130 Mass. Reg. 422.421

Current through Register 1519, April 12, 2024

Section 422.421 - PCA Program: Personal Care Management Agency Intake and Orientation and Functional Skills Training

(A)Intake and Orientation. Intake and orientation functions are provided to members about whom an inquiry is made to the PCM agency for PCA services and do not yet have a prior authorization for PCA services. The PCM agency must ensure that each member who seeks PCA services receives sufficient in-person intake orientation to the PCA program to ensure that the member, or surrogate or administrative proxy, if any, understands the rules, policies, and procedures of the PCA program. The PCM agency must provide intake and orientation to the member that include, but are not limited to, the following:

(1) responding, either by telephone or in person, to an initial request for PCA services within three business days of the inquiry submitted to the PCM agency for PCA services;

(2) completing an in-person determination of the member's initial eligibility for the PCA program within ten business days of the initial inquiry about a member to the PCM agency for PCA services in accordance with 130 CMR 422.403 and the PCM agency contract;

(3) ensuring that the member is eligible for MassHealth and meets the eligibility criteria for PCA services as described in 130 CMR 422.403(C)(1) through (4);

(4) providing in-person intake and orientation to each member who is determined initially eligible for the PCA program, but has not yet been granted a prior authorization for PCA services that includes, at minimum:

(a) a description of the member's rights and responsibilities when using the PCA program, including the member's responsibilities defined under 130 CMR 422.420(A);

(b) the rules, regulations, and policies governing the PCA program including, but not limited to, the member's responsibility to use PCA services as authorized by the MassHealth agency pursuant to 130 CMR 422.416(E);

(c) the roles and responsibilities of the PCM agency and the fiscal intermediary;

(d) the appropriate use of activity forms; and

(e) instruction in the skills and tasks necessary to manage PCA services;

(5) informing the member of the member's responsibility for enrolling with the fiscal intermediary before employing PCAs and assist the member with this process, if necessary; and

(6) notifying the fiscal intermediary of the name, MassHealth ID number, address, and telephone number of the member, and the name, address, and phone number of the surrogate, if any, who is responsible for submitting, reviewing, and/or signing the activity forms.

(B)Functional Skills Training. PCM agencies must provide members who have a prior authorization for PCA services, and surrogates and administrative proxies as applicable, with the functional skills training needed to successfully manage the PCA program and maximize the member's ability to self-direct care. The frequency and type of functional skills training that a member and the surrogate or administrative proxy, if any, receive must be documented in the member's service agreement.

(1) The PCM agency must provide functional skills training that includes, but is not limited to, the following.

(a)PCA Training. The PCM agency must instruct the member and the surrogate or administrative proxy, if any, in the functions and scheduling of PCAs in relation to the member's need;

(b)PCA Management. The PCM agency must instruct the member and the surrogate or administrative proxy, if any, in:

1. hiring, recruitment, training, and supervision of PCAs, including advertising for PCAs, and interviewing techniques;

2. methods for evaluating PCA competence and effectiveness and requesting assistance in dealing with training or other issues as necessary;

3. developing and maintaining a list of PCAs who can be used when an unforeseen event occurs that prevents the member's regularly scheduled PCA from providing services;

4. appropriate utilization of PCA services in accordance with 130 CMR 422.416(E);

5. appropriate utilization of PCA overtime in accordance with 130 CMR 422.418(A); and

6. appropriate utilization of EVV as required by the MassHealth agency in accordance with 130 CMR 422.420(A)(3), 422.420(A)(5)(c), 422.420(A)(8), and 422.420(A)(23).

(c)Personal Health Care Maintenance. The PCM agency must instruct the member and the surrogate, if any, about the respective roles of the member, PCAs, and others who assist the member in meeting personal health care needs and the respective abilities of each to:

1. identify, understand, and describe medical conditions, problems, and susceptibilities; and

2. identify, understand, and describe routines and treatments including medication schedules and dosages, nutritional planning, bowel and bladder routine, and range of motion routine.

(d)Emergency Management. The PCM agency must instruct the member and surrogate, if any, to develop and review procedures to:

1. describe how and when to use a physician and a local hospital emergency room;

2. identify and respond to the signs of an emergency;

3. understand the appropriate treatment, equipment, or action for dealing with an emergency;

4. maintain a list of emergency telephone numbers and procedures for use by the member, surrogate (if necessary), and PCAs; and

5. assist the member in identifying and maintaining a current list of back-up PCAs that are available to provide PCA services in an emergency.

(e)Skills Training Related to the Fiscal Intermediary. The PCM agency must instruct the member and the surrogate, if any, in:

1. the role of the fiscal intermediary;

2. the appropriate and accurate use of activity forms in the form and format as required by the MassHealth agency, including through the use of EVV; and 130 CMR 438.000: CONTINUOUS SKILLED NURSING AGENCY

(2) To ensure timely and thorough functional skills training, the PCM agency must:

(a) respond within three business days to all requests from members and surrogates and administrative proxies for functional skills training, including in-person issue-focused functional skills training sessions and issue-focused telephonic functional skills training session in accordance with the PCM agency contract;

(b) provide in-person issue-focused functional skills training when the member or surrogate or administrative proxy requests an in-person visit with the skills trainer;

(c) provide in-person comprehensive functional skills training on at least a quarterly basis to all members during the first year of approved PCA services and at least annually thereafter and in accordance with the PCM agency contract; and

(d) provide in-person issue-focused functional skills training to members within three business days of the request of EOHHS or the fiscal intermediary to resolve issues related to activity forms, utilization, completion of paperwork needed for payroll, and other PCA management issues and in accordance with the PCM agency contract.

(C)Payment.

(1) Payment for intake and orientation services is a per-member, per-month rate and is limited to a maximum of three consecutive months and only for members who are in the process of obtaining a prior authorization for PCA services.

(2) Payment for functional skills training is a per-member, per-month rate and is restricted to members for whom the PCM agency has obtained a prior authorization for PCA services, with the exception of member transfers. Rates for payment for intake and orientation and functional skills training are established by the Center under 101 CMR 309.00: Independent Living Services for the Personal Care Attendant Program and are inclusive of activities described under 130 CMR 422.421.