SECTIONS 14525-14530 - California Statutes

WELFARE AND INSTITUTIONS CODE

SECTION 14525-14530

14525. Any adult eligible for benefits under Chapter 7 (commencing
with Section 14000) shall be eligible for adult day health care
services if that person meets all of the following criteria:
(a) The person is 18 years of age or older and has one or more
chronic or postacute medical, cognitive, or mental health conditions,
and a physician, nurse practitioner, or other health care provider
has, within his or her scope of practice, requested adult day health
care services for the person.
(b) The person has functional impairments in two or more
activities of daily living, instrumental activities of daily living,
or one or more of each, and requires assistance or supervision in
performing these activities.
(c) The person requires ongoing or intermittent protective
supervision, skilled observation, assessment, or intervention by a
skilled health or mental health professional to improve, stabilize,
maintain, or minimize deterioration of the medical, cognitive, or
mental health condition.
(d) The person requires adult day health care services, as defined
in Section 14550, that are individualized and planned, including,
when necessary, the coordination of formal and informal services
outside of the adult day health care program to support the
individual and his or her family or caregiver in the living
arrangement of his or her choice and to avoid or delay the use of
institutional services, including, but not limited to, hospital
emergency department services, inpatient acute care hospital
services, inpatient mental health services, or placement in a nursing
facility or a nursing or intermediate care facility for the
developmentally disabled providing continuous nursing care.
(e) Notwithstanding the criteria established in subdivisions (a)
to (d), inclusive, of this section, any person who is a resident of
an intermediate care facility for the developmentally
disabled-habilitative shall be eligible for adult day health care
services if that resident has disabilities and a level of functioning
that are of such a nature that, without supplemental intervention
through adult day health care, placement to a more costly
institutional level of care would be likely to occur.

14525.1. (a) Except as provided in subdivisions (b) and (c), any
adult eligible for benefits under Chapter 7 (commencing with Section
14000) shall be eligible for adult day health care services if that
person meets all of the following criteria:
(1) The person is 18 years of age or older and has one or more
chronic or postacute medical, cognitive, or mental health conditions,
and a physician, nurse practitioner, or other health care provider
has, within his or her scope of practice, requested adult day health
care services for the person.
(2) The person has two or more functional impairments involving
ambulation, bathing, dressing, self-feeding, toileting, transferring,
medication management, and hygiene.
(3) (A) Except as provided under subparagraph (B), the person
requires substantial human assistance in performing these activities.
(B) The persons described in subdivisions (b) and (c) shall only
require assistance in performing these activities.
(4) The person requires ongoing or intermittent protective
supervision, assessment, or intervention by a skilled health or
mental health professional to improve, stabilize, maintain, or
minimize deterioration of the medical, cognitive, or mental health
condition.
(5) The person requires adult day health care services, as defined
in Section 14550, that are individualized and planned, including,
when necessary, the coordination of formal and informal services
outside of the adult day health care program to support the
individual and his or her family or caregiver in the living
arrangement of his or her choice and to avoid or delay the use of
institutional services, including, but not limited to, hospital
emergency department services, inpatient acute care hospital
services, inpatient mental health services, or placement in a nursing
facility or a nursing or intermediate care facility for the
developmentally disabled providing continuous nursing care.
(6) The person meets the level of care set forth in Section 51120
of Title 22 of the California Code of Regulations.
(b) A resident of an intermediate care facility for the
developmentally disabled-habilitative shall be eligible for adult day
health care services if that resident meets the criteria set forth
in paragraphs (1) to (5), inclusive, of subdivision (a) and has
disabilities and a level of functioning that are of such a nature
that, without supplemental intervention through adult day health
care, placement to a more costly institutional level of care would be
likely to occur.
(c) Persons having chronic mental illness or moderate to severe
Alzheimer's disease or other cognitive impairments shall be eligible
for adult day health care services if they meet the criteria
established in paragraphs (1) to (5), inclusive, of subdivision (a).
(d) This section shall only be implemented to the extent permitted
by federal law.
(e) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement the provisions of this section by means of
all-county letters, provider bulletins, or similar instructions
without taking further regulatory action.
(f) Prior to implementing this section, the department shall meet
and confer with provider representatives, including, but not limited
to, adult day health care, home- and community-based services, and
nursing facilities for the purpose of presenting and discussing
information and evidence to assist the department as it determines
the methods and procedures necessary to implement this section.
(g) Upon the determination of the director that all necessary
methods and procedures described in subdivision (f) have been
ascertained and are sufficient to implement the purposes of this
section, the director shall execute and retain a declaration
indicating that this determination has been made. Subdivisions (a) to
(e), inclusive, shall be inoperative, until the date of execution of
the declaration. Upon the date of execution of such a declaration,
subdivisions (a) to (e), inclusive of this section shall become
operative and Section 14525 shall become inoperative.

