Revised_SOW.pdf

Scope of Work

Contract No.: CTR048044

Description: Area Agencies on Aging (AAA)

1.0 ADES MISSION AND VISION STATEMENT

1.1 ADES Mission – The Arizona Department of Economic Security makes Arizona stronger by helping Arizonans reach their potential through temporary assistance for those in need, and care for the vulnerable.

1.2 ADES Vision – All Arizonans who qualify receive timely ADES services and achieve their potential.

2.0 PURPOSE

2.1 Purpose Statement – The purpose of this contract is to enable a designated Area Agency on Aging to develop, establish and maintain within their geographic planning and service area (PSA) a comprehensive and coordinated service delivery system that supports services and programs which include non-medical home and community-based programs, disease prevention and health promotion, coordination-elder refugees services, family caregiver supports, legal assistance, long-term care ombudsman, mature workers, state health insurance assistance program, and the senior Medicare patrol.

2.2 Legal Authority – Arizona Revised Statute (A.R.S.) §41-1954 (A) (6) and A.R.S. §41- 2501, Q. provides

ADES the authority to enter into contracts and incur obligations within the general scope of its activities and operations subject to the availability of funds.

2.2.1 The Older Americans Act of 1965, as amended, created the National Aging Network comprising the Administration for Community Living (ACL) on the federal level, State Units on Aging (SUA), and Area Agencies on Aging at the local level. Through this federal legislation, ADES provides services to vulnerable and older individuals living in Arizona.

2.2.2 The Non-Medical Home and Community Based Services System (NMHCBS) is designed to establish the necessary support services to retain functionally impaired individuals within their community and avoid premature institutionalization. The NMHCBS are intended to be client-centered and flexible. Service clusters allow for flexible care management based on the current needs of clients.

2.2.3 There are two service clusters within the Division of Aging and Adult Services (DAAS), and these are as follows:

1. The Home Care cluster consists of housekeeping, personal care, home health aide, home nursing, and attendant care, as may be amended.

2. The Family Caregiver Support Program cluster consists of outreach, information and referral, community education and information, case management, supportive intervention/guidance counseling, peer counseling, respite care, supplemental provisions, and general transportation, as may be amended.

3.0 FUNDING

Services may be funded through various sources including, but not limited to, the U.S. Department of Health and Human Services, Administration for Community Living (ACL) and the Office of Refugee Resettlement, U.S. Department of Labor, and Arizona State General Funds.

3.1 Non-Federal In-kind/Cash Match Requirement

3.1.1 In accordance with the Older Americans Act regulations, Title 45 Part 74 of the Code for Federal Regulations (CFR) as may be amended, and the DAAS policy as may be amended, agencies are required to provide ten percent (10%) non-federal match for all services funded under an approved Area Plan on

Aging for the cost of carrying out Older Americans Act programs. The match shall consist of non-federal cash and in-kind contributions and shall be expended for goods and services necessary for and specifically identifiable to the contract. Program income cannot be utilized to meet the match requirements. Program income is defined as “gross income earned by a recipient from activities part or all the cost of which is either borne as a direct cost by the grant or counted as a direct cost toward meeting a cost sharing or matching requirement of a grant”.

3.1.2 Contractor is required to provide ten percent (10%) of the non-federal share of the cost of carrying out a program under Family Caregiver Support Program (FCSP) in accordance with OAA Public Law 89-73, Section 373 the non-federal share shall be provided from local sources and may be met with cash or in-kind expenditures. Expenditures used to satisfy the non-federal share requirement must be related to the purpose of FCSP and may not be used to meet maintenance of effort or non-federal share requirements in other federal programs, including other sections of the Older Americans Act, Title III. Expenditures previously used to “over match” other programs may be used to satisfy the non-federal share requirement in the FCSP provided that those expenditures no longer are counted toward meeting the non-federal share requirement of such other programs and those expenditures are related to the purpose of the FCSP.

3.1.3 Non-federal in-kind/cash match requirement for Older Americans Act funding is based on the following formula:

(funds allocated) x (.10) (.90)

3.2 Definitions – See the DAAS Policy and Procedure Manual, Chapter 6000 the Aging and Adult Services

Glossary, at the following link: https://des.az.gov/services/aging-and-adult/partners/daas-policy-and-procedure-manual.

3.3 In this document, people 60 years of age or older are also referred to as “older people”, “elders”, “older adults” or “older individuals”.

4.0 PROGRAM DESCRIPTION

4.1 The DAAS is the designated SUA for Arizona. The DAAS’ mission is to ensure “Arizonans have access to systems of support that enable them to live safely, independently, and with dignity and self- determination.”

The Community Action in Aging Program Administration (CAAPA) Unit within DAAS houses a variety of programs and services to enable older persons and vulnerable adults to remain independent in their communities. Programs and services are provided through contracts with Area Agencies on Aging (AAA) that play a pivotal role in assessing community needs and developing programs that respond to those needs.

Additionally, the AAAs act as advocates for improving services for older adults, persons living with disabilities and their informal caregivers. They serve as portals to care, assessing multiple service needs, determining eligibility, authorizing, or purchasing services, and monitoring the appropriateness and cost-effectiveness of services.

