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DHS COVID-19 PROVIDER GUIDANCE // OLTL

Transition Plan to Phase Out Temporary Changes to the Community HealthChoices 1915(c) Waiver

Issued: June 25, 2020

Note: This transition plan is intended to be used in conjunction with the April 30, 2020 Temporary Changes to the Community HealthChoices 1915(c) Waiver (Revised) Guidance. That guidance, found below, contains complete descriptions of the temporary changes and guidelines for implementation.

The Centers for Medicare & Medicaid Services (CMS) approved temporary changes to the Community HealthChoices (CHC) waiver beginning March 6, 2020 in response to the COVID-19 pandemic.  Approval of these changes is covered under Appendix K, Emergency Preparedness and Response, which states may use during emergency situations to request amendments to their approved waivers.  These changes addressed potential staffing shortages and the need for service provision not included in approved service descriptions to ensure participant health and safety needs could be accommodated for the duration of the COVID-19 statewide emergency. As described in the Temporary Changes to the CHC Waiver (Revised) Guidance, the changes were not intended to apply to all participants nor to be considered across-the-board changes that must be implemented for each participant.  These flexibilities were to be evaluated on a case-by-case basis in coordination with the CHC Managed Care Organizations (MCOs).   

As we begin to ease restrictions on work and on social interactions, the temporary waiver changes can also be phased out, provided participants can be safely served and providers and service coordinators are taking proper precautions. The chart below provides guidance to the CHC-MCOs on phasing out the temporary waiver flexibilities.  The guidance is intended to be implemented at the county level as each county moves through the red, yellow and green phases of the Governor's phased reopening plan for Pennsylvania.

Appendix K
Flexibility

Red Phase
​Yellow Phase
​Green Phase
​Resurgance (Return
to Yellow or Red)

​Waiver Services
​Waiver Services may not be reduced on the participant’s Person-Centered Service Plan (PCSP).
​Same as Red
​The participant's PCSP will remain at pre-PHE service levels until the participant's county enters the green phase.  At that time the CHC-MCOs may begin conducting comprehensive needs reassessments that were missed due to the PHE and services can be adjusted based on the outcome of the reassessment.  

Assessments that are 90 days or older that did not result in adjustments to the PCSP at the time of the assessment because of the PHE cannot be used to make adjustments to the participant's PCSP.  The CHC-MCOs must follow the established comprehensive needs assessment process prior to making any service reductions on the participant's PCSP.1



​Same as Green for
the duration of the Appendix K approval.
​Personal Protective Equipment (PPE)
​PPE such as gloves, gowns and masks for participant use can be obtained as Specialized Medical Equipment and Supplies if no other source is available. PPE may be added to a participant’s PCSP without the need for a comprehensive needs assessment or a physician’s prescription.
​Same as Red
​Same as Red for the duration of the Appendix K approval
​Same as Red for the duration of the Appendix K approval.
​Service Limitations


​Adult Daily Living – Long-Term or Continuous Nursing may be provided temporarily as a separate service at the same time that Adult Daily Living Services are provided to ensure participant health and safety needs can be met.
​Same as Red
​Long-Term or Continuous Nursing may no longer be provided as a separate service at the same time that Adult Daily Living Services are provided
​Same as Red for the duration of the Appendix K approval.
​Residential Habilitation – Service definition limitations on the number of people served in each licensed home may be exceeded, provided that the number of participants can be safely served in the setting.
​Same as Red
​Service definition limitations on the number of participants served in each licensed home may not be exceeded.  Residential Habilitation providers must evaluate each setting’s space considerations, including participant and staff numbers, and develop a plan to transition participants back to their original homes in the Residential Habilitation setting.  The transition must be completed no more than 30 days after the county has entered the green phase or the issuance of this policy, whichever is later.  Providers who determine a need for additional time to transition participants should work directly with the participant’s CHC-MCO.
Same as Green for the duration of the Appendix K approval.
​Residential Habilitation – Long-Term or Continuous Nursing may be provided temporarily as a separate service at the same time that Residential Habilitation is provided to ensure participant health and safety needs can be met.
​​Same as Red
​Same as red if the need for long-term or continuous nursing is a result of COVID-19 and with prior approval of the CHC-MCO.  This remains in effect for the duration of the Appendix K approval.
​Same as Green for
the duration of the Appendix K approval.
Respite
​Respite in a licensed facility may be extended beyond 29 consecutive days without prior approval of the CHC-MCO, in order to meet the participant’s health and safety needs
​Same as Red
​Same as red if the need for additional Respite is a result of COVID-19 except prior approval of the CHC-MCO is required.  This remains in effect for the duration of the Appendix K approval.
​Same as Green for 
the duration of the Appendix K approval.
​Personal Assistance Services (Agency and Participant-Directed) and Participant-Directed Community Supports
​Spouses, legal guardians, and persons with power of attorney may serve as paid direct care workers only when scheduled workers are not available due to COVID-19 and the participant’s emergency backup plan cannot be implemented.
​Same as Red
​Spouses, legal guardians, and persons with power of attorney may no longer serve as paid direct care workers.  Participants will be expected to resume using their existing direct care worker or a replacement worker if necessary.
​Same as Green for
the duration of the Appendix K approval.
​Expanded Settings Where Services May Be Provided




