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Home Care and Support Services Definition
Purpose
Individuals who receive Home Care and Support Services obtain a maximum level of independence, functioning, and health, and extend the time it is possible to live safely at home and in the community.Definition
- personal care aide services such as supervised, basic activities of daily living; monitoring of self-administered medication; assistance with activities and care needs required to live at home safely; routine exercise, safe lifting, and healthy movement routines to maintain ambulation; and education and interventions to prevent falls, injuries, health decline and to maintain independent functioning; and
- homemaker services such as housekeeping, meal preparation and food safety, transportation, grocery shopping, monitoring of self-conducted household management tasks, monitoring of self-administered medications, and other instrumental activities of daily living.
Note:For the purposes of these standards, “caregiver” refers to friends, family, and other non-professional supports. “Care provider” refers to direct-care personnel providing in-home services.
Note:The Home Care standards are consistent with services known in the field as “professional-agency,” which include a prominent client-centered philosophy and worker training and support components, as compared to services with a self-directed orientation. The latter approach is being instituted in some states to place responsibility for obtaining services and payment directly with clients and caregivers.
Note:Please see PA-HCS Reference List for the research that informed the development of these standards.
Note:For information about changes made in the 2020 Edition, please see the HCS Crosswalk.
Home Care and Support Services (PA-HCS) 1: Person-Centered Logic Model
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-HCS 1.01
- needs the program will address;
- available human, financial, agency, and community resources (i.e. inputs);
- program activities intended to bring about desired results;
- program outputs (i.e. the size and scope of services delivered);
- desired outcomes (i.e. the changes you expect to see in persons served); and
- expected long-term impact on the agency, community, and/or system.
Examples: Information that may be used to inform the development of the program logic model includes, but is not limited to:
- needs assessments and periodic reassessments; and
- the best available evidence of service effectiveness.
PA-HCS 1.02
- change in functional status;
- health, welfare, and safety;
- quality of life;
- achievement of individual service goals; and
- other outcomes as appropriate to the program or service population.
Interpretation: Outcomes data should be disaggregated to identify patterns of disparity or inequity that can be masked by aggregate data reporting. See PA-PQI 5.02 for more information on disaggregating data to track and monitor identified outcomes.
Home Care and Support Services (PA-HCS) 2: Personnel
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A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-HCS 2.01
- provide services to the population served;
- read, understand, and carry out written and verbal care plan directions;
- exercise good judgment and tact in responding to an individual’s suggestions and preferences;
- work as a member of a care team including contributing observations and recommendations at care plan conferences or to supervisors;
- meet the training requirements for the position and services performed; and
- work in a client-centered service delivery environment.
PA-HCS 2.02
Personnel who conduct screening, level of care assessments and periodic re-assessments, care management and coordination, and supervision of care providers are qualified by:
- a bachelor's degree in a related human services field or licensure as a registered nurse;
- a minimum of two years of experience working with the service population; and
- demonstrated competence providing care decisions for in-home service delivery.
PA-HCS 2.03
- formal training in supervision; and/or
- on-the-job supervisory training for the first three months of service as a supervisor.
PA-HCS 2.04
- maintaining a clean, safe, and healthy home environment;
- reading and recording vital signs;
- supporting self administration of medication in accordance with agency procedures, when applicable;
- communicating client information, needs, and status;
- observing and documenting client status and care or service provided;
- following universal precautions and basic infection control procedures;
- adapting to a range of in-home care circumstances; and
- providing aid with activities of daily living.
Interpretation: Assistance with self-administered medications has a high possibility for error, representing a risk for the client and the agency. As such, personnel should have the competency needed to provide an appropriate level of assistance with self-administered medication when they will be assisting with that task.
PA-HCS 2.05
Personal care aides have received first aid and age-appropriate CPR training in the previous two years that included an in-person, hands-on CPR skills assessment conducted by a certified CPR instructor.
NA The agency provides homemaker services only.
PA-HCS 2.06
PA-HCS 2.07
PA-HCS 2.08
PA-HCS 2.09
- the qualifications and competencies of care providers and supervisors;
- case complexity;
- case status and progress toward achievement of desired outcomes;
- length and strength of the worker-client relationship;
- whether services are provided by multiple providers;
- ability of care providers to meet the individual's or family's needs; and
- relevant cultural and religious factors.
PA-HCS 2.10
PA-HCS 2.11
- assigning a worker at intake or early in the contact; and
- avoiding the arbitrary or indiscriminate reassignment of care providers.
PA-HCS 2.12
Home Care and Support Services (PA-HCS) 3: Requirements for Personnel Providing Services to Individuals with Special Needs
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-HCS 3.01
- are qualified by an advanced degree in an appropriate human service field and a minimum of two years supervisory experience in direct services, or case management; or
- have a bachelor's degree and an equivalent number of years supervisory experience and demonstrated skills providing level of care decisions for in-home service delivery.
PA-HCS 3.02
- attending to the physical, mental, social, economic, and emotional needs of the service population;
- recognizing problems and responding to impending emergencies or crises; and
- providing preventive and supportive services to ensure maximum participation and self-determination.