5.0 ADMINISTRATIVE REQUIREMENTS - The Contractor shall:

5.1 Ensure services are linguistically appropriate and culturally responsive to the eligible populations to be served.

5.2 Comply with the DAAS Policy and Procedure Manual, Chapters 1000 – 4000 as may be amended, located at: https://des.az.gov/services/aging-and-adult/partners/daas-policy-and-procedure-manual.

5.2.1 Comply with Discretionary Grants approved by the U.S. Department of Health and Human Services

ACL, as described in the DAAS Policy and Procedure Manual Chapter 3900.

5.3 Area Plan on Aging

5.3.1 Comply with all aspects of the Area Plan on Aging requirements as outlined in DAAS Policy and

Procedure Manual Chapter 2000 as may be amended, located at https://des.az.gov/services/aging-and- adult/partners/daas-policy-and-procedure-manual.

5.3.2 Implement the Area Plan on Aging, as approved by DAAS according to the DAAS Policy and Procedure Manual, as may be amended, Chapter 2000.

5.4 Comply with the following Federal and State Requirements as may be amended:

5.4.1 Medicare Prescription Drug, Improvement and Modernization Act of 2003. (PL-180-179),

5.4.2 Consolidated Appropriations Act, 2001 (PL-106-554),

5.4.3 Title 2 CFR Part 200, Uniform Administrative Requirements Cost Principles, and Audit requirements associated with Federal Awards, as appropriate,

5.4.4 Omnibus Budget Reconciliation Act of 1981 (P.L. 97-35) including Section 2352 “Title XX Block

Grants”, 42 U.S. C. 1397 and 42 U.S.C. 1297A, D, and e; 45 CFR, Part 96; and the Arizona Title XX Social Services Plan,

5.4.5 The Older American’s Act, 42 U.S.C., Chapter 35, Sub-chapter I, Section 3002, paragraph 33,

5.4.6 The Older Americans Act of 1965, as amended 42 U.S.C. 3001 through 3035,

5.4.7 45 CFR Parts 1321 and 1326, and

5.4.8 A.R.S. §46-452-01, and §46-191-193.

5.5 Staffing and Security

5.5.1 Maintain and utilize policies and procedures that requires its employees, subcontractors, and volunteers to declare if they have a conflict of interest with the provision and or management of the services, or programs contracted.

5.5.2 Maintain and utilize policies and procedures that establish a process for documenting training, verifying the qualifications, skills, and knowledge of employees/volunteers, and retaining required training and competency records for the services and/or programs contracted.

5.5.3 Maintain documentation in employee personnel file that supports key agency staff has received the appropriate orientation, training, and maintain current appropriate certification/licensure in accordance with their job descriptions.

5.5.4 Ensure training, assistance, and technical guidance is provided to all employees responsible for using and preparing client assessment and reporting forms as required by the service and/or program contracted.

5.5.5 Comply with and ensure that all agency employees, independent contractors, subcontractors, volunteers, and other agents comply with fingerprinting, certification, and criminal background checks prior to the provision of services under this contract as required in the Special Terms and Conditions, Fingerprinting and DAAS Policy and Procedure Manual, as may be amended, Chapter 1000.

5.5.6 Comply with DAAS Policy and Procedure Manual, as may be amended, Chapter 1000 which requires that contract entities shall ensure the confidentiality of client information. Confidential information shall be maintained in locked files. If electronic records are utilized, confidential information must be secured location.

5.5.7 If applicable, require that a newly hired employee providing non-medical home and community-based services submit three references from persons other than family members in order for the Contractor to verify the employee’s previous employment record. All references shall be contacted, and results documented in the personnel record.

5.6 Database

5.6.1 Maintain and utilize policy and procedures that require backup recovery procedures for computer systems to ensure no programmatic, financial or client data is lost, and no disruption or degradation of services occurs.

5.6.2 Maintain and utilize a computer-based tracking system from which required reports and/or requested information may be generated.

5.6.3 Comply with DAAS data sharing agreement (form J119) and security requirements to include at a minimum, but not limited to staff certification and annual re-certification training as required by DSA J-119, Section II, #8.

5.6.4 Directly input client and financial data into the DAAS reporting system Division of Aging and Adult Reporting System (DAARS) in accordance with system Guides, other national databases including State Health Insurance Assistance Program (SHIP) Tracking and Reporting System (STARS), and Senior Medicare Patrol (SMP) Information and Reporting System (SIRS), or as directed by ADES.

5.6.5 Directly extract programmatic and financial reports from DAARS to monitor service delivery and financial expenditures.

5.7 Service Provision

5.7.1 Conduct at a minimum, on-site contract compliance monitoring of subcontractors at least annually, to include but not limited to facilities, administrative and financial operations, and programmatic service delivery.

5.7.2 Maintain and utilize a policy and procedure manual that includes, at a minimum, detailed intake procedures, program description and eligibility requirements, client grievance procedures, non-discrimination policy, and confidentiality requirements.

5.7.3 Maintain client-focused facility locations which offer sufficient client waiting space or waiting rooms, adequate seating, and restrooms for program applicants at all permanent facility locations indicated on the Facility Location Chart.

