixed seat – daily rent
 T2029
 Side Rider – swivel seat – monthly rent
 T2029               WFRR
 Side Rider – swivel seat – daily rent
 T2029
 Repairs – hourly rate
 T2029               RPAR




I understand the rates above will be used to determine the actual reimbursement rate for the provider
named herein for both LTC funding sources, subject to the price ceiling for each Procedure Code. I affirm
the price information provided above is true, correct, and complete to the best of my knowledge.
 __________________________________ ________________________                        ______________
Signature of Authorized Representative                Title                         Date




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33.      VISION SERVICES: PRICE CERTIFICATION FORM


Provider name:________________________________________ County: _________________________

                                      REIMBURSEMENT RATES
                                                                           CUSTOMARY
                                                                                              RATE
                                    MEDICARE           MA RATE:            AND USUAL
                                                                                              REQUESTED
 PROCEDURE CODE                     RATE: _____        YEAR: ______        CHARGE
                                                                                              FROM LTC
                                    YEAR: _____                            YEAR: ____
                                                                                              PROGRAM


 VISION SCREEN
 (unit = visit) HEYN

 REFRACTION
 (unit = visit)       REFR


 GLASSES
 (unit = visit)       WEGL

 CO-PAY NOT COVERED
 (unit = visit) COPY

 MEDICARE DEDUCTIBLE
 NOT MET
 (unit = visit) DEDT

 XACT MEDICARE
 (unit = visit) HEYM

                                     South        West            North Central   Northwest    Northeast

 Service Areas Requested


I understand the rates above will be used to determine the actual reimbursement rate for the provider named herein for
both LTC funding sources, subject to the price ceiling for each Procedure Code. I affirm the price information
provided above is true, correct, and complete to the best of my knowledge. I Understand The Rate Requested
From The LTC Program May Not Exceed My Customary And Usual Rate.


                                                                                   _________
Signature of Authorized Representative                    Title                      Date




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                                    SECTION VI.



                                 ATTACHMENTS




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A.       Procedure codes for Aging Waiver:


B.       DME Supply List:


C.       Sample Insurance Certificate:


D.       Adult Day Care Congregate Meal Requirements:




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