14526. Participation in an adult day health care program shall
require prior authorization by the department. The authorization
request shall be initiated by the provider and shall include the
results of the assessment screening conducted by the provider's
multidisciplinary team and the resulting individualized plan of care.
Participation shall begin upon application by the prospective
participant or upon referral from community or health agencies, or
the physician, hospital, family, or friends of a potential
participant.

14526.1. (a) Initial and subsequent treatment authorization
requests may be granted for up to six calendar months.
(b) Treatment authorization requests shall be initiated by the
adult day health care center, and shall include all of the following:
(1) The signature page of the history and physical form that shall
serve to document the request for adult day health care services. A
complete history and physical form, including a request for adult day
health care services signed by the participant's personal health
care provider, shall be maintained in the participant's health
record. This history and physical form shall be developed by the
department and published in the inpatient/outpatient provider manual.
The department shall develop this form jointly with the statewide
association representing adult day health care providers.
(2) The participant's individual plan of care, pursuant to Section
54211 of Title 22 of the California Code of Regulations.
(c) Every six months, the adult day health care center shall
initiate a request for an updated history and physical form from the
participant's personal health care provider using a standard update
form that shall be maintained in the participant's health record.
This update form shall be developed by the department for that use
and shall be published in the inpatient/outpatient provider manual.
The department shall develop this form jointly with the statewide
association representing adult day health care providers.
(d) Except for participants residing in an intermediate care
facility/developmentally disabled-habilitative, authorization or
reauthorization of an adult day health care treatment authorization
request shall be granted only if the participant meets all of the
following medical necessity criteria:
(1) The participant has one or more chronic or post acute medical,
cognitive, or mental health conditions that are identified by the
participant's personal health care provider as requiring one or more
of the following, without which the participant's condition will
likely deteriorate and require emergency department visits,
hospitalization, or other institutionalization:
(A) Monitoring.
(B) Treatment.
(C) Intervention.
(2) The participant has a condition or conditions resulting in
both of the following:
(A) Limitations in the performance of two or more activities of
daily living or instrumental activities of daily living, as those
terms are defined in Section 14522.3, or one or more from each
category.
(B) A need for assistance or supervision in performing the
activities identified in subparagraph (A) as related to the condition
or conditions specified in paragraph (1) of subdivision (d). That
assistance or supervision shall be in addition to any other nonadult
day health care support the participant is currently receiving in his
or her place of residence.
(3) The participant's network of non-adult day health care center
supports is insufficient to maintain the individual in the community,
demonstrated by at least one of the following:
(A) The participant lives alone and has no family or caregivers
available to provide sufficient and necessary care or supervision.
(B) The participant resides with one or more related or unrelated
individuals, but they are unwilling or unable to provide sufficient
and necessary care or supervision to the participant.
(C) The participant has family or caregivers available, but those
individuals require respite in order to continue providing sufficient
and necessary care or supervision to the participant.
(4) A high potential exists for the deterioration of the
participant's medical, cognitive, or mental health condition or
conditions in a manner likely to result in emergency department
visits, hospitalization, or other institutionalization if adult day
health care services are not provided.
(5) The participant's condition or conditions require adult day
health care services specified in subdivisions (a) to (d), inclusive,
of Section 14550.5, on each day of attendance, that are
individualized and designed to maintain the ability of the
participant to remain in the community and avoid emergency department
visits, hospitalizations, or other institutionalization.
(e) When determining whether a provider has demonstrated that a
participant meets the medical necessity criteria, the department may
enter an adult day health care center and review participants'
medical records and observe participants receiving care identified in
the individual plan of care in addition to reviewing the information
provided on or with the TAR.
(f) Reauthorization of an adult day health care treatment
authorization request shall be granted when the criteria specified in
subdivision (d) or (g), as appropriate, have been met and the
participant's condition would likely deteriorate if the adult day
health care services were denied.
(g) For individuals residing in an intermediate care
facility/developmentally disabled-habilitative, authorization or
reauthorization of an adult day health care treatment authorization
request shall be granted only if the resident has disabilities and a
level of functioning that are of such a nature that, without
supplemental intervention through adult day health care, placement to
a more costly institutional level of care would be likely to occur.
(h) Subdivision (e) shall become operative commencing on the first
day of the month following 30 days after the effective date of the
act adding this subdivision.