5.7.4 Utilize client grievance procedures which respond timely and effectively to client complaints as required in DAAS Policy and Procedure Manual Chapter 1000 and Special Terms and Conditions, Fees, and Program Income.

5.7.5 Impose no fees upon recipients for service unless the fund source permits a fee to be charged for the service. A fee policy shall have written approval by the DAAS prior to implementation. The Contractor shall comply with any restriction or stipulation set by the DAAS. Income generated from client fees shall be used exclusively to expand existing program services.

5.7.6 Participate as requested by DAAS in any state and/or national studies and evaluations.

5.8 Subcontract Related Service Provisions

5.8.1 Comply with the Special Terms and Conditions, Subcontracts, before entering into subcontracts for the provision of services under this contract.

5.8.2 Comply with DAAS Policy and Procedure Manual Chapter 1000 regarding the Documentation and reporting of all costs associated with the provision of subcontracted services.

5.8.3 Provide administrative assistance, training, and technical assistance to subcontractors in support of administrative, financial, and programmatic functions as needed or requested by subcontractors.

5.8.4 Require subcontractors to comply with administrative and emergency preparedness requirements as well as requirements specified in service scopes of work.

5.8.5 Provide technical assistance to subcontractors through procedural interpretation and/or by additional research upon request.

5.8.6 Develop and present initial and refresher training to subcontractor staff as deemed necessary by the Contractor, subcontractor, or DAAS.

5.8.7 Implement a coordinated service delivery system that establishes standards for service delivery and operations across the designated service area.

5.8.8 Hold periodic meetings with subcontractors to communicate new developments, discuss problems, share ideas for improvements, or address other identified topic areas.

5.8.9 Train appropriate personnel in the use and preparation of client assessment and other forms.

5.9 Networking

5.9.1 Develop partnerships and network with related programs to provide timely resolution to issues and expand resources.

5.9.2 Form local partnerships with social service professionals and community agencies to enhance program service information sharing and delivery.

5.9.3 Collaborate to hold and participate in education, training, and information seminars, workshops, and conferences.

5.9.4 Participate in conference calls and attend meetings initiated by DAAS to receive training, share best practices and/or obtain information.

6.0 EMERGENCY PREPAREDNESS REQUIREMENTS – The Contractor shall:

6.1 Coordinate activities and develop long-range disaster/emergency preparedness plans with local and state disaster/emergency response agencies, relief organizations, local and state governments, and any other institutions that have responsibility for disaster relief service delivery as required by the Special Terms and

Conditions, Pandemic Contractual Performance.

6.2 Establish and implement, as necessary, a Disaster/Emergency Management Plan that includes components of disaster/emergency preparedness, disaster/emergency response, and disaster/emergency recovery as described in the DAAS Policy and Procedure Manual Chapter 1105, as may be amended.

7.0 NOTICES

7.1 The Contractor shall address all correspondence regarding this contract to the assigned Contract Specialist or as directed by ADES.

8.0 REPORTING REQUIREMENTS – The Contractor shall:

8.1 Submit the following items to the ADES Contract Specialist as directed by ADES:

8.1.1 Programmatic and financial reports as identified in the DAAS Policy and Procedure Manual Chapter

1000, as may be amended.

8.1.2 Current Contractor’s Insurance Certificate(s) that meets the requirements specified in the Special

Terms and Conditions, Indemnification Clause, and Insurance Requirements. Insurance certificates are required ten (10) days after contract award and prior to contract commencement.

8.1.3 Contractor’s Equipment List form (FES1000AFORFF) for all equipment costing $5,000 or more purchased by Contractor or Subcontractor, in whole or in part with ADES/DAAS funds (Exhibit A).

8.1.4 By June 30th annually, a 12-month monitoring plan that includes at a minimum: which direct service subcontractors are to be monitored during the twelve (12) month period beginning July 1st (of the same year), and for each: the type (desk or on-site) and scope (administrative, fiscal, and/or programmatic) of the monitoring for each, the specific service(s) to be monitored, and the target monitoring start and completion dates for each.

8.1.5 Provide by July 31, 2020, or any time changes are made, for ADES review and comment, the template used by the contractor to sub-contract with service providers.

9.0 ADAPTIVE AIDS AND DEVICES - ASSISTIVE TECHNOLOGY

9.1 Purpose Statement

9.1.1 The service provides medically necessary adaptive aids, devices, and assistive technology to individuals in their residence which allows them to perform normal living skills and remain independent in their homes and communities.

9.1.2 For the Family Caregiver Support Program, this service is provided on a limited basis, to complement the care provided by the caregiver.

9.2 Service Description

9.2.1 Taxonomy Definition – A service that provides or fabricates specialized equipment that will assist persons in performing normal living skills, and any necessary installation, fitting, adjustment, and training.

9.2.2 For purposes of the Family Caregiver Support Program, this service is provided as a supplemental service, on a limited basis. The adaptive aid, device, or assistive technology must be shown to complement the care provided by the caregiver.

9.2.3 Adaptive Aids and devices/assistive technology is a case-managed service.

9.2.4 Assisted technology (AT) includes thousands of devices and products that enable people to be more independent in activities such as communication, self-care, mobility, education, and employment.

9.2.5 AT devices can offer an alternative way to accomplish a task, and work by enhancing existing abilities or by compensating for absent or non-functional skills.

