C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-13, subsec. 144-101-II-13.07

Current through 2024-51, December 18, 2024

Subsection 144-101-II-13.07 - POLICIES AND PROCEDURES

13.07-1 Service Requirements

A. The member must be given the option of whether or not to utilize Targeted Case Management Services.

B. If the member chooses Targeted Case Management Services, he/she must also be given a choice of providers approved by the Department.

C. Services must be provided in settings accessible to the member.

D. Each member must have an Individual Care Plan based on a Comprehensive Assessment or Re-Assessment. The Individual Care Plan and Comprehensive Assessment and Re-Assessment must contain all of the necessary components as stated in 13.07-3.

13.07-2Provider Requirements

Targeted Case Management services must be provided by agencies and providers that meet all of the following criteria:

A. Agency Qualifications:

1. Targeted Case Management agencies must execute a MaineCare Provider Agreement

2. Targeted Case Management agencies must complete the "MaineCare Targeted Case Management Provider Enrollment" form.

3. Targeted Case Management agencies must promote effective operation of the various programs and agencies in a manner consistent with applicable State and Federal laws, regulations, and procedures.

4. Targeted Case Management agencies must maintain clear policy guidelines for decision making, program operations, and provision for monitoring the same.

5. Targeted Case Management providers must:

a. Provide orientation, continuing education, and on-going communication with all applicable governing boards;

b. Have policies and procedures to protect the rights of members of service;

c. Have a comprehensive set of personnel policies and procedures;

d. Have job descriptions and qualifications, including licensure, for all staff employed either directly or by contract with the provider; and

e. Ensure that staff or contractors possess the skills, attitudes, and knowledge needed to perform job functions, and provisions for performing regular staff evaluations. Written definitions and procedures for use of all volunteers must be maintained.

6. Targeted Case Management providers must exhibit effective inter-agency coordination that demonstrates a working knowledge of other community agencies. This means the provider and its contracting agencies must be aware of information regarding the types of services offered and limitations on these services. Similarly, providers must ensure that other human service agencies are provided with accurate, up-to-date information regarding the provider's services, service limitations, and priorities within those services.

7. Providers must meet and comply with any and all additional agency requirements as defined in contract and/or MaineCare provider agreements between the Department and the designated case management agency, as applicable.

B. Staff Qualifications

1. Comprehensive Case Manager Qualifications

a. Staff must have a minimum of a:

1. Bachelor's Degree from an accredited four (4) year institution of higher learning with a specialization in psychology, mental health and human services, behavioral health, behavioral sciences, social work, human development, special education, counseling, rehabilitation, sociology, nursing or closely related field, OR

2. Master's Degree in social work, education, psychology, counseling, nursing or closely related field from an accredited graduate school, OR

3. Bachelor's Degree from an accredited four (4) year institution of higher learning in an unrelated field and at least one (1) year of full-time equivalent relevant human services experience, OR

4. For staff of children's TCM service providers serving children with special cultural needs only, have necessary linguistic and cultural background and have parented a child or adolescent with special needs; OR

5. Have been employed on 8/1/2009 as a case manager providing services under the former subsections of Section 13. A person so employed will be considered qualified for the purposes of this section.

b. Additional staff qualifications as defined in contract agreements between the Department and the designated case management agency, as applicable, must be met.

2. Case Management Supervisor Qualifications

a. Supervision of comprehensive case managers must be provided by a:

1. Licensed physician, licensed physician assistant, licensed psychologist, licensed clinical social worker, licensed clinical professional counselor, licensed marriage and family therapists, advanced practice nurse, psychiatric nurse, registered nurse or a licensed social worker as defined below in Section 13.07-2 B.3., Professional Staff, OR

2. Person who was employed on 8/1/2009 as a case management supervisor providing supervision under the former subsections of Section 13. Such staff will be considered qualified for the purposes of this section.

b. Additional case management supervisor qualifications as defined in contract agreements between the Department and the designated case management agency, as applicable, must be met.

3. Professional Staff Qualifications

All professional staff must be conditionally, temporarily, or fully licensed in the State or Province in which services are provided and approved to practice as documented by written evidence from the appropriate governing body. All professional staff must provide services only to the extent permitted by Qualified Professional Staff licensure and approval to practice. Services provided by the following staff are reimbursable under this Section:

a. Physician

b. Physician Assistant

c. Psycologist

d. Social Worker

A social worker must:

(a) hold a Master's degree from a school of social work accredited by the Council of Social Work Education, and

(b) be either licensed or certified in accordance with 32 M.R.S.A., Chapter 83, §7001 or be eligible for examination by the Maine Board of Social Worker Registration, which eligibility is documented by written evidence from such Board.

f. Licensed Marriage and Family Therapist

g. Registered Nurse

h. Psychiatric Nurse

A psychiatric nurse must be licensed as a registered professional nurse and certified as a psychiatric nurse by the American Nursing Credentialing Center or other acceptable national certifying body for this specialty.