​Residential Habilitation and Structured Day Habilitation Services may be provided to participants by Residential Habilitation and Structured Day Habilitation staff in private homes.
​Same as Red
​Providers are required to evaluate the setting's space considerations, participant and staff numbers, work flow and develop a plan to support social distancing, arrivals and departures, lunch, activities space, and any other considerations unique to the space or program activities for individuals and staff at all times when present at the setting.  Based on the evaluation, providers must develop a plan for transitioning participants back to Residential Habilitation and Structured Day Habilitation settings.  Examples of the elements to be included in the plan are as follows:
Alternating days for participants
  • Alternating arrival and departure times
  • Reducing the number of participants
  • Re-arranging program space so that participants are a minimum 6 feet apart
  • Erecting barriers, tape, or other visual indicators to support social distancing measures




Providers must adhere to the cleaning and disinfecting guidelines issued by the Centers for Disease Control and Prevention (CDC).  In addition, Residential Habilitation providers should continue to monitor and adhere to the guidance issued by OLTL which pertains to Personal Care Homes and Assisted Living Residences as well as the CDC guidance around congregate settings and direct service providers.


Participants will be transitioned back to Residential Habilitation and Structured Day Habilitation settings within 30-days of the county moving to green or the issuance of this policy, whichever is later.
​Residential Habilitation – Same as Green for the duration of the Appendix K approval.
​Structured Day Habilitation – Same as Green for the duration of the Appendix K approval.
​Structured Day Habilitation may be provided remotely using phone or video conferencing only to participants who received the services face-to-face prior to the COVID emergency declaration.
​Same as Red
​Structured Day Habilitation providers are required to evaluate the setting's space considerations, participant and staff numbers, work flow and develop a plan to support social distancing, arrivals and departures, lunch, activities space, and any other considerations unique to the space or program activities for individuals and staff at all times when present at the setting.  Based on the evaluation, providers must develop a plan for transitioning participants back to Structured Day Habilitation settings.  Examples of the elements to be included in the plan are as follows:Alternating days for participants

  • Alternating arrival and departure times
  • Reduced numbers of participants
  • Re-arranging program space (minimum 6 feet apart)
  • Erecting barriers, tape, or other visual indicators to support social distancing measures.
Providers must adhere to the cleaning and disinfecting guidelines as well as the general guidelines for businesses and employers and direct service providers issued by the CDC.

Participants will be transitioned back to Structured Day Habilitation settings within 30-days of the county moving to green or the issuance of this policy, whichever is later.