9.2.6 Eligibility Requirements – The Contractor shall provide services to individuals that meet the eligibility requirements described in Chapters 3000, Sections 3100 and 3600 of the DAAS Policy and Procedure Manual, as may be amended.

9.3 Service Requirements – The Contractor shall:

9.3.1 Provide service on a temporary and limited basis as defined in the DAAS Policy and Procedure

Manual, as may be amended, Chapter 3000, Section 3600-Family Caregiver Support Program.

9.3.2 Review the individual’s medical conditions and the results of specialist evaluations or examinations.

9.3.3 Determine the aid and/or device best suited to meet those needs in consultation with the referral source or in accordance with professionally identified needs.

9.3.4 Provide, construct, or adapt the appropriate aid or device (including augmentative and/or alternative communication devices).

9.3.5 Provide aids or devices that meet all generally accepted standards for those products and for product performance, as well as any applicable safety and health standards set by law or generally accepted in the industry.

9.3.6 Install/or fit the aid and/or device, as necessary.

9.3.7 Train the individual, his/her family and/or the care contractor in the proper use and maintenance of the aid or device, including but not limited to provision of maintenance and operation manuals.

9.3.8 Provide follow-up evaluations and make any adjustments as necessary.

9.3.9 Offer adaptive aids, devices and assistive technology include access to maintenance and repair services.

9.4 Licensure/Certification Requirements – The Contractor shall:

9.4.1 Provide services in accordance with:

1. A.R.S. §32 1681, et. seq. for dispensing opticians, as may be amended,

2. A.R.S. §32-1684.01 for optical establishments, as may be amended,

3. A.R.S. §32-1293, et. seq. for denturist, dental technologist, and dental lab technician, as may be amended, and

4. A.R.S. §36-1921, et. seq. for dispenser of hearing aids, as may be amended.

9.5 Reporting Unit

9.5.1 One (1) unit of service equals one (1) adaptive aid or device provided to an eligible individual.

10.0 ADULT DAY CARE/ADULT DAY HEALTH CARE

10.1 Purpose Statement

10.1.1 The service improves the emotional and mental well-being of eligible individuals, enabling eligible individuals to interact socially, receive health monitoring, and to acquire knowledge and skills, and provides respite for the caregivers of eligible individuals. Services provide respite for family caregivers from the demanding responsibilities of their role, helping to avoid costly and unwanted placement of the care recipient in a full-time care facility.

10.2 Service Description

10.2.1 Taxonomy Definition – A service that provides supervised planned care and health-related services to adults in a group setting during a portion of a 24-hour day.

10.2.2 Caregivers typically select the type of center a care recipient attends based on the care needed. In general, there are three types of adult day centers:

1. Social - Provides meals, recreation, and some health-related services,

2. Medical/Health - Provides social activities as well as more intensive health and therapeutic services, and

3. Specialized - Provide services only to specific care recipients, such as those with diagnosed dementias or developmental disabilities).

10.2.3 Adult Day Care is:

1. A component of community-based long-term care systems and a service that supports the caregiver,

2. A case-managed service focused on general supervision, socialization, recreation,

3. A caregiver-focused service but can be provided to individuals living at home alone as an opportunity for socialization,

4. Short-term (4-8 hours at a time), with preference in length based on the caregiver’s specific need, and

5. Normally planned in advance as part of a care plan but can also be provided on an emergency basis.

10.2.4 Adult Day Health is:

1. A component of community-based long-term care systems and a service that supports the caregiver,

2. A case-managed service focused on more intensive health-related services,

3. A caregiver-focused service but can be provided to individuals living at home alone as an opportunity for health care supervision,

4. Short-term (4-8 hours at a time), with preference in length based on the caregiver’s specific need, and

5. Normally planned in advance as part of a care plan but can also be provided on an emergency basis.

10.2.5 For the purpose of the Family Caregiver Support Program, this service is to be provided to the caregiver as a form of respite care service and is considered to be a temporary substitute supportive service that provides a brief period of relief or rest for caregivers. Temporary service not to exceed an average of 60 hours per month.

10.2.6 Eligibility Requirements – The Contractor shall provide services to individuals that meet the eligibility requirements described in the DAAS Policy and Procedure Manual, as may be amended.

10.3 Service Requirements – The Contractor shall:

10.3.1 Review case manager authorization for duration of service and any special service requirements.

10.3.2 Develop a written care plan for each care recipients/caregiver upon entry. The care plan shall utilize the individual’s family and/or friends when applicable/possible. The care plan shall include a plan of action to be followed in the event of an emergency:

1. Maintain monthly progress notes for each care recipients/caregiver, and

2. Reassess at least every six months, in writing, the adequacy of the care recipient’s/caregiver’s care plan, or more frequently if a change occurs that affects eligibility or need.

10.3.3 Refer individuals/caregivers to and coordinate with the appropriate agencies and resources when additional social, emotional, or physical needs are present.