14526.2. (a) Initial and subsequent treatment authorization
requests may be granted for up to six calendar months, initial and
subsequent treatment authorization requests may, at the discretion of
the department, be granted for up to 12 calendar months.
(b) Treatment authorization requests shall be initiated by the
adult day health care center, and shall include all of the following:
(1) A complete history and physical form, including a request for
adult day health care services signed by the participant's personal
health care provider shall be obtained annually. A copy of the
history and physical form shall be submitted with an initial
treatment authorization request and maintained in the participant's
health record. This history and physical form shall be developed by
the department and published in the inpatient/outpatient provider
manual.
(2) The participant's individual plan of care, pursuant to Section
54211 of Title 22 of the California Code of Regulations.
(c) Whenever a subsequent treatment authorization request is
submitted, the adult day health care center shall obtain and submit
an updated history and physical form from the participant's personal
health care provider using a standard update form that shall be
maintained in the participant's health record. This update form shall
be developed by the department for that use and shall be published
in the inpatient/outpatient provider manual.
(d) Authorization or reauthorization of an adult day health care
treatment authorization request shall be granted only if the
participant meets all of the following medical necessity criteria:
(1) The participant has one or more chronic or post acute medical,
cognitive, or mental health conditions that are identified by the
participant's personal health care provider as requiring one or more
of the following, without which the participant's condition will
likely deteriorate and require emergency department visits,
hospitalization, or other institutionalization:
(A) Assessment and monitoring.
(B) Treatment.
(C) Intervention.
(2) The participant has a condition or conditions resulting in
both of the following:
(A) Two or more functional impairments involving ambulation,
bathing, dressing, self-feeding, toileting, transferring, medication
management, and hygiene.
(B) As set forth in subparagraph (A) and (B) of paragraph (3) of
subdivision (a) of Section 14525.1, the need for assistance or
substantial human assistance in performing the activities identified
in subparagraph (A) as related to the condition or conditions
specified in paragraph (1). That assistance or substantial human
assistance shall be in addition to any other nonadult day health care
support the participant is currently receiving in his or her place
of residence.
(3) Except for participants residing in an intermediate care
facility/developmentally disabled-habilitative, the participant's
network of nonadult day health care center supports is insufficient
to maintain the individual in the community, demonstrated by at least
one of the following:
(A) The participant lives alone and has no family or caregivers
available to provide sufficient and necessary care or supervision.
(B) The participant resides with one or more related or unrelated
individuals, but they are unwilling or unable to provide sufficient
and necessary care or supervision to the participant.
(4) A high potential exists for the deterioration of the
participant's medical, cognitive, or mental health condition or
conditions in a manner likely to result in emergency department
visits, hospitalization, or other institutionalization if adult day
health care services are not provided.
(5) The participant's condition or conditions require adult day
health care services specified in subdivisions (a) to (d), inclusive,
of Section 14550.6, on each day of attendance, that are
individualized and designed to maintain the ability of the
participant to remain in the community and avoid emergency department
visits, hospitalizations, or other institutionalization.
(e) When determining whether a provider has demonstrated that a
participant meets the medical necessity criteria, the department may
enter an adult day health care center and review participants'
medical records and observe participants receiving care identified in
the individual plan of care in addition to reviewing the information
provided on or with the TAR.
(f) Reauthorization of an adult day health care treatment
authorization request shall be granted when the criteria specified in
subdivision (d) or (g), as appropriate, have been met and the
participant's condition would likely deteriorate if the adult day
health care services were denied.
(g) For individuals residing in an intermediate care
facility/developmentally disabled-habilitative, authorization or
reauthorization of an adult day health care treatment authorization
request shall be granted only if the resident has disabilities and a
level of functioning that are of such a nature that, without
supplemental intervention through adult day health care, placement to
a more costly institutional level of care would be likely to occur.
(h) This section shall only be implemented to the extent permitted
by federal law.
(i) Notwithstanding Chapter 3.5 (commencing with Section 11340) of
Part 1 of Division 3 of Title 2 of the Government Code, the
department may implement the provisions of this section by means of
all-county letters, provider bulletins, or similar instructions
without taking further regulatory action.
(j) Upon the date of execution of the declaration described under
subdivision (g) of Section 14525.1, this section shall become
operative and Section 14526.1 shall become inoperative and on that
date is repealed.

