Extended Personal Care Service 525-05-30-27

(Revised 07/01/2024 ML #3847)

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Legal Authority

N.D. Admin. Code 54-05-01

N.D. Admin. Code 54-05-02

Purpose

The purpose of Extended Personal Care Services (EPCS) is to complete tasks that are medical in nature and specific to the needs of an eligible individual. Approval to complete these tasks is provided by the Nurse Educator who has provided training to the EPCS Provider and is enrolled with the Department to provide Nurse Education. Or, if a necessary medical task is too complex to be taught to an unlicensed provider the nurse may provide the service directly to the individual. Services that must be provided by a licensed nurse include but are not limited to nurse assessments, care planning, care coordination, training, periodic review of individual's care needs, medication set up, foot care, feeding tubes, changing, and flushing catheters, bowel programs that include manual removal of waste and bowel stimulation, or the provision of direct care that is too complicated to delegate to an extended personal care provider.

Per NDAC 54-05-01 and 54-05-02: The initial or comprehensive nursing assessment shall be completed and implemented by an RN. The RN will develop a nursing plan of care based on the assessment and medical diagnoses and can provide education on nursing interventions for which the QSP has the necessary skills and competence to accomplish safely.

Approval of the Nursing Plan of Care is required by the R.N. Program Administrator, before implementing the service.

This service may include nursing care to the extent permitted by state law under NDCC 43-12.1 and NDAC 54-05, which will maintain the health and well-being of the individual and allow the individual to remain in the community. EPCS are services that an individual without a functional disability would customarily and personally perform without the assistance of a licensed health care provider, such as administration of medications, or wound care.

Service Eligibility, Criteria for:

The individual receiving EPCS must be:

1. Eligible for the Medicaid Waiver for Home and Community Based Services or Service Payments to the Elderly & Disabled.
2. Competent to participate in the education of the Extended Personal Care Service Provider by the Nurse Educator or have a legally responsible representative directly participate in the process.
3. The need for EPCS is limited to individuals who have a cognitive or physical impairment that prevents them from performing extended personal care service activities.
4. Requires skilled or nursing care that requires training by a nurse licensed under NDCC 43-12.1.
5. Have an informal caregiver support system to provide contingency (backup) care in case of the absence of EPCS providers.
6. Be competent to actively participate in the development and monitoring of their individual care plan or have a legally responsible party available to participate.

Service Location

Services will be administered in the most integrated setting consistent with the Person-Centered Plan of Care, including (checked if allowable):

üThe individual's home

ü Workplace

ü Other community service settings

Authorization for Service

1. The initial Request for Extended Personal Care Services (written request by the HCBS Case Manager), Individual Care Plan, Authorization to Provide Services, and Nursing Plan of Care (NPOC) (including documentation of education provided for tasks, monitoring plan, and instructions for incident reporting) must be pre-approved by the Extended Personal Care Service (EPCS) RN Program Administrator, Adult & Aging Services Section. The HCBS case manager is responsible to submit/upload the completed documents to the electronic record.
   
   
2. The Authorization and NPOC must be updated and reviewed at the six-month level by the Extended Personal Care Service (EPCS) RN Program Administrator, Adult & Aging Services Section. The HCBS case manager is responsible for uploading the completed documents to the electronic record for review and approval by Adult & Aging Services/HCBS. The NPOC must be approved by the Extended Personal Care Service (EPCS) RN Program Administrator before pre-authorizations are entered to provide Extended Personal Care Nurse (S5115-TD) or Extended Personal Care (S5115) into the electronic record.
   
   
3. The Individual Care Plan, Authorization, and NPOC must be completed and reviewed every six months by the Extended Personal Care Service (EPCS)Program Administrator, Adult & Aging Services Section. The HCBS case manager is responsible to submit/upload the completed documents to the electronic record.

Service Delivery

EPCS and Nurse Education are provided in accordance with the nursing plan of care (NPOC), developed by the individual and the RN Nurse Educator, to meet the identified needs of the individual. The Case Manager is responsible to complete the Individual Care Plan and Authorization taking into consideration the needs identified in the NPOC.