10.3.4 Provide services to the care recipient that include, but are not limited to:

1. Short-term personal care and supervision,

2. Supervision of the individual to protect the individual’s welfare and safety,

3. An initial visit may be conducted to set up a care plan that addresses the individual’s interests,

4. The individual receiving medication as prescribed,

5. First aid and appropriate attention to injury and illness,

6. Food to meet daily dietary needs, including a therapeutic diet, if prescribed,

7. General supervision of the care recipient’s activities of daily living, including activities such as bathing, dressing, eating, toileting, etc.,

8. Family or care recipient psycho-social intervention, when applicable, and

9. Service provision only when there is a discharge plan which indicates a definite timeline for transitioning back into the community for individuals living in nursing homes or assisted living centers.

10.4 Licensure/Certification Requirements

10.4.1 Services provided in non-tribal facilities shall be licensed by the Arizona Department of Health Services according to the Arizona Administrative Code (A.A.C.) R9-10-501 through R9-10-514, as an Adult Day Care/Adult Day Health Care facility, as may be amended.

10.4.2 Services provided in tribal facilities shall be authorized by a tribal government or the Bureau of Indian Affairs as an Adult Day Care/Adult Day Health Care facility.

10.4.3 Programs providing meals must comply with the nutrition requirements as specified in the A.A.C.

R9-10- 509, as may be amended.

10.5 Reporting Unit

10.5.1 One (1) unit of service equals 60 minutes of service time.

11.0 ADVOCACY

11.1 Purpose Statement

11.1.1 Services that take action to protect the rights of individuals and ensure they receive appropriate services and benefits or to seek needed changes in the law and/or administrative rules to protect the rights of individuals and ensure adequate service levels.

11.2 Service Description

11.2.1 Taxonomy Definition- Services that take action to protect the rights of individuals and ensure they receive appropriate services and benefits or to seek needed changes in the law and/or administrative rules to protect the rights of individuals and ensure adequate service levels.

11.2.2 Services that take action to protect the rights of individuals and ensure they receive appropriate services and benefits or to seek needed changes in the law and/or administrative rules to protect the rights of individuals and ensure adequate service levels.

1. Advocacy ensures the availability of information about and access to human services and community resources and enhances and/or supports the provision of direct services to eligible individuals and families. The AAA provide information to agencies, organizations, legislators, and the general public about issues affecting older individuals, planning to meet current needs, and formulating policy that will address the future needs of older individuals. Continued advocacy efforts are necessary to reduce barriers and to improve responsiveness to the needs and concerns of older and vulnerable adults.

11.3 Service Requirements - The Contractor shall:

11.3.1 Identify the individual’s legal and social problems and need for services.

11.3.2 Identify appropriate providers to provide needed services.

11.3.3 Identify barriers to an individual’s access to needed services and assist to remove barriers which prevent them from meeting identified needs.

11.3.4 Identify changes in procedures, laws, regulations, or appropriations which would increase an individual’s access to necessary services or increase or clarifies legal protections.

11.3.5 Assist in training community groups and individuals in advocacy techniques, community organizations, and the legislative process.

11.3.6 Provide advocacy to assist in modifying, changing, or adding to procedures, laws, regulations, or appropriations, as necessary.

11.3.7 Provide technical assistance and support to individuals and groups involved in advocacy actions to remove impeding barriers.

11.3.8 Disseminate information or provide education to appropriate agencies or groups to assist in effecting necessary changes in laws, regulations, or appropriations.

11.3.9 Identify gaps in necessary services.

11.4 Optional Tasks/Activities - The Contractor may:

11.4.1 Assess the nature and level of counseling and/or representation necessary to assist an individual to realize his/her rights and/or entitlements under the law.

11.4.2 Provide counseling or representation for the individual as appropriate to the level of expertise of the advocate and the individual’s needs. Where legal representation or counseling is required, it shall be provided by licensed attorneys or by paralegals or lay advocates under the supervision and direction of a licensed attorney as is consistent with or required by the ethical requirements of the Arizona Bar Association or existing laws.

11.4.3 Identify appropriate existing resources.

11.4.4 Refer individuals to appropriate resources.

11.4.5 Assist individuals in completion of application for service.

11.4.6 Follow-up referrals to verify service delivery.

11.4.7 Initiate and enforce standardized follow-up procedures.

11.4.8 Institute a regular assessment procedure, which shall include individual or consumer participation.

11.4.9 Establish an individual grievance or appeals procedure.

11.4.10 Inform individuals of grievance and appeals procedures.

11.4.11 Establish standardized assessment methods for analysis of the service delivery system.

11.4.12 Analyze and assess the problems in the delivery system.

11.4.13 Make recommendations with individual input as necessary to improve the service system.

11.4.14 Make assessment of existing attitudes and policies.

11.4.15 Identify problem(s) and/or need(s).

11.4.16 Develop a plan of action to be taken within a specified time frame.

11.4.17 Implement the plan of action.

11.4.18 Evaluate the plan of action.

11.4.19 Modify the plan as necessary.

11.5 Reporting Unit

11.5.1 One (1) unit of service equals 60 minutes of staff time.

12.0 ATTENDANT CARE / PERSONAL ASSISTANCE

12.1 Purpose Statement

12.1.1 The service provides assistance with routine housekeeping tasks, personal physical needs, and related services at an individual’s place of residence, helping clients to maintain their independence and avoid costly and unwanted placement in a care facility.

