Liberty Healthcare PCS Provider Training May 2016
The Freedom to Succeed™
Welcome
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AGENDA
9:00-9:15 am Welcome and Introductions Denise Hobson, Director of Clinical Services
Liberty Healthcare
9:15-9:45 am Review of PCS Policy Requirements
Lyneka Judkins, Chief Operations Officer
Liberty Healthcare
9:45-10:40 am Understanding the Beneficiary’s Assessment
Denise Hobson, Director of Clinical Services
Liberty Healthcare
10:40 -11:00 am Break
11:00 – 11:15 pm Proposed Policy 3L and Eligibility Updates
Lyneka Judkins, Chief Operations Officer
Liberty Healthcare
11:15 – 11:30 am Internal DMA Audit Lyneka Judkins, Chief Operations Officer
Liberty Healthcare
11:30 – 12:30 pm Q&A Session
Review of PCS Policy Requirements (Interactive Presentation)
The Freedom to Succeed™
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Test Your Knowledge
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PCS ICD-10 Transition Forms
• When is an ICD-10 Transition Form required for a beneficiary?
• Before their annual review if scheduled after 10/1/2015
• What are the two ways a provider may submit the transition form to Liberty?
• Fax or Upload into QiReport
• Where are the 3 places a PCS Provider can locate an ICD-10 Transition Form?
• DMA Website, LHC Website, Annual Notification Letter
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PCS ICD-10 Transition Form
Completed forms can be submitted to Liberty in one of two ways:
Fax – The PCS Provider or Practitioner can fax the form directly to Liberty at 919-573-9694.
Upload – The PCS Provider can upload the completed form to ‘Supporting Docs’ through the provider portal.
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PCS ICD-10 Transition Form
To upload the ‘Transition Form’ through the provider portal, select the ‘Referrals’ tab on the top toolbar, then click ‘Supporting Docs’ from the left index bar:
2. Select ‘Supporting Docs’ to upload form.
1. Select the ‘Referrals’ tab.
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PCS ICD-10 Transition Form
Where is the DMA 3137 PCS ICD-10 Transition Form located?
1. Liberty website: http://nc-pcs.com/Medicaid-PCS-forms/
2. N.C. Division of Medical Assistance (DMA) PCS webpage under “Forms.”
http://www2.ncdhhs.gov/dma/pcs/pas.html
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Completing the Service Plan
• How many days does the PCS Provider have to complete the required Service Plan? • 7 Business Days
• How many days does the PCS Provider have to get the completed Service Plan signed and uploaded into QiReport? • 14 Business Days
• When is a Service Plan required for a beneficiary? • Every time a PCS Provider receives and accepts a ‘referral’ in QiReport
• How should the PCS Provider proceed when the amount of approved hours does not match the hours reflected in the assessment? • Complete a manual Service Plan, upload into QiReport, and Call Liberty
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Discharges
• How many days does the PCS Provider have to complete a discharge when the beneficiary is no longer under their care?
• 7 Business Days
• How does a PCS Provider discharge a PCS beneficiary?
• Through QiReport
• If the beneficiary is not approved for PCS that is reimbursed by Medicaid, but remains under the care of the PCS Provider, do they have to discharge in QiReport?
• Yes.
• Does the PCS Provider need to discharge a beneficiary if they are hospitalized for a brief time?
• If the beneficiary has been approved for PCS and the PCS Provider will resume care once the beneficiary is discharged from the hospital, then a discharge is NOT required in QiReport
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Discharges
The PCS Provider is required to discharge a beneficiary from QiReport if they are no longer providing PCS that is reimbursed through Medicaid.
2. Select ‘Discharge’ to discharge beneficiary.
1. Select the ‘Referrals’ tab.
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Provider Acceptance
• How many days does the PCS Provider have to respond to a referral for PCS?
• 2 Business Days
• What happens if the PCS Provider does not respond in 2 business days?
• The referral will be rejected and the next provider selection will be sent a referral
• Where can the PCS Provider locate their referrals and respond?
• In QiReport on the ‘Referrals’ page
• Does the time the PCS Provider takes to accept a beneficiary effect their PA’s?