​Same as Red for
the duration of the Appendix K approval.
​Cognitive Rehabilitation and Behavior Therapy may be provided remotely using phone or video conferencing only to participants who received the services face-to-face prior to the COVID-19 emergency declaration
​Same as Red
​Within 30 days of the county moving to green or the issuance of this policy, whichever is later, Cognitive Rehabilitation and Behavior Therapy should transition to face-to-face sessions where possible.  Participants may continue to receive services remotely via phone or video conferencing for the purpose of social distancing within an outpatient setting AND when it has been determined that the participant can actively participate and benefit from receiving the service remotely.  Providers must follow maintain safe behavioral practices as defined by the CDC and the Department of Health when doing so.
​Same as Red for
the duration of the Appendix K approval.
​Counseling Services may be provided remotely using phone or video conferencing.
​Same as Red
​Within 30 days of the county moving to green, or the issuance of this policy, whichever is later, Counseling Services should transition to face-to-face sessions where possible.  Participants may continue to receive services remotely via phone or video conferencing for the purpose of social distancing within an outpatient setting AND when it has been determined that the participant can actively participate and benefit from receiving the service remotely.  Providers must follow maintain safe behavioral practices as defined by the CDC and the Department of Health when doing so.
​Same as Red for the duration of the Appendix K approval.
​Modification of Worker Qualifications
​Residential Habilitation, Structured Day Habilitation Services, Adult Daily Living, and Personal Assistance Services – Individual staff members who are qualified to provide any one of these services may be reassigned to provide Residential Habilitation, Structured Day Habilitation Services, Adult Daily Living, and Personal Assistance Services
​Same as Red
​Providers have 30 days to transition staff who were reassigned to different program areas per the transition plan referenced above.
​Same as Red for
the duration of the Appendix K approval.
​Modification of Licensure or Other Requirements for Settings Where Waiver Services are Furnished

​Licensed Residential Habilitation, Structured Day Habilitation Services and Adult Daily Living – The maximum number of individuals served in a service location may be exceeded to address staffing shortages or accommodate use of other sites as quarantine sites. Minimum staffing ratios as required by licensure, service definition or the participant’s PCSP may be exceeded due to staffing shortages.
​Same as Red
​The maximum number of individuals served in a service location may no longer be exceeded to address staffing shortages or accommodate use of other sites as quarantine sites.Minimum staffing ratios as required by licensure, service definition or the participant's PCSP may no longer be exceeded due to staffing shortages. Providers should continue to follow all guidance issued by the CDC and the Department of Health for staff and participant screening and infection controls, and to the cleaning and disinfecting guidelines issued by the CDC.​Same as Green for
the duration of the Appendix K approval.
​Adult Daily Living providers should follow the guidance for reopening and operating Older Adult Daily Living Centers during COVID-19 issued by the Department of Aging.
​Initial Level of Care Assessments


​Initial Level of Care Assessments using
the FED may be conducted remotely using phone or video conferencing; the face-to-face requirement is temporarily waived.
​ ​
​Same as Red
​ ​
​Assessors must receive education and training from the Independent Assessment Entity on how to evaluate individual risk factors and protect themselves from potential exposure according to the guidance issued by the CDC and the Department of Health.
​Same as Red for
the duration of the Appendix K approval.
​ ​
​Initial level of care assessments using the FED that take place in the participant's home should be conducted face-to-face when possible.  Assessments may be conducted remotely when risk factors may be present in the participant's home.  Assessors must follow the guidance issued by the Independent Assessment Entity for resuming face-to-face assessments and maintain safe behavioral practices as defined by the CDC and the Department of Health when doing so.
​Initial level of care assessments using the FED that take place in nursing facilities should be conducted remotely using phone or video conferencing.  Assessors should follow guidance around visitation in nursing facilities that is issued by the CDC and the Department of Health.
​Needs Assessments/ Reassessments

​Annual Reassessments, including the needs assessment and level of care reassessment, may be conducted remotely using phone or video conferencing; the face-to-face requirement is temporarily waived. The 365-day time limit for annual reassessments to be performed is also temporarily waived. If a reassessment is going to be delayed beyond 365 days, the Service Coordinator must contact the participant at least 30 days prior to the normal reassessment due date to verify with the participant or representative that the current PCSP, including services and providers, remains acceptable for the upcoming year. If necessary, the Service Coordinator will ensure the PCSP is modified to allow for additional supports and/or services due to changes in participant needs. If no updates to the participant’s PCSP are needed due to COVID-19 or a change in the participant’s needs that require an increase in services, the existing PCSP will remain in place until the annual reassessment can be completed. At the end of the COVID-19 emergency declaration, the Service Coordinator will have up to 6 months to complete the annual reassessment and update the PCSP.
​Same as Red
​Service Coordinators must receive education and training from the CHC-MCOs on how to evaluate individual risk factors and protect themselves from potential exposure according to the guidance issued by the CDC and the Department of Health.Annual Reassessments, including the needs assessment, should be conducted face-to-face when possible.  Reassessments may be conducted remotely when risk factors may be present in the participant's home.  Service Coordinators should maintain safe behavioral practices as defined by the CDC and the Department of Health when doing so.