12.2 Service Description

12.2.1 Taxonomy Definition - A service that provides a qualified individual to supply needed services in order for an individual to remain in his/her home and/or participate in work/community activities.

12.2.2 Attendant care is:

1. A case managed service,

2. Provides assistance with housekeeping homemaker services, personal care, coordination of services, general supervision and assistance, companionship, socialization and skills development at an individual’s place of residence,

3. A component of community-based long-term care systems, and

4. Increases an individual’s ability to live independently in the community.

12.2.3 NMHCBS is designed to establish the necessary support services to retain functionally impaired individuals within their community and avoid premature institutionalization.

12.2.4 The service may be used as part of the Home Care cluster and is a case managed service.

12.2.5 Eligibility Requirements – The Contractor shall provide services to individuals that meet the eligibility requirements described in the DAAS Policy and Procedure Manual, as may be amended.

12.3 Service Requirements – The Contractor shall:

12.3.1 Provide assessment, supervision, and monitoring.

1. Upon authorization by a case manager, an initial supervisory visit by the service provider to determine specific tasks is to be performed. During this visit, a Care Plan is developed, and specific tasks can be assigned to the attendant care worker for completion at each visit in the time allotted, and

2. The Supervisor shall conduct home visits for each individual at least every 90 days, or more frequently if required, to determine if the attendant care worker is performing tasks according to the care plan and to remedy areas of deficiency.

12.3.2 Attendant Care Workers shall not give personal care services until they have been certified competent in this area by their agency.

12.3.3 Provide services in accordance with the individual’s Care Plan as authorized by the case manager. Services include but are not limited to:

1. Routine Housekeeping/Homemaker tasks to maintain safe and sanitary living conditions for

Individuals,

2. Provide cleaning tasks to include dusting, cleaning floors, bathrooms, windows (if necessary to attain safe or sanitary living conditions); cleaning oven and refrigerator (if necessary to prepare food safely); cleaning kitchen; washing dishes; changing linens; making beds; and routine maintenance of household appliances,

3. Wash, dry and fold laundry. Ironing to be included if clothes cannot be worn otherwise,

4. Assist with personal care services including:

a) Showering, bathing, toileting, dressing, oral care and shampooing to maintain good personal hygiene,

b) Transfer to and from wheelchair/other seating and/or bed,

c) Eating, where the assistance is required, may include:

i. Remind or encourage to maintain intake,

ii. Serve or bring food,

iii. Prepare food through prep work such as cutting of meats, vegetables, fruit, opening of containers, etc. and other set-up activities,

iv. Assist with menus/food selection), and

v. Feeding the individual, if applicable.

5. Routine ambulation activities assistance,

6. Routine nail and skin care assistance,

7. Assist with tasks necessary for the comfort and safety of the movement-restricted that do not require medical or nursing supervision,

8. Assist with special appliances and/or prosthetic devices, if the procedure is routine and well established per the Care Plan,

9. Train the individual, his/her family members, and/or friends in personal care tasks, as appropriate,

10. General supervision which includes but not limited to:

a) Self-administration of medications, and

b) Monitoring general medical condition and functional level.

11. Assist with recreational/socialization skill development,

12. Encouraging the individual, family, caregiver or representative to provide input into and support the individual’s care plan to verify that activities and services are provided to meet the objectives of the individual’s care plan,

13. Other tasks such as documenting and communicating to the individual’s case manager, any decline, improvement, or continuing maintenance of the individual’s condition, and

14. Refer for appropriate action all individuals who present additional medical or social problems during the course of service delivery.

12.3.4 Not handle individual’s personal finances.

12.4 Other Tasks/Activities - The Contractor may:

12.4.1 Provide or monitor nutritional maintenance for eligible individuals:

1. Plan and cook meals,

2. Shop for and store food, and

3. Shop for and store household supplies and medicines.

12.4.2 Attain safe living conditions for individuals:

1. Provide heavy cleaning such as ceiling, walls or floors,

2. Provide yard work such as cleaning yard and hauling away debris, and

3. Arrange for pest control services when insect infestation presents a health concern for the client.

Pest control services should be purchased from licensed agencies if no other funding for this service is available.

12.4.3 Assist individuals in obtaining and/or caring for basic material needs for water, heating/cooling, and food:

1. Haul water for household use,

2. Gather and haul firewood for household heating or cooking, including sawing and chopping firewood into usable sizes,

3. Care for livestock used for consumption, this includes feeding, watering, and milking,

4. Care for the garden used for food consumption, including planting, and harvesting,

5. Dig out dirt floors and replace with fresh dirt, and

6. Turn heating and/or cooling systems on or off. The Attendant Care worker performing the service of turning on/off utilities shall receive instruction about heating and cooling systems from the local utility company or weatherization project.

12.5 Licensure/Certification Requirements

12.5.1 Require that direct service providers have current certification in CPR and training in home accident prevention and first aid. (Licensed medical personnel are not required to provide this service.)

12.5.2 Adhere to the following staffing standards:

1. Newly hired employees providing Attendant Care shall submit three (3) references from persons other than family members. All references shall be contacted, and results documented in the personnel record,

2. Attendant Care Workers shall not give personal care services until they have been certified competent in this area by their agency. As described in the DAAS Policy and Procedure Manual, as may be amended, staff providing Attendant Care shall demonstrate knowledge and skills consistent with the Arizona Direct Care Training standards before providing services. The complete curriculum, competencies and information related to agencies that are interested in becoming an approved testing site are available on the ADES website, located at www.azdirectcare.org.

