Compliance Strategies for Home Care Agencies providing SLS and CES waiver services

This guidance is intended to help home care agencies providing Home and Community Based Service-Intellectual and Developmental Disabilities (HCBS-IDD) - Supported Living Services (SLS), Children’s Extensive Services (CES) and case management agencies understand how to apply and be in compliance with home care rules. Information herein is to be used as guidance only with the assumption that there is always the potential for extenuating circumstances and agencies may have other systems or processes in place that meet the intent of the rule.
Personal Care Worker (PCW) includes: Relative Personal Care Worker (RPCW), Direct Care Provider (DCP), Family Caregiver (FCG), Staff and Provider/Contractor
Consumer includes: Persons Receiving Services (PRS), Client, Participant
Frequently asked questions (FAQ)
When does a Supported Living Services (SLS) and/or Children’s Extensive Services (CES) agency need to be a licensed home care agency?  
SLS and CES agencies which provide hands-on personal care services/activities(excluding emergent or one time incidental response to an unanticipated situation) are required to be licensed as a home care agency. Personal care services/activities means assistance with activities of daily living, including but not limited to bathing, dressing, eating, transferring, walking or mobility, toileting, and continence care. It also includes housekeeping, personal laundry, medication reminders, and companionship services furnished to a home care consumer in the home care consumer's temporary or permanent home or place of residence. This service covers those normal daily routines that the home care consumer could perform for himself or herself were he or she physically capable, which are intended to enable that individual to remain safely and comfortably in the home care consumer's temporary or permanent home or place of residence. (6 CCR 1011-1 Chapter 26, section 5) A home care agency does not include an individual who is not employed by or affiliated with a home care agency and who acts alone, without employees or contractors to provide services to SLS or CES consumers.
Does an agency providing respite care need to be a licensed home care agency?
A home care license is not required for agencies which provide respite care without hands-on care, or when a respite staff member needs to respond to an isolated, emergent or incidental occurrence that was not anticipated or care planned. An example of this may be an unanticipated, isolated incontinence episode.
What is considered a ‘temporary place of residence’?
Depending on the consumer's living situation, a temporary place of residence may include temporary accommodations such as hotels, shelters, a family member’s residence, a friend's residence,  etc. It is the place consumers would provide as their address and where they would receive mail-in a temporary situation.
Are personal care workers able to assist a person to eat?
Assistance with eating/feeding may be provided by a personal care worker when the task is considered "unskilled", meaning the consumer is able to independently chew, swallow and be positioned upright. Unskilled feeding includes assistance with eating by mouth and using common eating utensils, such as spoons, forks and straws.  Verbal cues or verbal prompting is not considered hands-on assistance with feeding.
Whenever there is a high risk that the consumer may choke as a result of the feeding, the consumer should be in the care of an agency licensed to provide skilled home care services. Certified Supported Living Services (SLS) and Children’s Extensive Services (CES) agencies may only provide assistance with skilled feeding needs when licensed as a Class A, medical home care agency.
For an eating/feeding situation where special food preparations are necessary, staff must be provided step-by-step, care planned instruction on how to prepare the food, what texture and size of portions are to be provided, how to help the consumer safely drink during the meal, and instructions on the use and setup of any adaptive equipment that may be used by the consumer. The agency must maintain documentation to show any staff who are assigned to help prepare and/or assist a consumer with special food preparations are trained by a qualified professional. If there is a need for a texture-modified diet, the agency must ensure an eating/swallowing assessment was completed by an appropriate therapist (10 CCR 2505-10, 8.609.6C). Qualified professional reviews of any assessments must be periodically conducted (10 CCR 2505-10, 8.609.6 C 1).
Can gastrostomy (G-Tube) services be provided to Supported Living Services (SLS) and Children’s Extensive Services (CES) consumers receiving home care services?
Home and Community Based Service-Intellectual and Developmental Disabilities (HCBS-IDD) regulations allow personal care workers to administer nutrients, water and medications through gastrostomy tubes, as long as the PCW has successfully passed the training and monitoring requirements outlined in the SLS/CES waiver regulation, and is under the monitoring and supervision of a licensed nurse or physician. The agency must maintain proof that all staff providing G-Tube services and administering medications have successfully passed the required courses (10 CCR 2505-10, 8.614).
Can personal care workers assist consumers with medicated shampoos while providing hair care?
Hair care may include shampooing with non-medicated shampoo or shampoo that does not require a physician’s prescription.  The personal care worker may not apply any over-the-counter medicated shampoos (e.g.: Selsun Blue Medicated, Tegrin) or shampoos requiring a prescription. Certain conditions; such as eczema, psoriasis or dandruff; may be unknowingly made worse or prolonged by over-the-counter medicated shampoos without proper physician guidance. Supported Living Services (SLS) and Children’s Extensive Services (CES) personal care workers who are Qualified Medication Administration Persons (QMAP) may apply medicated or prescription shampoos as prescribed and ordered by a physician.  
Can personal care workers use nail clippers to trim fingernails or toenails?
A personal care worker may not use fingernail or toenail clippers to trim consumer finger or toe nails. Personal care workers may only file nails. The use of nail clippers creates a high risk of injury when disease states such as diabetes, neuropathy, peripheral vascular disease, multiple sclerosis or cerebral palsy are present.  Unexpected movements, infections, skin conditions and an inability of the consumer to recognize or respond to pain also present a risk of injury. Consumers with a medical condition that may involve peripheral circulatory problems or loss of sensation should be under the care of a physician or an agency licensed to provide skilled home care services to meet this need.
Can a personal care worker assist consumers with exercise?
A personal care worker may assist a consumer with exercise only when the assistance takes the form of verbal prompts, reminders and encouragement of normal bodily movement, or the performance of a prescribed exercise program. A personal care worker may not perform any hands on exercise that moves the consumer’s limbs or joints through a range of motion.
