130 Mass. Reg. 419.416

Current through Register 1520, April 26, 2024

Section 419.416 - Day Habilitation Provider Responsibilities

In addition to meeting all of the qualifications set forth in 130 CMR 419.000 and 130 CMR 450.000: Administrative and Billing Regulations, the DH provider must meet all of the following requirements.

(A)Policies and Procedures Manual. Each DH provider must develop, maintain, and periodically review and update policies and procedures governing the delivery of DH. The policy and procedures manual must at minimum include

(1) governance documentation, including, but not limited to

(a) a mission statement;

(b) the goals and objectives of the program;

(c) an organizational chart describing the lines of authority and communication needed to manage the DH program, including the lines of authority for delegation of responsibility down to the member care level;

(d) job descriptions that include titles, reporting authority, qualifications, and responsibilities;

(e) a description of the governing body; and

(f) a description of the fiscal/business management system that clearly specifies the use of funds within budgetary constraints and fiscal restrictions and fiscal reporting by month, reflecting all sources of income and program expenses.

(2) administrative policies and procedures, including, but not limited to

(a) human resources and personnel;

(b) staff and staffing requirements;

(c) backup staff in the event coverage is required due to illness, vacation, or other reasons;

(d) staff education and training;

(e) DH provider staff evaluation and monitoring;

(f) emergencies including fire, safety, and disasters, including notifying the fire department and police in emergencies and relocating members during an emergency;

(g) MassHealth member rights;

(h) human rights and nondiscrimination;

(i) incident and accident reporting;

(j) staff and member grievances;

(k) cultural competency;

(l) quality assurance and improvement;

(m) emergency services and plans;

(n) first aid and cardiopulmonary resuscitation requirements;

(o) Health Insurance Portability and Accountability Act (HIPAA);

(p) food storage and preparation areas;

(q) coordination of DH with other services the member is receiving; and

(r) procedures to be followed if a member is missing or lost.

(3) clinical policies and procedures, including, but not limited to

(a) evaluations and assessments;

(b) privacy and confidentiality;

(c) medication administration, management, storage, and disposal;

(d) universal precautions;

(e) infection control and communicable diseases;

(f) recognizing and reporting abuse (physical, sexual, emotional, psychological), neglect, self-neglect and financial exploitation;

(g) description and use of positive behavioral supports (PBS);

(h) admission criteria; and

(i) discharge planning and follow-up.

(4) All documentation required in 130 CMR 419.416(A) must be kept on-site or readily accessible.

(B)Recordkeeping and Reporting Requirements.

(1)Recordkeeping. The DH provider must maintain records in compliance with the requirements set forth in 130 CMR 450.000: Administrative and Billing Regulations and all other applicable state and federal laws. All records, including, but not limited to, the following, must be accessible and made available on site for inspection by the MassHealth agency or its designee.

(a)Member Records. The record must contain information necessary to identify the member. Each member's record also must include all documentation pertaining to the DHSP and the design of an appropriate DHSP, including, but not limited to, the following:

1. the member's name, member identification number, address, telephone number, sex, age, marital status, next of kin or authorized representative, school or employment status, the date of initial contact with the program, and the emergency fact sheet in accordance with 130 CMR 419.430(D);

2. a member profile that includes a brief history, including diagnoses and clinical and behavioral needs. If applicable, the member profile must also include specialized service needs, the name of the DHSM assigned to the member, and the name and contact information of the DDS service coordinator, if applicable;

3. an educational, social, medical, and vocational history with assessment reports from providers, as applicable;

4. an updated record of past and present immunizations and tuberculin tests or screening, based on the recommendations of the CDC;

5. a copy of the initial clinical assessment, and copies of any reassessments;

6. a report of the member's most recent annual physical examination or wellness visit;

7. the name, address, and telephone number of the PCP serving the member;

8. written approval of the DHSP from the IDT and the member or the member's authorized representative;

9. documentation that the PCP was notified in writing of the approved DHSP;