Documentation of test results (knowledge and skills) or verification of prior testing shall be included in the employee personnel record, and

3. Direct Service Staff Supervisor shall have at a minimum:

a) At least two (2) years full time employment experience in a supervisory capacity,

b) One (1) year of studies at an accredited college in a related field can substitute for one (1) year experience,

c) Orientation to target population is also required, unless otherwise evident in background that s/he has previous experience serving the target population, and

d) Demonstrate knowledge and skills consistent with the Arizona Direct Care standards at the same level, at a minimum, as the employees being supervised.

12.6 Reporting Unit

12.6.1 One (1) unit of service equals 60 minutes of service time.

13.0 CAREGIVER TRAINING – FAMILY CAREGIVER SUPPORT PROGRAM

13.1 Purpose Statement

13.1.1 The family caregiver training service provides training to enhance caregiver skills, well-being, and to help decrease risk of compassion fatigue. The successful delivery of family caregiver training will help avoid costly and unnecessary placement in a care facility.

13.2 Service Description

13.2.1 Taxonomy Definition – A service that provides training to assist caregivers in performing care giving activities, decision making, and problem solving.

13.2.2 Caregiver Training is an educational service that focuses on improving informal caregivers’ practice of providing care and assists caregivers in the areas of health, nutrition, financial literacy, decision-making and problem-solving related to their caregiving roles. The service provides information about and access to human services and community resources, to improve the physical, emotional, and mental health of eligible individuals, and to meet the needs of diverse caregivers who have different preferences and schedules. Specific training designed to mitigate the effects of stress and burden related to caregiving can also be included in this service.

13.2.3 This service provides training for family members and other home-based caregivers which focuses on caregiver related topics including:

1. Assistance with basic activities of daily living, including bathing, dressing, eating, toileting, transferring, and walking,

2. Assistance with instrumental activities of daily living, including medication management, meal preparation, money management, and use of communication devices,

3. Making the home environment safe and barrier-free, and

4. Stress management and other self-care techniques to help the caregiver take care of him or herself.

13.2.4 Specific Caregiver Training for grandparents raising grandchildren is allowable, including skills training related to guardianship, school enrollment, and other child-related training that may include Trauma- informed care, financial, and community resources.

13.2.5 Eligibility Requirements – The Contractor shall provide services to individuals that meet the eligibility requirements described in Chapter 3000, of the DAAS Policy and Procedure Manual, as may be amended.

13.3 Service Requirements – The Contractor shall:

13.3.1 Provide caregiver training on a one-on-one basis or in a classroom setting.

13.3.2 Provide training with cultural sensitivity and flexibility suitable to the caregiver’s needs.

13.3.3 Provide training that is appropriate in design and implementation to account for different types of interventions caregivers will provide and to account for the cultural diversity of the caregivers being trained.

13.3.4 Provide training that, at a minimum, assists caregivers in the areas of health, nutrition, financial literacy, decision-making, and problem solving related to their caregiving roles. Topics may include but not be limited to:

1. Nutrition education or instruction,

2. Home injury control services (including screening of high-risk home environments),

3. Proper lifting techniques, bathing, and patient care skills,

4. Medical management and/or medication administration,

5. Money management,

6. Helping caregivers to care for themselves, how to obtain necessary information and resources,

7. Mental health education for family caregivers and their care recipients,

8. Long-term care insurance information and resources,

9. Life-Care Planning review and guidance, and

10. Other additional caregiver training, as needed.

13.4 Licensure/Certification Requirements

13.4.1 Utilize instructors/trainers that meet the educational qualifications and/or required certifications for the applicable subject matter to be taught.

13.5 Performance Measures

13.5.1 Evaluation instruments used at training sessions show that participants have increased their skill of the subject matter(s).

13.6 Reporting Requirement

13.6.1 Submit the Quarterly Family Caregiver Support Program Report form as found in the DAAS Policy and Procedure Manual.

13.7 Reporting Unit

13.7.1 One (1) unit of service equals one (1) training session.

14.0 CASE MANAGEMENT

14.1 Purpose Statement

14.1.1 The service identifies, facilitates, and coordinates formal and informal services in order to assist clients to maintain independence and avoid institutional placement, while complementing caregiver support.

14.2 Service Description

14.2.1 Taxonomy Definition – A service or process that establishes a relationship with an individual or family in order to enhance their functioning and/or integration into the community. Appropriate services and/or benefits are identified, planned, obtained, provided, recorded, monitored, modified when necessary and/or terminate. This may include assessment to determine their needs and eligibility when applying for/receiving services, assistance in finding necessary resources in addition to covered services to meet basic needs, assistance in obtaining entitlements, communication, and coordination of care as well as follow-up of crisis contacts or missed appointments.