The EPCS individual or their legally responsible person is required to identify and oversee their EPCS providers. The individual, with the assistance of the HCBS Case Manager, must develop a contingency plan to assure health, welfare, and safety in the event the individual’s care needs change or providers are not available.

The RN Nurse Educator must complete and send the following forms to the HCBS Case Manager

1. Nursing Plan of Care (SFN 807)

• Completed by RN, initially, and every 6-months while services are in place.

• Comprehensive assessment must be completed face-to-face with the individual by the RN.

• Billing service code

• POC and Nurse Educator training: S5108.

• Nurse completing the medical task: S5115-TD.

• Non-nurse QSP completing medical task: S5115

2. Extended Personal Care Services (EPCS) Provider Training Procedure Agreement (SFN 576) completed by all trained staff and RN Nurse Educator.

3. If the Nurse Educator is training staff, use NE code S5108 for the training time only.

4. Update NPOC if there are changes in the individual’s instructions before the 6-month assessment is due. RN Nurse Educator must send updated NPOC to HCBS Case Manager for EPCS RN Program Administrator approval.

The HCBS Case Manager will upload all forms into the electronic record for the EPCS RN Program Administrator’s review.

NPOCs will not be approved until all forms are received accurate and signed by the RN Nurse Educator, if applicable.

Incidents

The Nurse Educator provides written documentation to the Department that shows he or she has provided instructions to the EPCS Provider that outlines the types of situations that are considered reportable incidents, and instructions on who should be contacted, and this may include contacting the individual’s primary health care provider for instruction and then contacting the HCBS Case Manager. If the HCBS Case Manager and Nurse Educator determine that the incident is indicative of abuse, neglect, or exploitation, the HCBS Case Manager must immediately report the incident to the Department. The Case Manager must also follow the policy found in HCBS Case Management 525-05-30-05, Monitoring for Abuse, Neglect, or Exploitation. The incident plan needs to be updated on an annual basis and a copy provided to the Extended Personal Care Service (EPCS) Program Administrator.

Limits

1. Units for routine assessments for the health and welfare of the individual, incident reporting, assistance with activities of daily living (ADLs) and instrumental activities of daily living are not part of this service.
2. Due to the complexity of the care provided to individuals receiving Extended Personal Care Services, contingency plans are required as a prerequisite to receive this service to assure that health welfare and safety are maintained if a provider is unavailable to provide the service.  
3. The Nursing Plan of Care (NPOC) assessments must be done face to face to assure the health, welfare, and safety needs of the individual are met.
4. Vital signs may only be authorized under EPCS if a written order from an outside agency medical practitioner is obtained with the frequency and parameters listed. The HCBS Case Manager must keep a current order for vital signs in the electronic record.
5. Authorized EPCS approvals are nontransferable between QSP Agencies or individual QSPs.
6. Virtual Supports Option may only be utilized after approval from a EPCS RN Program Administrator. The EPCS RN Program Administrator will document approval.

Providers

Extended Personal Care Services may be provided by the following individual QSP or employees of a QSP agency (checked if allowable):

□ Guardian

ü Legally Responsible Person - Legal spouse or parent of a minor child.

üRelative within the definition of Family Home Care under subsection 4 of N.D.C.C. 50-06.2-02.

Per NDAC 54-05-01 and 54-05-02: The initial or comprehensive nursing assessment shall be completed and implemented by an RN.

1. The RN will develop a nursing plan of care based on the assessment and diagnoses .

2. The RN provides education on nursing interventions that the QSP Provider has the necessary skills and competence to accomplish safely.

The LPN can:

1. Participate in the development, evaluation, and modification of the nursing plan of care.

2. Conduct a focused nursing assessment and contribute that information to the nursing plan of care.

3. Provide education on nursing interventions for which that QSP provider has the necessary skills and competence to accomplish safely. The NPOC must be signed by an RN.