• Yes. PA’s are made effective based off of the provider acceptance date, with exception of initial assessments.
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Provider Acceptance
The PCS Provider should check their ‘Referrals’ tab daily for any new PCS referrals.
2. Select beneficiary to accept/reject.
1. Select the ‘Referrals’ tab.
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Preadmission Screening and Resident Review (PASRR)
• Who requires a PASRR screen?
• Any Medicaid beneficiary seeking admission into an Adult Care Home after January 1, 2013; including those who are private pay and become Medicaid eligible after this date.
• Who does not require a PASRR screen?
• Any individual who was admitted into the Adult Care Home prior to 1/1/2013 regardless of payer, private pay individuals, and those who reside in the 5600 A or C settings
• What is the purpose of the PASRR screen?
• To evaluate for serious mental illness
• If a beneficiary is transferred from a nursing home to an Adult Care Home and has a PASRR with an A code, do they require another PASRR?
• Yes; the beneficiary must have a PASRR with an Adult Care Home code.
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Preadmission Screening and Resident Review (PASRR)
The following are acceptable Adult Care Home Codes for PASRR:
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Quality Improvement Program
• What form is required to be completed and submitted to DMA?
• DMA 3136 Internal Quality Improvement Program Attestation Form
• The DMA 3136 Form is required to be submitted by what date?
• December 31st of each year
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Quality Improvement Program
• What are the requirements for the PCS Provider regarding an Internal Quality Improvement Program?
• Develop, and update at least quarterly, an organizational Quality Improvement Plan or set of quality improvement policies and procedures that describe the PCS CQI program and activities;
• Implement an organizational CQI Program designed to identify and correct quality of care and quality of service problems;
• Conduct at least annually a written beneficiary PCS satisfaction survey for beneficiaries and their legally responsible person;
• Maintain complete records of all CQI activities and results;
Understanding the Beneficiary’s Assessment
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Where It All Starts…..
PCS request is dropped in QIR queue for
scheduling
Scheduling schedules visit
with the beneficiary and time and date
are established
Assessor receives the
assignment and contacts
beneficiary the day before to
confirm appointment
Assessor conducts the assessment
based on the beneficiary’s
demonstrated ability to
perform ADLs
Assessor submits the assessment
and a decision
generates
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What The Assessor Captures In An Assessment
Available caregivers
Daily medicine regimen
Diagnosis information
Paid supports/Non Paid supports
Demonstrations of a beneficiary’s ability to perform their activities of daily living (ADLS)
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What The Assessor Captures In An Assessment
Special assistive tasks
Exacerbating conditions that impact their ability to perform their ADLs
Home safety evaluation
Provider choice
Need frequency
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Activities of Daily Living (ADLs)
Bathing
Dressing
Mobility
Toileting
Eating
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Understanding Assessment Fields •Beneficiary attempts to demonstrate how they would perform an ADL task.
Demonstrated Ability
•The beneficiary requires assistance to complete task.
Check If Required
•Level of assistance the beneficiary requires to complete the task.
Assistance Level
•Identified if there is an assistance need for the indicated ADL.
IADL Task Needs
•Number of days the beneficiary performs the task.
Frequency
•Number of days the beneficiary has an alternate caregiver other than the PCS aide to assist with meeting the need.
Need Fully Met
•Auto-populated number of days of unmet need for PCS service.
PCS Need Frequency
• Task need is inclusive of weekend need. Weekend
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Bathing: What Is Assessed?
Bathe by means of shower, tub bath, bed bath ,or sponge bath
Hair care - shampooing and combing hair
Nail care - cleaning/cutting nails
A beneficiary‘s ability to demonstrate/perform the following tasks:
Skin care - applying lotion/washing hands and feet
Mouth care - brushing teeth, dentures etc. and reinserting
Shaving - face, legs, axilla (armpit) areas
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Bathing Section
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Dressing: What Is Assessed?
