Section 52.3. Definitions

The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:

ADL—Activities of daily living—The term includes eating, drinking, ambulating, transferring in and out of a bed or chair, toileting, bladder and bowel management, personal hygiene, self-administering medication and proper turning and positioning in a bed or chair.

Act 150—A State-funded program under the Attendant Care Services Act (62 P. S. § § 3051—3058).

Aging waiver—A Federally-approved 1915(c) waiver under section 1915(c) of the Social Security Act (42 U.S.C.A § 1396n(c)) that authorizes services to participants 60 years of age or older.

Applicant—An individual or legal entity in the process of enrolling as a provider.

Attendant Care waiver—A Federally-approved 1915(c) waiver under section 1915(c) of the Social Security Act that authorizes services to participants 18 years of age or older but under 60 years of age with physical disabilities.

Attestation engagement—Financial services that result in the issuance of a report on a subject matter or an assertion about the subject matter that is the responsibility of another party. The term includes audits, examinations, reviews, compilations and agreed-upon procedures.

Back-up plan—A component of the service plan that is comprised of the individualized back-up plan and the emergency back-up plan.

CAP—Corrective action plan—A plan created by the provider or the Department to address provider noncompliance with this chapter.

CHAMPUS—Civilian Health and Medical Program of Uniformed Services.

COMMCARE—A Federally-approved 1915(c) waiver under section 1915(c) of the Social Security Act called the Community Care waiver that authorizes services to participants 21 years of age and older with traumatic brain injuries.

Community transition service—A one-time service which assists a participant to move from an institution to the participant’s home, apartment or another noninstitu-tional living arrangement.

Community transition service provider—A provider who renders community transition services.

Complaint—Dissatisfaction with program operations, activities or services received, or not received, involving HCBS.

Critical incident—An occurrence of an event that jeopardizes the participant’s health or welfare including:

(i) Death, serious injury or hospitalization of a participant. Pre-planned hospitalizations are not critical incidents.

(ii) Provider and staff member misconduct including deliberate, willful, unlawful or dishonest activities.

(iii) Abuse, including the infliction of injury, unreasonable confinement, intimidation, punishment or mental anguish, of the participant. Abuse includes the following:

(A) Physical abuse.

(B) Psychological abuse.

(C) Sexual abuse.

(D) Verbal abuse.

(iv) Neglect.

(v) Exploitation.

(vi) Service interruption, which is an event that results in the participant’s inability to receive services and that places the participant’s health or welfare at risk.

(vii) Medication errors that result in hospitalization, an emergency room visit or other medical intervention.

Department—The Department of Human Services of the Commonwealth.

Direct care worker—A person employed for compensation by a provider or participant who provides personal assistance services or respite services.

EPLS—Excluded Parties List System—A database maintained by the United States General Services Administration that provides information about parties that are excluded from receiving Federal contracts, certain subcontracts and certain Federal financial and nonfinancial assistance and benefits.

Emergency back-up plan—A plan which outlines the steps to be taken by the provider and the participant to ensure that the participant’s needs are met in an emergency.

Fee schedule service—A service paid based on the MA Program fee schedule rates established by the Department.

Financial management services—A service which provides payroll, invoice processing and payment, fiscal reporting services, employer orientation, skills training and other fiscal-related services to participants choosing to exercise employer or participant-directed budget authority.

Financial review—A review of billing records against provider documentation to ensure services were provided in the type, scope, amount, duration and frequency as required by the participant’s service plan and to ensure that a billing for a service rendered by a provider is accurate.

Finding—An identified violation of the following:

(i) This chapter.

(ii) The MA provider agreement, including the waiver addendum.

(iii) Chapter 1101 (relating to general provisions).

(iv) The approved applicable waiver, including approved waiver amendments.

(v) A State or Federal requirement.

HCBS—Home and community-based services—Services offered as part of a Federally-approved MA waiver or Act 150 program.

IADL—Instrumental activities of daily living—The term includes the following activities when done on behalf of a participant:

(i) Laundry.

(ii) Shopping.

(iii) Securing and using transportation.

(iv) Using a telephone.

(v) Making and keeping appointments.

(vi) Caring for personal possessions.

(vii) Writing correspondence.

(viii) Using a prosthetic device.

(ix) Housekeeping.

ICF/ORC—Intermediate care facility/other related conditions.

Independence waiver—A Federally-approved 1915(c) waiver under section 1915(c) of the Social Security Act that authorizes services to participants 18 years of age and older but under 60 years of age with physical disabilities.

