C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-102, subsec. 144-101-II-102.08
In order for services to be reimbursable, a service must meet the following standards:
The provider must be accredited by the Rehabilitation Accreditation Commission (CARF) to provide brain injury rehabilitation services (other than vocational services, which are not covered by MaineCare,) or otherwise have an eighteen (18)-month provisional certification from the Maine Department of Health and Human Services to cover the period the provider is working to secure CARF accreditation. The Department is responsible for determining compliance with the provisional certification standards in Appendix I of this Section. A copy of the Department issued provisional certification, or evidence of current CARF accreditation, must be on file with the MaineCare Services. Additionally, the provider must also supply the Department with a copy of the current CARF accreditation survey and if applicable, any plans of corrections.
Providers must maintain CARF accreditation to receive MaineCare reimbursement. CARF accreditation is for a specified period of time and requires periodic review and approval. To maintain accreditation beyond the expiration date, a provider must be resurveyed by CARF by the expiration date or be in the process of a resurvey by the expiration date. Evidence that the resurvey visit has been scheduled can indicate that the resurvey process is underway, as long as the visit was scheduled prior to the expiration date. MaineCare reimbursement will be subject to recoupment, back to the day on which accreditation expired, if CARF accreditation is denied. The facility must provide to the office listed below written evidence of the scheduled CARF survey visit. Evidence of current CARF accreditation, upon receipt, must also be submitted to this office:
Provider File Unit
MaineCare Services
11 State House Station
Augusta, ME 04333-0011
AND
Office of Adults with Cognitive and Physical Disabilities-Brain Injury Services
11 State House Station
Augusta, ME 04333-0011
Each provider must have a written agreement for services with a clinical director, or shall employ a physician, a neuropsychologist, and other professional personnel to assure appropriate supervision, medical review, and approval of services provided. The clinical director must have responsibility for the overall management of the service and have two (2) years experience in the rehabilitation of individuals with brain injury, as well as have management and specific training that will enable the director to understand and respond to the unique needs of individuals with brain injuries. The clinical director must be actively involved in the service and provide oversight for day-to-day operations.
If a Provider plans to add a new BI service component that will require additional CARF accreditation (CARF requires new services to be delivered for at least six (6) months prior to a survey visit), the provider may receive MaineCare reimbursement for these new services while working toward CARF survey and certification, so long as the Department is notified in writing at least two (2) months in advance of the intent to seek CARF certification and the date services will start. Additionally, the CARF survey visit must be scheduled prior to the end of the six (6)-month period, i.e. a survey visit must be scheduled, not necessarily completed, and the Department notified in writing of the CARF survey appointment date. Reimbursement for the new service component will be subject to recoupment, back to start date of the new services, if CARF accreditation is denied.
These services are intended to be provided on an outpatient basis. However, services may, in some instances, be provided in Home and Community settings if the treatment plan addresses the medical necessity for the member to receive services outside of the outpatient setting. All facilities providing rehabilitative services must be accessible to people with disabilities, in accordance with Section 504 of the Rehabilitation Act of 1973, as amended ( 29 USC, Section 794) , and the Americans with Disabilities Act of 1990, ( 42 USC, 1281 et seq.).
Providers must submit some or all of the following documents to the Department or its Authorized Agent:
All professional staff must be conditionally, temporarily, or fully licensed/certified as documented by written evidence from the appropriate governing body for the State or province in which services are provided. All professional staff must provide services only to the extent permitted by licensure. All staff will have expertise in brain injury rehabilitation as demonstrated by achieving the Certified Brain Injury Specialist (CBIS) designation from the Academy of Certified Brain Injury Specialists (ACBIS) or demonstrating competency through an approved equivalent training program supervised by the provider. New staff will achieve CBIS or demonstrate equivalent competency within fourteen (14) months from date of hire. If an equivalent training program is used, the provider must submit documentation and receive approval from the Department (Brain Injury Services) for this program. The provider must demonstrate the equivalency of its alternate training and evaluation methods used to determine the staff member's competence in brain injury rehabilitation. The provider will submit a detailed curriculum, training and evaluation plan. Approval of equivalent training programs will occur annually. Documentation of plan approval and results of all training and evaluation of staff will be maintained by the provider for Department inspection.
A roster of provider staff, their CBIS (or equivalent) status, date of hire, and professional license status (type, number & standing) if applicable, will be submitted to the Department (Brain Injury Services) annually. Failure to meet minimum training or licensing standards will result in disallowance of services provided by the staff member failing to meet the standard, and referral to Program Integrity.
The following staff may provide services:
Physician services may include, but are not limited to the following:
In addition to licensure as a psychologist, a neuropsychologist must meet either criterion 1, 2, or 3 below:
Neuropsychologist services may include, but are not limited to the following:
The registered nurse in the rehabilitation setting focuses on promoting health and maximizing human potential. The registered nurse is an integral member of the health care team whose priorities are based on each patient's needs at any given time.
The registered nurse assists the member in developing appropriate responses to situations, adjusts the environment to meet the needs of the person with a disability, and promotes participation in society.
A certified recreational therapist must have completed a four (4)-year program in therapeutic recreation from an accredited college or university, and be certified as a therapeutic recreation specialist under the National Council for Therapeutic Recreation Certification.
Therapeutic recreation services are directed toward the correction of physical and mental impairments, and may include, but are not limited to, the amelioration of disorders such as attention-span deficits, cognitive difficulties, or dysfunctional behaviors.