A beneficiary’s ability to demonstrate/perform the following tasks:
Don clothing/socks/shoes
Remove clothing/socks/ shoes
Manage clothing and shoe fasteners
Manage TEDS (compression
stockings) - removing and applying
Manage splints/braces- removing and applying
Manage - removing and applying
Manage prosthetics- removing and applying
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Dressing Section
Factoid: TED is an acronym for thromboembolism-deterrent hose!
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Mobility: What Is Assessed?
Transfer to/from the bed
Transfer to/from chair
Ambulate room to room – by limb or assistive device
A beneficiary’s ability to demonstrate/perform the following tasks:
Negotiating stairs within the home – only to areas of service provision
Perform range of motion (ROM)
Turn and reposition in bed
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Mobility Section
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Toileting: What Is Assessed?
A beneficiary’s ability to demonstrate/perform the following tasks:
Remove /pull up/ fasten garment
Perform hygiene after toileting/incontinence
Transfer to and from the bedside commode or toilet
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Toileting Section
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Eating: What Is Assessed?
Cutting food
Ability to feed self
Use of utensils
Ability to lift limb to mouth
Ability to perform tube feedings
The beneficiary ability to demonstrate/perform the following tasks:
Ability to clean meal service area
Clean utensils/dishes/empty trash
Perform meal prep: opening packages
Perform meal prep: heat and assemble food
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Eating Section
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Special Assistive Tasks: What Is Assessed?
Break up fecal impactions
IV fluids
O² therapy
Ostomy
Sterile dressing changes
A beneficiary’s ability to demonstrate/perform the following tasks:
Suctioning
Urinary catherization
Wound irrigation
Tube feeding and g tube management
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Delegated Medical Monitoring Tasks
A beneficiary’s ability to demonstrate/perform the following tasks:
BP monitoring
Blood glucose monitoring
Med self-administration reminders
Other treatment monitoring
IV fluids
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Delegated Medical Monitoring Tasks
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Special Assistive Tasks Section
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Conditions Affecting Beneficiary ADL Performance/Assistance Time
Exacerbating conditions or conditions affecting ADL performance allow the assessor to identify those that affect the beneficiary’s ability to perform their ADLs.
All body systems are covered in these conditions:
Respiratory System
Cardiovascular
Gastrointestinal
Neurological
Behavioral
Sensory Impairment, and
Musculoskeletal system
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Conditions Affecting ADL Performance Time
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Safety And Environmental Conditions
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Provider Choice /Return Frequency
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How Does The Beneficiary Qualify For Services?
The beneficiary must have:
At least 3 Limited Overall Self -Performance Capacity Ratings out of the 5 ADLs and have unmet needs.
At least 1 extensive or greater overall self performance capacity and one or more limited assist or greater overall self performance capacity and have unmet needs.
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How Many Hours Can A Beneficiary Receive?
80 Hours
• For a beneficiary who does not meet the criteria for Session Law 2013-306
60 Hours
• EPSDT on the initial assessment hour generation. All EPSDT assessments go to DMA for final hour calculation/evaluation
Up to 130 Hours
• For a beneficiary who meets the criteria for Session Law 2013-306
BREAK
Proposed Policy 3L and Eligibility Updates
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Proposed Policy 3L & Eligibility Updates
• Policy 3L has been revised and will be open for public comment;
• The proposed policy will be located on the DHHS website here: http://dma.ncdhhs.gov/get-involved/proposed-medicaid-and-nc-health-choice-policies;
• Finalized changes will go into effect July 1, 2016; • Questions about proposed changes should be
submitted through the public comment page or via email at [email protected]
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Proposed Policy 3L & Eligibility Updates
Section 4.2.2 Medicaid not covered specific criteria
Medicaid shall not cover PCS when:
13. Independent medical information does not validate the assessment, PCS hours may be reduced, denied, or terminated based on the additional information.
*13. added to existing Medicaid not covered specific criteria.