14527. Participation in an adult day health care program shall be
voluntary. The participant may end the participation at any time.
However, an adult day health center shall not otherwise terminate the
provision of adult day health services to any participant unless
approved by the state department.
No provider may employ, or contract for, persons specifically for
the sole purpose of solicitation of eligible participants. A provider
shall not use false advertising or false statements to induce
participants. No solicitation of participants shall include the
granting or offering of any monetary or other valuable consideration
for participation.
All informational material for potential participants prepared by
the provider shall have the prior approval of the department.

14528. Before acceptance into the program, all adult day health
providers shall conduct a multidisciplinary assessment directed
towards ascertaining the individual's pathological diagnosis,
physical disability, functional ability, psychological status, and
social and physical environment.

14528.1. (a) The personal health care provider, as defined in
Section 14552.3, shall have and retain responsibility for the
participant's medical care.
(b) If the participant does not have a personal health care
provider during the initial assessment process to determine
eligibility for adult day health care, the adult day health care
center staff physician may conduct the initial history and physical
for the participant.
(c) The adult day health care center shall make all reasonable
efforts to assist the participant in establishing a relationship with
a personal health care provider.
(d) If the adult day health care center is unable to locate a
personal health care provider for the participant, or if the
participant refuses to establish a relationship with a personal
health care provider, the adult day health care center shall do both
of the following:
(1) Document the lack of personal health care provider
relationship in the participant's health record.
(2) Continue to document all efforts taken to assist the
participant in establishing a relationship with a personal health
care provider.
(e) (1) A personal physician for one or more of an adult day
health care center's enrolled participants may serve as the adult day
health care staff physician.
(2) When a personal physician serves as the staff physician, the
physician shall have a personal care services arrangement with the
adult day health care center that meets the criteria set forth in
Section 1395nn(e)(3)(A) of Title 42 of the United States Code.
(3) A personal care physician, an adult day health care staff
physician, or an immediate family member of the personal care
physician or adult day health care staff physician, shall comply with
ownership interest restrictions as provided under Section 654.2 of
the Business and Professions Code.

14529. (a) The multidisciplinary health team conducting an
assessment shall consist of at least the individual's personal
physician or a staff physician, or both, a registered nurse, and a
social worker.
(b) For the initial assessment, the multidisciplinary health team
shall also include a physical therapist and an occupational
therapist. In addition, when the need is identified by a physician or
nurse, qualified consultants with skills in recreational therapy,
speech language pathology, or dietary assessment shall serve as team
members.
(c) The multidisciplinary team described in subdivision (b) shall
conduct an initial assessment. At the time of reassessment, if an
individual plan of care has been developed by the physical therapist
or the occupational therapist, they shall reassess the participant to
determine any ongoing or different needs for physical therapy or
occupational therapy services. If it is determined that no further
physical therapy or occupational therapy is needed, the physical
therapist and the occupational therapist shall not be required to
sign the treatment plan. For further reassessments, the nurse or
physician shall determine if the physical therapist or occupational
therapist is needed.
(d) The assessment team shall:
(1) Determine the medical, psychosocial, and functional status of
each participant.
(2) Develop an individualized plan of care, including goals,
objectives, and services designed to meet the needs of the person,
which shall be signed by each member of the multidisciplinary team,
except that the signature of only one physician member of the team
shall be required.
(3) At least biannually reassess the participant's individualized
plan care and make any necessary adjustments to the plan.
(4) If the initial assessment or any subsequent reassessment shows
that restorative therapy is needed, acute rehabilitative treatment
shall be provided by the appropriate licensed or certified personnel.
(5) If the initial assessment or any subsequent reassessment shows
that restorative therapy is not needed, the multidisciplinary team
shall determine whether the participant requires maintenance program
services and if the team finds that the participant requires these
services, the multidisciplinary team shall develop an individual
maintenance program as part of the plan of care.

14530. (a) Individual plans of care shall be submitted to the
department. Services for each participant shall be provided as
specified in the individual plan of care approved pursuant to Section
14526.
(b) Individual monthly service reports shall be submitted to the
department.
(c) Each provider shall supply a written statement to the
participant explaining what services will be provided and specifying
the scheduled days of attendance. This statement, which shall be
known as the participation agreement, shall be signed by the
participant and a provider representative and retained in the
participant's file.