Annual reassessments, including the needs assessment, that were delayed beyond the 365-day must be completed no later than 6 months after the county has transitioned to green or the issuance of this policy, whichever is later. 


​Same as Red for
the duration of the Appendix K approval.
Comprehensive Needs Reassessments may be conducted remotely using phone or video conferencing when a participant’s needs change, when the participant requests a reassessment, or following trigger events.​​Same as Red
​Comprehensive Needs Reassessments should be conducted face-to-face when possible.  Reassessments may be conducted remotely when risk factors may be present in the participant's home.  Service Coordinators should maintain safe behavioral practices as defined by the CDC and the Department of Health when doing so.
​Same as Red for the duration of the Appendix K approval.
​Person-Centered Service Planning/Service Coordination

​Service Coordinators may monitor participants and PCSPs remotely by telephone where face-to-face contacts are usually required. Service Coordinators are encouraged to contact participants frequently to ensure participants’ needs are being met during the COVID-19 emergency declaration.
​Same as Red
​Service Coordinators should monitor participants and PCSPs through face-to-face contacts when possible.  Monitoring of participants and PCSPs may be done remotely when risk factors may be present in the participant's home.  Service Coordinators should maintain safe behavioral practices as defined by the CDC and the Department of Health when doing so.  Service Coordinators should continue to contact participants to ensure participants' needs are being met and utilization of services.
​Same as Red for the duration of the Appendix K approval.
​Person-Centered Planning Team (PCPT) meetings and plan development may be conducted entirely using telecommunications. Members of the PCPT, determined at the discretion of the participant, may also participate remotely using phone or video conferencing
​Same as Red
​PCPT meetings and PCSP development may be conducted face-to-face if possible.  PCPT meetings and PCSP development may be conducted remotely when risk factors may be present in the participant’s home.  Service Coordinators and any other members of the PCSP team should maintain safe behavioral practices as defined by the CDC and the Department of Health when doing so.
​Same as Red for the duration of the Appendix K approval.
​Incident Management Reporting Requirements

​Critical Incident Reports: The CHC-MCO and providers must submit critical incident reports for Service Interruptions even if the reason for the Service Interruption is due to insufficient staff to provide care due to COVID-19.
​Same as Red
​Same as Red for the duration of the Appendix K approval.
​Same as Red for the duration of the Appendix K approval.
​Critical Incident Investigations: The CHC-MCO will not need to conduct an investigation for Service Interruptions when the Service Interruption is due to insufficient staff to provide care due to COVID-19. The CHC-MCO must ensure that participants at highest risk continue to receive services.
​Same as Red
​The CHC-MCO is required to conduct an investigation for Service Interruptions when the Service Interruption is due to insufficient staff to provide care due to COVID-19.
​Same as Red for the duration of the Appendix K approval.
Retainer Payments to Address Emergency Related Issues​
​During the COVID-19 emergency, retainer payments to direct care workers providing Personal Assistance Services in both the agency and participant-directed models may be made when the participant is hospitalized, absent from their home, or in isolation and unable to receive services due to COVID-19. Personal Assistance Services retainer payments may not exceed 15 days – the number of days for which OLTL authorizes a payment for "bed-hold" in nursing facilities.
​Same as Red
​Same as Red for the duration of the Appendix K approval.
​Same as Red for the duration of the Appendix K approval.
​Authorization for Changes to the PCSP
​If delays are occurring while waiting for approval and authorization of PCSP changes in the CHC-MCO authorization system, documented email approval of changes and additions to PCSPs will suffice as authorization. Upon validation that an email approval was provided for requested changes, the CHC-MCO may backdate authorizations for waiver services.
​Same as Red
​Approval and authorization of PCSP changes follow normal protocol.
​Same as Red for the duration of the Appendix K approval.

1 Services on the PCSP that were increased or provided in a modified manner to address COVID-19 related needs are considered temporary increases/changes.  The CHC-MCOs will notify participants that services will revert back to service levels and modalities that were in place prior to being impacted by COVID-19 following the already established process for handling temporary increases/changes to PCSPs.  Participants will have the opportunity to file a grievance/appeal should they disagree with the action and services will continue at the current level pending the resolution of the grievance and appeal.


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