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Proposed Policy 3L & Eligibility Updates
Section 5.2.3 EPSDT Additional Requirements for PCS Medicaid may authorize services that exceed the PCS service limitations if determined to be medically necessary under EPSDT based on some or all of the following documents submitted by the provider before PCS is rendered:
a. Work and School verification, where applicable, for the beneficiary’s caregiver, legal guardian, or power of attorney…..
b. Verification from the Exceptional Children’s program per county if PCS is being requested in school setting; or
c. Health record documentation……or
d. Physician documentation of primary caregiver’s limitation that would prevent the caregiver from caring for the beneficiary, if applicable.
e. Any other independent records that address ADL abilities and need for PCS.
If additional information does not validate the assessment, PCS hours may be reduced, denied, or terminated based on additional records.
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Proposed Policy 3L & Eligibility Updates
Section 5.4.4 Requirements for PCS Expedited Assessment Process
To qualify for the expedited process the beneficiary shall:
a. be medically stable;
b. eligible for Medicaid or pending Medicaid eligibility;
c. have a Pre-Admission Screening and Resident Review (PASRR) if seeking admission to an Adult Care Home licensed under G.S. 131 D-2.4;
d. in process of being discharged from the hospital following a qualifying stay;
e. in process of being discharged from a skilled nursing facility;
f. be under adult protective services; or
g. be an individual served through the transition to community living initiative
*LME – MCO transition coordinators are responsible for requesting the expedited PCS process for individuals served through the transition to community living initiative.
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Proposed Policy 3L & Eligibility Updates
Pettigrew v. Brajer (Pashby v. Wos)
PCS will be amended to include additional program requirements agreed upon in this settlement; identified action items include:
Updates to Eligibility Criteria
Implementation of a Reconsideration Process
Reinstatement and Reassessment of Qualifying Individuals
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Proposed Policy 3L & Eligibility Updates
Pettigrew v. Brajer (Pashby v. Wos)
Updates to Eligibility Criteria: • The Settlement requires that DMA will assure the PCS eligibility
criteria is the same regardless of residential setting.
• In Adult Care Homes clean-up and basic meal preparation tasks are covered services paid for by State/County Special Assistance. Effective July 1, 2016, clean-up and basic meal preparation services that duplicate State/County Special Assistance (Section M, tasks 6-9 on the assessment) will be scored as needs met.
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Proposed Policy 3L & Eligibility Updates
Pettigrew v. Brajer (Pashby v. Wos)
Implementation of a Reconsideration Process:
Beneficiaries 21 and older who receive an initial approval for less than 80 hours per month may submit a Reconsideration Request to the IAE if they do not agree with the initial level of service determined. Section 5.6 Reconsideration Request for Initial Authorization for PCS
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Proposed Policy 3L & Eligibility Updates
Section 5.6 Reconsideration Request for Initial Authorization for PCS
When is reconsideration appropriate?
The request for increasing hours above the initial approval are not based on a Change of Status;
The beneficiary is able to provide supporting documentation that specifies, explains, and supports why
additional authorized hours of PCS is needed and which ADLs and tasks are not being met with the current hours.
*Form and instructions will be made available on the DMA website.
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Proposed Policy 3L & Eligibility Updates
Section 5.6 Reconsideration Request for Initial Authorization for PCS
The Process:
1. After receiving an initial approval for an amount of hours less than 80 hours per month, a beneficiary must wait 30 days before submitting a request for reconsideration.
2. The beneficiary must submit a request to increase hours above the initial approval no earlier than 31 calendar days and no later than 60 calendar days from the date of the approval notification.
3. The Request for Reconsideration form and supporting documentation should provide information indicating why the beneficiary believes that the prior assessment did not accurately reflect the beneficiary’s functional capacity or why the prior determination is otherwise insufficient.
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Proposed Policy 3L & Eligibility Updates
Section 5.6 Reconsideration Request for Initial Authorization for PCS
The Process:
4. Upon receipt of a completed reconsideration request for additional hours, a reassessment may be scheduled or the previous assessment modified. A reconsideration request is not considered complete without supporting documentation as indicated in 5.6(d).
5. If the reconsideration determines a need for additional PCS hours, additional hours will be authorized according to Policy. This constitutes an approval and no adverse notice or appeal rights are provided. The provider will have to complete a new service plan.