Can a personal care worker provide catheter care to a consumer?
A personal care worker may empty urinary collection devices such as catheter bags. Insertion and removal of catheters and care of external catheters (such as condom catheters) is considered skilled and must be completed by a licensed professional. Any time the personal care worker would disrupt the closed system for a Foley or suprapubic catheter (such as changing from a leg bag to a night bag) the activity is considered skilled and must be provided by a licensed professional, under the supervision of a licensed Class A, skilled home care agency.
Can medications be administered by a personal care worker?
Medication administration by the personal care worker is only allowed if the worker has successfully passed the CDPHE-approved training program for Qualified Medication Administration Persons (QMAP). A QMAP may only provide medication administration for consumers of Supported Living Services (SLS) or Children’s Extensive Services (CES) and may not provide medication administration for other consumers of home care. The agency must maintain proof that all staff administering medications for SLS or CES clients have successfully passed the QMAP course (10 CCR 2505-10 8.603.9, 8.609.2, 8.609.6 D 1-8 and 6 CCR 1011-1 Chapter 24).
What is required when a consumer’s short-term or long-term needs change, such as after a hospitalization?
The SLS or CES interdisciplinary team (IDT) is required to meet and discuss how the consumer’s needs have changed and what additional services are needed.  The consumer's primary physician should be notified of any changes in the consumer’s condition and the need for additional services. If home care is required and the agency is not a licensed home care agency, the consumer's Medicaid waiver case manager will coordinate initiation of the additional services with an appropriately licensed home care agency.  
Can a licensed home care agency also provide behavioral services?
If the agency is certified by the Colorado Department of Health Care Policy and Financing (HCPF) to provide behavioral services through the Supported Living Services (SLS), they may provide any of the following: Behavioral Consultation services; Behavioral Line services; Behavioral Plan Assessment services and Individual or Group Counseling services.  The care plan must be specific as to the individual and unique needs of the consumer and the expectations of the personal care worker. Appropriate training and education for each consumer circumstance must be provided.
Can a licensed home care agency provide massage therapy services to consumers?
An agency may provide massage therapy if it employs appropriately qualified staff and has been certified by the Colorado Department of Health Care Policy and Financing (HCPF) to provide this service for Supported Living Services (SLS) and Children’s Extensive Services (CES) consumers. Personal care workers cannot perform massage therapy.
Can a licensed home care agency provide music therapy to consumers? Music therapy is not an approved service under the Supported Living Services (SLS) or Children’s Extensive Services (CES) waivers. However, under the Professional services portion of the SLS and CES waivers, movement therapy (the use of music and/or dance as a therapeutic tool for the habilitation, rehabilitation and maintenance of behavioral, developmental, physical, social, communication, pain management, cognition and gross motor skills) may be provided if the agency is certified to provide these specific services through the Department of Health Care Policy and Financing (HCPF).  
Can a family member be paid for providing care to a consumer under the SLS or CES waivers?
Under the Supported Living Services (SLS) and Children’s Extensive Services (CES) waiver, the legally responsible adult for a child (typically the parent of the child or guardian who has a duty to provide care to the child) may not be reimbursed for personal care services under the CES waiver. Only in “extraordinary circumstances specified by the state” can legally responsible adults be paid relative caregivers under the CES waiver. This does not however, prohibit other family members such as adult siblings from providing personal care services and being reimbursed as an employee of a certified CES agency (2014 SLS and CES waiver in Appendix C, C-2 d).
For circumstances where the above restrictions do not apply, a family member (relative personal care worker) may receive payment to deliver personal care services as an employee of an agency certified to provide SLS/CES services. Family members, as employees of an agency, are subject to the same requirements for education, training, supervision and documentation that apply to other, non-family personal care workers. Agencies employing relative personal care workers must follow all regulations regarding hiring, education, training, supervision and documentation set forth in 10 CCR 2505-10 8.600 and 6 CCR 1011-1 Chapter 26.
In what ways can supervision of personal care workers be accomplished?
Supervision of personal care workers must be performed by an employee of the agency who is in a designated supervisory capacity and available to the worker for questions at all times. Supervision includes at least annual evaluation of the personal care worker providing consumer services, inclusive of observation of tasks performed and the caregiver’s relationship with the consumer. Additional supervision may also be conducted through consumer satisfaction surveys, annual performance evaluations, and review of personal care worker contact/service notes. For consumers that receive intermittent care, such as occasional respite services (e.g. 1-3 times a year), supervision shall occur at the time the respite services are being provided. The facility must maintain documented evidence that personal care workers are supervised as required.
Can an agency use the Individualized/Service Plan to meet home care license requirements for what needs to be in a consumer's Care Plan for home care? What if the Individualized Plan/Service Plan does not include all the required information?
An Individualized/Service Plan can meet the requirements for a Care Plan if the Individualized/Service Plan includes the tasks/care to be provided, the schedule and frequency of planned visits, including the specific days of the week and the specific times of day visits are to occur. If the Individualized/Service Plan does not contain that level of specificity the agency needs to develop a separate consumer Care Plan that includes the level of detail listed above.
This is for informational purposes only. Following this guidance does not guarantee that deficient practice will not be cited as part of a survey visit. This guidance is not intended to be the best or the only way to be compliant.
Rule Links:
Home and Community Based Service-Intellectual and Developmental Disabilities (HCBS-IDD) - Supported Living Services (SLS) and Children’s Extensive Services (CES) Rules:  10 CCR 2505-10 8.600 and 10 CCR 2505-10 8.500.
In cases where there is is no CES or SLS regulation to cover a specific situation, Home Care licensure rules will still apply.