Home Care and Support Services (PA-HCS) 4: Access to Services
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-HCS 4.01
PA-HCS 4.02
- the extent and kind of services an individual needs and wants; and
- the strengths and capabilities of caregivers, including unidentified quality of life concerns related to care giving demands.
PA-HCS 4.03
Home Care and Support Services (PA-HCS) 5: Intake
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-HCS 5.01
- how well their request matches the agency's services; and
- what services will be available and when.
PA-HCS 5.02
- gather information necessary to identify critical service needs and/or determine when a more intensive service is necessary;
- give priority to urgent needs and emergency situations;
- clarify needs and preferences including the choice to execute an advance directive;
- support timely initiation of services; and
- provide for placement on a waiting list or referral to appropriate resource when individuals cannot be served or cannot be served promptly.
PA-HCS 5.03
Home Care and Support Services (PA-HCS) 6: Assessment-Based Care Planning and Coordination
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-HCS 6.01
- completed within established timeframes;
- focused on information pertinent for meeting service requests and objectives; and
- supplemented with information provided by collaborating providers, when appropriate.
PA-HCS 6.02
- the individual’s view of his or her current health and functioning;
- baseline functional, mental, emotional, and physical status information including prescription medication use and recent or progressive functioning to confirm capacity, decline, or progress; and
- a caregiver assessment including level of caregiver burden, caregiver health, choice in serving in the caregiver role, and presence of informal support.
Interpretation:All care providers, including those who may not have responsibility for the comprehensive assessment and determination of appropriate level of care, should obtain, at a minimum, information regarding an individual's and/or family's special needs.
Interpretation: The Assessment Matrix - Private, Public, Canadian, Network determines which level of assessment is required for COA’s Service Sections. The assessment elements of the Matrix can be tailored according to the needs of specific individuals or service design.
PA-HCS 6.03
- specific services to be delivered by the care provider; and
- a plan for coordinating services with other providers including nurses, physicians, rehabilitative personnel, and mental health providers, as needed.
PA-HCS 6.04
- link interventions to service recipient goals;
- assess service appropriateness;
- approve service plans prior to implementation; and
- assist the care provider with plan implementation, as necessary.
PA-HCS 6.05
- the role of family members in caretaking and related needs;
- any current concerns including household and community safety;
- specific services to be provided by the care provider;
- limits of services provided;
- preferences and choices of service recipients that can affect service delivery;
- information about advanced directives and crisis planning as appropriate; and
- guidelines for resolving differences between service recipient and care providers, including the role of supervisors.
PA-HCS 6.06
- off-site supervision;
- safety of personnel while off site; and
- timely communication and record keeping practices.
Home Care and Support Services (PA-HCS) 7: Care Monitoring
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-HCS 7.01
- in person at least every 30 days for cognitively impaired clients, or clients with other special needs;
- in person at least every 60 days for clients who are not cognitively impaired and are receiving personal care aide services;
- in person at least every 90 days for clients receiving homemaker services only; and
- by phone, in addition to the in-person timeframes listed above, when needed.
PA-HCS 7.02
- document all interventions and how the person responds;
- monitor and document changes in physical, mental, and emotional status and gains of the individual and their caregivers;
- respect and note the individual’s choices;
- help individuals make independent choices or assume more responsibility for making decisions;
- recognize service gaps and alert applicable service providers to unmet needs;
- recognize emergency situations and follow procedures to ensure the safety and well being of care recipients; and
- report on plan implementation and progress to a supervisor or case manager at least weekly.
PA-HCS 7.03
- review progress toward achievement of agreed upon service goals; and
- sign revisions to service goals and care plans.
PA-HCS 7.04
- care plan implementation;
- progress toward achieving service goals and desired outcomes; and
- the continuing appropriateness of the agreed upon service goals.
Home Care and Support Services (PA-HCS) 8: Coordinated Home Management, Activities of Daily Living, and Health Services
- a comprehensive package of services; and
- a flexible approach to service delivery that meets their changing needs.
Examples: Services provided directly or by a cooperating provider can include:
- housekeeping tasks and home management activities and education;
- companionship;
- chores, safe food handling and storage, and nutritious meal preparation;
- assistance with personal care;
- monitoring of overall health and well-being including observing, reporting, and documenting changes in bodily function;
- assistance with self-administered medications;
- assistance or prompting with activities of daily living;
- assistance with personalizing homes and purchasing personal necessities;
- assistance with ambulation and transfer; and
- assistance with accessing community activities, including access to transportation.
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Home Care and Support Services (PA-HCS) 9: Case Closing and Aftercare
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-HCS 9.01
- is a clearly defined process that includes assignment of staff responsibility;
- begins at intake; and
- involves the care provider, persons served, and others as appropriate to the needs and wishes of the individual.
PA-HCS 9.02
PA-HCS 9.03
PA-HCS 9.04
- develop an aftercare plan, sufficiently in advance of case closing, that identifies short- and long-term needs and goals and facilitates the initiation or continuation of needed supports and services; or
- conduct a formal case closing evaluation, including an assessment of unmet need, when the agency has an interagency agreement that does not include aftercare planning or follow-up.
PA-HCS 9.05
NA The agency has an interagency agreement that does not include aftercare planning or follow-up.