Individualized back-up plan—A plan which outlines the steps to be taken by the provider and participant to ensure that services are delivered to the participant in a situation where routine service delivery is interrupted.

Informal community supports—Services provided by a family member, friend, community organization or other entity for which funding is not provided by the Department.

LEIE—List of Excluded Individuals and Entities—A database maintained by the United States Department of Health and Human Services, Office of the Inspector General, that identifies individuals or entities that have been excluded Nationwide from participation in a Federal health care program.

Level of care re-evaluation—A redetermination of a participant’s clinical eligibility under a waiver or the Act 150 program.

MA—Medical Assistance.

MA provider agreement—An enrollment agreement signed by the provider which establishes requirements relating to the provision of services.

Medicaid—MA provided under a State Plan approved by the United States Department of Health and Human Services under Title XIX of the Social Security Act (42 U.S.C.A. § 1396a).

Medicaid State Plan—A plan to provide MA developed by the Department and approved by the United States Department of Health and Human Services under Title XIX of the Social Security Act which serves as the basis for Federal financial participation in the program.

Medicheck—A Departmental list identifying providers, individuals and other entities precluded from participation in the Commonwealth’s MA Program.

Monitoring—A review of a provider’s compliance.

Nursing facility—

(i) A long-term care facility that is:

(A) Licensed by the Department of Health.

(B) Enrolled in the MA Program as a provider of nursing facility services.

(C) Owned by a person, partnership, association or corporation and operated on a profit or nonprofit basis.

(ii) The term does not include the following:

(A) Intermediate care facilities for individuals with developmental or intellectual disabilities or other related conditions

(B) Federal or State-owned long-term care nursing facilities.

OBRA waiver—A Federally-approved 1915(c) waiver under section 1915(c) of the Social Security Act named for the Omnibus Budget and Reconciliation Act of 1981 (Pub. L. No. 97-35) that authorizes services to participants 18 years of age or older but under 60 years of age with developmental disabilities.

OHCDS—Organized Health Care Delivery System provider—A provider who is authorized by the Department to contract with an entity to provide a vendor good or service.

Participant—A person receiving services through a waiver or the Act 150 program.

Participant-directed budget authority—The spending authority granted to the participant through a waiver whereby the participant is authorized to spend the amount of money allocated in the participant’s service plan on goods and services.

Participant goal—A service plan requirement that states a participant’s objective towards obtaining or maintaining independence in the community.

Participant need—A service plan requirement based on a person-centered assessment.

Participant outcome—A service plan requirement that measures whether a service, TPR or informal community support is achieving a participant goal.

Person-centered approach—A holistic approach to serving participants which focuses on a participant’s individual and specific strengths, interests and needs.

Person-centered assessment—A Department-approved questionnaire used to determine the specific needs of a participant by utilizing a person-centered approach.

Personal assistance services—Services aimed at assisting the participant to complete ADLs and IADLs that would be performed independently if the participant did not have a disability.

Preventable incident—A critical incident that could be avoided through appropriate training of a staff member or participant following established policies and procedures or implementation of other reasonable precautionary measures.

Provider—A Department-enrolled entity which provides a service.

QMP—Quality Management Plan—A provider-created plan to address areas of quality improvement identified by the provider or the Department.

Respite services—Personal assistance services which are provided on a temporary, short-term basis when a noncompensated caregiver is unavailable to provide personal assistance services.

Risk mitigation strategies—Methods to reduce risks to a participant’s health and safety.

SCE—Service coordination entity—A provider authorized to render service coordination services in a waiver or Act 150 program.

Service—A benefit which a participant receives under an approved MA waiver or the Act 150 program.

Service coordination—Service that assists a participant in gaining access to needed waiver services, MA State Plan services and other medical, social and educational services regardless of funding source.

Service coordinator—A staff member who provides service coordination services at an SCE.

Service plan—The Department-approved comprehensive written summary of a participant’s services, TPR and informal community supports.

TPR—Third party medical resource—Medical resources used to pay for participant services, including Medicare, CHAMPUS, workers’ compensation, for profit and nonprofit health care coverage and insurance policies, and other forms of insurances.

Vendor good or service—A rendered item or service that is not on the MA fee schedule for which the Department reimburses an OHCDS or provider.

Waiver—The Aging, Attendant Care, COMMCARE, Independence, and OBRA Home and Community-Based Service waivers approved by the Federal Centers for Medicare and Medicaid Services.