14.2.2 Case Management is:

1. A service or process that establishes a relationship through a strength-based collaboration with an individual, family and/or caregiver in order to assist individuals in organizing and managing their care by coordinating and facilitating access to a variety of services in a timely manner,

2. Consists of intake, screening, assessment, service planning, service implementation, follow-up, monitoring, reassessment, and termination of services, and

3. Specifically related to the Family Caregiver Support Program, case management for a Caregiver focuses on the needs of the caregiver and doesn’t include client (care-recipient) assessment or authorization of client-supported services.

14.2.3 Eligibility Requirements - The Contractor shall provide services to individuals that meet the eligibility requirements described in Chapter 3000, of the DAAS Policy and Procedure Manual, as may be

14.3 Service Requirements – The Contractor shall:

14.3.1 Provide Case Management as follows:

1. Conduct an in-depth assessment using an ADES approved tool (see the DAAS Policy and

Procedure Manual Chapter 3000, as may be amended),

2. Provide the individual or caregiver with information about available services, eligibility, and conditions of acceptance for services,

3. Inform the individual or caregiver of:

a) Rights and responsibilities in relation to services, and

b) Arrangements for or access to one-time-only or emergency services needed by the individual or caregiver. Document the name of the individual or caregiver and the type of service for which arrangements were made.

4. Develop a Service Plan in collaboration with the individual or caregiver and other appropriate person to identify and record:

a) Services have been chosen to be provided to the individual or caregiver,

b) How services will be provided,

c) Who will provide the service,

d) With input from the individual or caregiver, on the plan start and end dates, when specified milestones are to be accomplished, and when progress is to be assessed,

e) Criteria for measuring the results to be achieved by the service plan, and

f) Process to be utilized for renegotiating the service plan as needed.

5. Provide Service Plan Implementation:

a) Authorize and record the covered services to be provided to the individual or caregiver,

b) Record referrals made for non-covered services (services other than those authorized),

c) Give each individual or caregiver seeking services a list of agencies that provide similar services,

d) Coordinate and facilitate the access to and the delivery of services to the individual or caregiver and record information,

e) Assist the individual or caregiver in obtaining needed services and resources through education and advocacy, and

f) Provide direct intervention to assist with the individual or caregiver’s service plan overall goals.

6. Provide Service Plan Monitoring:

a) Determine and record the type and quantity of services the individual or caregiver received,

b) Identify and record the individual or caregiver’s progress toward established goals,

c) Identify and record the quality and appropriateness of the services provided,

d) Identify, record, and reassess the service goals and resolve any problems related to the service assist the individual or caregiver with appeals, hearings and/or grievances,

e) Monitor service plans at least every 90 days or when a change occurs that affects eligibility or need,

f) Conduct a home visit at least every six (6) months,

g) Re-determine eligibility for services at least annually or if changes have occurred since the last review. A home visit is required for annual re-determination, and

h) Follow up to determine whether changes were implemented.

7. Provide Service Plan Closure:

a) Identify, assess, and record the individual or caregiver’s progress toward his/her service plan goals,

b) Identify and record the individual or caregiver’s status at the close of the service plan, and

c) Identify and record the reasons for closure of the plan.

14.4 Staffing Requirements – The Contractor shall:

14.4.1 Require that case managers have at a minimum a bachelor’s degree in social work, sociology, psychology, counseling, nursing, or other closely related fields, or have two (2) years’ experience in social or health services.

14.4.2 Require that the Case Management Supervisor has at least a master’s degree or at least four (4) years’ experience in social or health services.

14.4.3 Require that case managers have a thorough knowledge of the services provided by their respective programs and an understanding of procedures for integrating services.

14.4.4 Require that case managers have the knowledge, skills, and experience necessary to assess the client’s strengths and need for services and perform the core functions of case management.

14.4.5 Require that case managers confirm that appropriate assistance is given to each individual, family member, caregiver, or an individual’s legal representative, by providing accurate and complete information about available services allowing the individual self-directed care.

14.4.6 Require that case managers display effective communication skills and be able to work as part of a team of service providers on behalf of the individual.

14.4.7 Require that case managers assume responsibility for their own professional growth and continuing education to enhance their case management skills and keep up with the many changes of available resources in the health and social service fields.

14.4.8 Require that case managers do not engage in any personal relationships with the individual, caregiver, or family members that may lead to any personal or professional gain or impair professional judgment.

14.4.9 Require that staff providing intake have the knowledge, skills, and experience necessary to refer individuals to case management as appropriate.

14.5 Reporting Unit

14.5.1 One (1) case management unit of service equals 60 minutes of service time.

15.0 COMMUNITY EDUCATION AND INFORMATION

15.1 Purpose Statement

15.1.1 The service helps to create awareness and provide information to the community related to services available to assist individuals in maintaining their independence and ability to remain in their home and community.

15.1.2 Specifically related to the Family Caregiver Support Program, the purpose is to create awareness and provide information to the community related to support services available to family caregivers.

15.2 Service Description

15.2.1 Taxonomy Definition – A service that provides information on, and/or instructions in, various subjects through public contact and/or meetings, printed materials and media presentations focused on a particular subject, field of interest, agency, or service(s).

15.2.2 The service is designed to distribute information and educational resources related to aging issues, aging services, long-term care, long-term care planning, retirement planning, and other related topics.

15.2.3 The Older Americans Act indicates that AAA are to include community education services in their area plans related to the need to plan for long-term care in advance and the full…