The occupational therapist maximizes the member's ability to perform functional daily living tasks such as feeding, bathing and dressing. The therapist's emphasis is on providing tasks meaningful to members with the goal of remediating perceptual and functional deficits, which affect performance.
An occupational therapy assistant must work only under the supervision of an occupational therapist.
The physical therapist uses a variety of modalities to maximize the member's physical capabilities. Treatment goals may include but are not limited to maintaining flexibility, facilitating movement, providing movement experiences and stimulation, especially tactile, vestibular, kinesthetic or proprioceptive.
Treatment may be directed toward organizing functional learning in normal motor development sequence, teaching appropriate-level functional skills, as well as necessary collateral contacts.
A physical therapist assistant must work only under the supervision of a physical therapist.
The speech-language pathologist provides diagnosis and treatment for members with varying degrees of impairment in their communicative abilities.
Services for members may address speech, language, voice, and swallowing disorders. Group therapy may address communication skills, feeding problems, and higher level cognitive/linguistic problems.
A speech-language pathology assistant must be registered under the license of a speech-language pathologist in the state or province in which services are provided; and work only under the supervision of that speech-language pathologist.
The social worker provides services that enable a member to integrate into the community by assisting the member to develop appropriate responses to his or her environment.
The professional counselor provides counseling services to assist the member in achieving more effective personal, emotional, social, educational, and vocational development and adjustment.
The professional counselor provides counseling services to assist the member in achieving more effective personal, emotional, social, educational, and vocational development and adjustment.
Other qualified staff are staff members, other than professional staff defined above, who have appropriate education, training, and experience in treatment of individuals with brain injury as approved by CARF, have a satisfactory criminal background check annually, and work under documented supervision, conducted at least monthly, by the professionals defined above.
Assessment, coordinated service planning, and direct services on a regular and continuing basis must be provided by a coordinated, interdisciplinary team. This team must:
- be the major decision-making body in determining the goals, process, and time frames for accomplishment of the goals and expected benefits of the admission;
- be composed of the treating member of each discipline essential to the individual's accomplishment of the goals and expected benefits of the admission; and
- meet on a formalized basis at a frequency necessary to carry out their decision- making responsibilities. A team conference should occur for each member served at least monthly.
This team, comprised of the member, family, legal guardian, professional and other qualified staff, must be specifically designated to serve members requiring rehabilitative services and must include a physician and a neuropsychologist. In addition, the interdisciplinary team must include the disciplines in Section 102.08-5 as required on an individual basis in order to receive reimbursement for covered services.
A Clinical Initial Assessment and Reassessment, which must confirm a tentative diagnosis of brain injury, must be done face-to face with a member and by a licensed physician who is Board certified, or otherwise Board eligible, in either physical medicine and rehabilitation or neurology, or a neuropsychologist meeting the requirements of Section 102.08-5(B) and by an interdisciplinary team that meets the requirements of Section 102.08-6, and be included in the member's clinical record. The Clinical Initial Assessment and Reassessment must include the member's medical and social history, an assessment of the scope and success of acute care provided as a result of the brain injury, and the member's diagnosis. The Clinical Initial Assessment and Reassessment must also identify and list all other relevant services the member is currently receiving, regardless of payer, so that services can be coordinated and any duplication of services avoided.
Based on the Clinical Initial Assessment or Reassessment of the member, an individual treatment plan must be developed. This plan must be in writing and identify all specific services to be provided (including those services not MaineCare reimbursable), the frequency and duration of each service, who will provide the service and the goals of each service. The plan will include measurable goals with target dates for achieving the goals with objectives that allow for measurement of progress.
The member shall be informed about the treatment options available to meet his or her needs and the member's preferences shall be taken into consideration in the development of the treatment plan. The plan must be specific to meeting the member's identified needs. Rehabilitative services must be coordinated with all other services the member is receiving as well as avoid any duplication of services. The plan must be approved, signed, and dated by a physician or neuropsychologist within thirty (30) days of the date the member began treatment and must specify the clinical rehabilitative services to be provided, the frequency and duration of each phase of service, the expected duration of treatment, and the expected rehabilitative goals or outcomes of services.
The individual treatment plan must be reviewed by a professional staff member and reauthorized, signed, and dated by a physician or neuropsychologist at least every one hundred and eighty (180) days or more frequently based on the member's needs. The individual treatment plan will be updated when there is a change in the member's condition, when the service appears not to be benefitting the member or when the member is over or under utilizing a service. Goals attained or not attained are identified and the individual treatment plan updated concerning goals not met.
Written treatment or progress notes must be maintained in accordance with the treatment plan and be made every time a service is provided. All entries must identify the qualified staff and credentials who provided the service, date of each service, its duration and progress the member is making toward attaining the goals stated in the treatment plan. The qualified staff performing the services must sign all entries. The interdisciplinary team must maintain written notes of all meetings.
For each service covered under this Section that is delivered in the member's home or residence (including PNMIs), the provider must maintain records that show the arrival and departure times of each care provider, for type of provider (e.g. RN, OT, PT, therapeutic recreation specialist, other qualified staff, etc.), for each visit, and the total time spent in the home/residence for each provider, excluding travel time. This information must be documented in a clear and concise format and available to the Department, upon request.
The clinical record must also include written reports on all medication reviews, consultations, testing, evaluations, and collateral contacts made on behalf of the member.
A discharge summary must be signed and dated and included in the clinical record and provided to the member or guardian, if applicable. The summary must include:
All providers are subject to the Department's Program Integrity activities. Refer to Chapter I, General Administrative Policies and Procedures, for rules governing these functions.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-102, subsec. 144-101-II-102.08