6. If the reconsideration determines that the PCS hours authorized during the initial assessment are sufficient to meet the beneficiary’s needs, an adverse decision will be issued with appeal rights.
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Proposed Policy 3L & Eligibility Updates
Pettigrew v. Brajer (Pashby v. Wos)
Reinstatement and Reassessment of Qualifying Individuals:
Those denied or terminated under Clinical Coverage Policy 3L, prior to the amendment effective 7/1/16 whom:
• Were determined to have cognitive impairment or a mental health diagnosis with no third party present during the assessment; and
• Were denied or terminated due to receipt of hospice services.
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Proposed Policy 3L & Eligibility Updates
Pettigrew v. Brajer (Pashby v. Wos)
Qualifying Individuals for Reinstatement or Reassessment will be:
• Sent a letter with instructions on how to begin the process;
• If previously terminated from PCS, reinstated at the hours prior to termination (will be reassessed within 6 months under PCS policy effective 7/1/2016);
• If previously denied PCS, reassessed under PCS policy
effective 7/1/2016.
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Proposed Policy 3L & Eligibility Updates
Pettigrew v. Brajer (Pashby v. Wos)
Reinstatement and Reassessment of Qualifying Individuals, the PCS Provider must:
• Accept the referral from the beneficiary once the reinstatement is processed; and
• Provide Medicaid with a PCS ICD-10 Transition Form before the provider can bill Medicaid for your PCS services. However, this does not need impact effective start days for services.
*Providers may see the beneficiary displayed in their portal, but services should not begin until after formal acceptance and delivery of an approval letter.
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Provider Manual – New Version Coming July 2016!
Located on the Liberty Healthcare website at: http://nc-pcs.com/pcs-provider-manual/
Will include all new policy updates in addition to a few revisions.
PCS Internal Audit
The Freedom to Succeed™
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PCS Internal Audit
• In spring of 2015, PCS underwent an internal audit conducted
by Office of the Internal Auditor (OIA). This audit was concluded in July of 2015.
• Two areas of concern identified by OIA were Supervisory Visits and Aide Training requirements.
• As a result of the PCS program internal audit, DMA began conducting audits of PCS providers in January 2016.
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PCS Internal Audit
• The PCS internal audit is an independent audit conducted by DMA PCS nurse consultants and is not associated with DMA Program Integrity (pre or post-payment review).
• Although, this audit process is independent from Program Integrity; audit findings that are non-compliant with the PCS policy will be reported to DMA Program Integrity.
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Forwarded to DMA Staff Faxed to DMA
within 2 Calendar Days
by Provider
Faxed to DMA within 5
Calendar Days by Provider
PM Receives random sample of Beneficiaries for identified Month
DMA verifies Provider Fax Number and
Contact Information
DMA Requests by Fax specific documents from
Provider for RN Supervisory Visits and
PCS Aide Training
DMA Completes QI Parameter Review
Tool for each Beneficiary in
sample
DMA will follow up with the Provider
for any missing documentation
Results will be documented internally by
DMA
PM Review of Provider Compliance
Providers determined not in
Compliance submitted to PI
Providers may request the
results of their audit two weeks after submission
of documentation
PCS Internal Audit Process
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PCS Internal Audit
• DMA will conduct the PCS internal audit on a quarterly basis; randomly selecting between 50-75 beneficiaries each quarter for review of Supervisory visits and/or Aide Training Requirements.
• Providers will have five (5) calendar days from the date of contact to submit documentation via fax to DMA.
• Providers are contacted via telephone call with a follow-up fax sheet that requests required documentation.
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PCS Internal Audit
• Documentation on Supervisory visits will be audited based on PCS Clinical Coverage Policy Section 7.10 b. (1-9).
• Documentation on Aide Training Requirements will be audited based on PCS Clinical Coverage Policy Section 6.1.2 (a – g). Providers must submit corresponding aide task sheet for date requested by DMA staff.
* Aide Training documentation requested for residents who reside in an Adult
Care Home will be requested for first shift aides on the date requested.
Question and Answer Session
Liberty Healthcare PCS Provider Training May 2016
The Freedom to Succeed™
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