10. documentation supporting the level of payment associated with services provided to the member;

11. DH staff documentation of all conferences with the member, the member's authorized representatives, and with outside professionals;

12. daily attendance records;

13. transportation records when MassHealth DH or subcontracted transportation is provided;

14. progress notes updated monthly by the DHSM when appropriate and available, and by other people significantly involved in implementing the DHSP;

15. progress notes written by the health care supervisor, updated quarterly or more often as necessary to address any significant changes in member's status;

16. reports of all semi-annual reviews conducted in accordance with 130 CMR 419.405(A)(1)(d) and 419.419(C)(3) and any other reports generated in compliance with 130 CMR 419.000;

17. written authorization from the member or the member's authorized representative for the release of information, as applicable;

18. the discharge notice, if the member is discharged;

19. a copy of the Level II PASRR notice, if applicable;

20. documentation that the PA approval supporting the need for DH ISS was obtained prior to billing, if applicable;

21. documentation of each 15-minute unit of ISS delivered to the member, if applicable; and

22. documentation received from a hospice provider, if applicable, affirming DH services are not related to the member's terminal illness.

(b)Administrative Records. The DH provider must maintain

1. payroll records;

2. personnel records, including requirements set forth in 130 CMR 419.421(A), including evidence of completed staff orientation and training;

3. financial and billing records;

4. member utilization records, including the number of members being served and, if applicable, number of individuals on a waiting list;

5. records of staffing levels and staff qualifications;

6. records of complaints and grievances; and

7. contracts for subcontracted services.

(c)Incident and Accident Records. The DH provider must maintain an easily accessible record of member and staff incidents and accidents. The record may be kept within the individual member medical record or employee record or within a separate, accessible file.

(2)Reporting Requirements.

(a)Program Reporting.

1. The DH provider must submit all of the following information in the format and time frames as requested by the MassHealth agency or its designee:

a. cost and expense information in accordance with the requirements of 957 CMR 6.03: Reporting Requirements for Type 1 Providers; and

b. any change in DH provider contact information.

2. The DH provider must make available to the MassHealth agency or its designee any additional information requested by MassHealth or its designee related to the provider's provision of DH, including information such as clinical and statistical or cost and expense information, accreditation correspondence with CARF or Council on Quality and Leadership, and other data necessary to measure the quality of the services delivered by the DH provider.

3. The DH provider must comply with all applicable reporting requirements of other state agencies such as DDS.

(b)Critical Incident Reporting. The DH provider must immediately notify the MassHealth agency of any critical incidents outlined on the MassHealth Critical Incident Report Form.

(C)Staffing Ratios and Requirements. A DH provider must have sufficient qualified staffing in accordance with 130 CMR 419.421 to deliver DH and have specific personnel policies, including procedures for monitoring current licensure or certification of professional staff, staff training, supervision, and evaluation. Definitions and minimum qualifications relating to these disciplines can be found at 130 CMR 419.421.

(1) A DH provider must have a full-time program director.

(2) A DH provider must have the following clinicians, either by contract or direct hire, as part of the interdisciplinary team:

(a) physical therapist;

(b) speech and language pathologist;

(c) occupational therapist; and

(d) behavioral professional.

(3) DH providers must have a registered nurse health care supervisor available at all times when members are receiving DH services. Licensed Practical Nurses may carry out all duties as delegated and overseen by the nurse health care supervisor, as appropriate. A nurse must be available to be on site within 30 minutes during the core hours of DH operation. The RN/health care supervisor will provide supervision of Licensed Practical Nurses (LPNs). Additional nursing supports should be provided to ensure all members' needs are met.

(4) A DH provider may employ direct care staff (paraprofessionals) to help meet the needs of its members and reach the minimum staff-to-member ratio of one-to-seven. Additional staff may be required to meet the needs of the members served.

(5) Staffing ratios will be based on the average daily census of members enrolled with the DH provider at the specific DH site during the rate year, calculated using data from the last quarter.