i. Advanced Practice Registered Nurse

An advanced practice nurse must be licensed as a registered professional nurse and approved to practice as an advanced practice registered nurse by the Maine State Board of Nursing and certified by a national certifying body acceptable by the Maine State Board of Nursing.

j. Advanced Practice Psychiatric Nurse

An advanced practice nurse must be licensed as a registered nurse by the Maine State Board of Nursing, certified as a psychiatric nurse practitioner or psychiatric and mental health clinical nurse specialist by the American Nurse's Credentialing Center, and approved to practice as an advanced practice registered nurse by the Maine State Board of Nursing or other acceptable national certifying body for this specialty, within the specialty of psychiatric nursing.

4. Personnel Requirements

Comprehensive Targeted Case Management providers must:

a. Maintain documentation of staff qualifications in staff personnel files. Documented evidence includes, but is not limited to: transcripts, licenses, and certificates.

b. Have a review process to ensure that employees providing Targeted Case Management Services possess the minimum qualifications outlined above. The review process must occur upon hiring new employees and on an annual basis to assure that credentials remain valid.

c. Plan staff development and continuing education activities for their employees and contractors that broaden their existing knowledge in the field of developmental disabilities, mental health, substance abuse, long term care, chronic medical conditions and related areas, as applicable.

d. Provide staff orientation specific to Targeted Case Management prior to the staff assuming their Targeted Case Management duties.

e. Maintain documentation of staff continuing education, staff development, and Targeted Case Management Training in staff personnel files.

13.07-3Provider Documentation Requirements

The provider must complete and maintain all documentation requirements as set forth below:

A.Content of Member Case Record

The provider must maintain a specific record for each member, which must include but not be limited to:

1. A comprehensive assessment that must be completed within the first thirty (30) days of initiation of services, and reassessment must occur as change in the member's needs warrants or at a minimum on an annual basis.

Assessments and re-assessments must be conducted on a face-to-face basis. The comprehensive assessment must minimally include:

a. The member's name, address, and birth date;

b. The member's history (including physical and social environment) including: past service use, health/medical status, determination of chronic or severe medical problems; a social and family history; determination of educational status, developmental status, substance abuse problems; assessment of social, daily living and other habilitative skills; and

c. The member's needs, strengths and preferences including: current functional level, level of risk, individual needs, existing strengths and supports, and available family support/social networks; and

d. Documentation of an evaluation by a psychiatrist, physician, physician assistant, psychologist, advanced practice psychiatric nurse, advanced practice registered nurse, LCSW, LMSW or an LCPC, which includes appropriate diagnosis.

2. An Individual Plan of Care based on the Comprehensive Assessment including:

a. The amount, frequency, and duration of each service to be provided, a record of service delivery, target dates for completion, and person responsible;

b. The procedures and instruments to be used in evaluating the member's progress with re-evaluation as change in the member's needs occur or at a minimum every ninety (90) days;

c. Documentation of member and/or family involvement in the development of the plan/plan of care must include their signatures;

d. The problems to be resolved, measurable goals and objectives to be attained and/or outcomes to be realized through provision of identified services;

e. Documentation if the member declines services listed in the individual care plan;

f. The psychiatric, medical, social, educational and family support and other services and resources identified to address each identified problem or need and how and by whom the services and resources may be most appropriately delivered;

g. Referrals to appropriate providers of services and follow-up documentation;

h. Plans for coordination with other agencies and providers, as appropriate; and

i. identification of any other case management providers and what services they are currently providing, and

j. Documentation that the individual or their guardian or legal representative has been offered choice of provider of TCM services which includes documentation of their choice.

3. Other Documentation, including:

a. Written progress notes and status reports, including dates of service; and

b. Accountability as evidenced by signature and date; and

c. Relevant assessment and evaluation reports and correspondence from and to other providers; and

d. Release of information statements as necessary, signed by member or when necessary, by guardian as required by law.

B.Record Entries

Entries are required for each case management service provided and must include:

(1) The name of the individual.

(2) The dates of the case management services.

(3) The name of the provider agency (if relevant), the person providing the case management service and the place of service delivery.

(4) The nature, content, units of the case management services received, progress toward goals specified in the care plan and/or if the goals have been achieved or modified.

(5) Whether the individual has declined services in the care plan.

(6) A timeline for obtaining needed services.

(7) A timeline for re-evaluation of the plan.

13.07-4Program Integrity Unit

Refer to Chapter I, General Administrative Policies and Procedures of the MaineCare Benefits Manual for a definition and description of Program Integrity.

13.07-5Interpreter Services

Please refer to Chapter I, General Administrative Policies and Procedures of the MaineCare Benefits Manual for a definition and description of Interpreter Services.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-13, subsec. 144-101-II-13.07