Service Activities, Authorized and Limits

1. Documentation outlining the tasks the nurse has trained the Extended Personal Care Service Provider on are maintained by the Nurse and a copy is sent to the HCBS Case Manager. A copy of the training documentation form is also given to the trained Extended Personal Care Provider listing the tasks to be completed. The Case Manager notes the units authorized by the EPCS Program Administrator.
2. If a necessary medical task is too complex to be taught to an unlicensed provider, the nurse may be paid to provide the service directly to the individual. Services provided by a licensed nurse include but are not limited to nurse assessments, care planning, training, periodic review of individual care needs, care coordination, medication set up, foot care, feeding tubes, changing, and flushing catheters, bowel programs that include manual removal of waste and bowel stimulation, or the provision of direct care that is too complicated to delegate to an extended personal care provider.
3. The nurse educator will provide at a minimum, a review of the individual’s needs every six months to determine if additional training and or tasks are required.
4. If the nurse educator fails to provide six-month NPOC service documents the HCBS Case Manager and EPCS Nurse Program Administrator will re-educate the EPCS nurse educator. If the documents are not provided to the Department after re-education has been provided to the Nurse Educator, a Qualified Service Provider (QSP) complaint will be filed with the QSP Complaints Program Administrator.
5. Nurse education service may be provided remotely through virtual supports as determined necessary to ensure services are delivered while considering participant choice, compliance with CMS requirements and identified in the participant's person-centered plan.

   If the participant requires hands on assistance for a specific task, then virtual supports service delivery cannot be an option for that task but may be utilized for other tasks that do not need hands on support.

    

   Examples of when Nurse Education, virtual supports MAY be used:

   • Toenail Care

   • Vitals when ordered by a physician

   • Bowel program

   • Compression Wraps

   • Nebulizers

   • Topical prescriptions

      

   Examples of when Nurse Education, virtual supports may NOT be used:

   • Medication Set-up – Required by the Nurse

   • Tubes, wounds and suctioning tasks

   • Lab work

   • Colostomy Care

   • Injections

      

   Requirements for utilizations of Nurse Education – Virtual Supports

   • Virtual Supports require the initial NPOC has been completed in person with the provider, individual and other team members during the person-centered planning process.

     1. The NPOC will ensure that the planning process has considered service needs and if these needs can be met by using a virtual supports method of service delivery.

     2. The NPOC includes a Virtual Support Checklist will be required to be completed by the Nurse Educator and the team during the person-centered planning process.

     3. This checklist will act as a safeguard to ensure virtual supports can help meet the needs of the participant in a way that protects the right to privacy, dignity, respect, and freedom from coercion.

     4. Any issues will be addressed prior to the implementation of remote supports. The checklist will ensure that the planning process has considered service needs and if these needs can be met by using a virtual supports method of service delivery.

     5. The Virtual Support Checklist will include consideration of the estimated hours/visits that virtual supports delivery will be utilized.

   • The risk assessment and service plan require the team to develop a plan to address health, safety, and behavioral needs while remote supports are utilized so appropriate assistance can be provided.

   • In virtual supports, the use of cameras in bathrooms or bedrooms impacting the participant’s dignity and privacy is not permitted.

   • Virtual supports reinforce community integration by encouraging the participant to engage in community life as independently as possible and to be able to safely engage in activities in his or her home or in the community without relying on the physical presence of staff to accomplish those activities.

   • The participant’s services may not be delivered via virtual support 100% of the time.

   • The participant must always have the option to request in-person services. The amount of time chosen shall be determined during the person-centered planning process and outlined in the Individual Program Plan (IPP).

   • Provider must use a HIPAA compliant service delivery method (e.g. Microsoft Teams, Zoom for Healthcare). HIPAA rules apply to all covered entities regarding HIPAA Privacy and Security.

   • Participant will be given education and support on the use of virtual supports by their chosen provider. Virtual supports are not a system to provide surveillance or for staff convenience.