C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-19, subsec. 144-101-II-19.08

Current through 2025-02, January 8, 2025

Subsection 144-101-II-19.08 - POLICIES AND PROCEDURES

19.08-1Home Delivered Meals: a provider must meet the following criteria:

1. be a qualified vendor as approved by DHHS and enrolled by the MaineCare program;

2. be a licensed eating establishment by the State of Maine and meet the requirements of Maine DHHS-Centers for Disease Control, Environmental Health Division and local municipalities;

3. have a Maine-licensed dietician on staff or available on a consultant basis;

4. be able to provide meals to meet participating members' special dietary needs;

5. be able to produce and deliver meals to members' homes; and

6. be able to provide up to one meal per day, seven (7) days per week to eligible members. This includes meals that are either hot, cold, shelf stable or frozen.

19.08-2Living Well for Better Health: a provider must meet the following criteria:

1. be licensed by Stanford University's CDSMP to provide Living Well for Better Health classes;

2. have the experience and the capacity to train and manage volunteers to facilitate program delivery;

3. have the experience and the capacity to meet evidence-based health and wellness program dissemination standards;

4. have the capacity to market and deliver community-based workshops;

5. have experience providing services to older adults or those with chronic conditions or disabilities; and

6. provide training materials and manuals, program administration; and

7. conduct volunteer leader background checks to verify volunteer leader eligibility.

19.08-3Matter of Balance: a provider must meet the following criteria

1. be licensed by Boston University to provide Matter of Balance classes;

2. have the experience and the capacity to train and manage volunteers to facilitate program delivery;

3. have the experience and the capacity to meet evidence-based health and wellness program dissemination standards;

4. have the capacity to market and deliver community based workshops;

5. have experience providing services to older adults or those with chronic conditions or disabilities;

6. provide training materials and manuals, program administration; and

7. conduct volunteer leader background checks to verify volunteer leader eligibility.

19.08-4Member Complaint Logs: The ASA, SCA, Fiscal Intermediary, and Waiver Services Provider shall each be responsible for maintaining a log of member complaints regarding home and community benefits. This shall include all verbal and written complaints. There shall be documentation containing at least the member's name, name of the complaining party, date and nature of the complaint, the date of resolution, and how each complaint was addressed or resolved. The member complaint log shall be made available to the Department upon request.

19.08-5Member Surveys: The ASA, SCA, Fiscal Intermediary and WSP shall be responsible for conducting annual member surveys as approved by the Department.

19.08-6Reports and Monitoring

The SCA shall submit the following reports/data to the Department within the specified time frames:

Monthly

Program census including the number of new admissions and discharges within each reporting month. Total number of consumers self-directing their care. Total number of unstaffed/partially staffed cases by county and unstaffed hours by county and discipline. Monthly compliance reports for initial home visits, to include: indication of date of initial notification of authorization by the ASA, date of home visits, and days in between. Cost and utilization reports upon request by the Department, in a format determined by the Department.

Quarterly

Health and welfare report, Event tracking report,

Annually

Consumer Satisfaction Survey Report

1) Compiled data related to annual surveys including number of surveys conducted, number of survey responses, aggregate survey responses for each survey question,

2) Narrative summary of performance based on survey data, including any action steps taken in response to survey data, and goals to improve performance.

The Fiscal Intermediary shall submit the following reports/data to the Department within the specified timeframes:

Monthly

Number of active members served, including new referrals, within the Participant-Directed Option Number of background checks (categorized as initial or annual) conducted for Attendants. Total number of Attendants reimbursed and hours of reimbursement each month.

Annually

Consumer Satisfaction Survey Report

1) Compiled data related to annual surveys including number of surveys conducted, number of survey responses, aggregate survey responses for each survey question.

2) Narrative summary of performance based on survey data, including any action steps taken in response to survey data, and goals to improve performance.

The ASA shall submit reports to the Department as specified in the contract between the Department and the ASA.

Ongoing monitoring shall be conducted by the Department of Health and Human Services, Office of Aging and Disability Services, which will include on-site visits to the SCA, the ASA and visits to a sample of members. The Department will monitor compliance with the waiver document and regulations.

19.08-7Electronic Visit Verification (EVV)

Effective January 1, 2020, every provider of the following services: Home Health Services, Personal Care Services (also known as Personal Support Services), Attendant Services, and Respite Services in the home - must utilize an Electronic Visit Verification system ("EVV"). Visits conducted as part of such services must be electronically verified with respect to: the type of service performed; the individual receiving the service; the date of the service; the location of the service delivery; the individual providing the service; and the time the service begins and ends. Providers may utilize the Maine DHHS EVV system at no cost, or may procure and utilize their own EVV system, so long as data from the provider-owned EVV system can be accepted and integrated with the Maine DHHS EVV system and otherwise is compatible.

19.08-8Professional and Other Qualified Staff

All professional and other qualified staff must be trained upon hire, prior to the provision of services to a member, and annually thereafter on the federal HCBS requirements.

If registered professional nurses, physical therapists, occupational therapists and speech-language pathologists are acting as independent contractors, they must be enrolled as a MaineCare provider in order to provide services under this Section. Services shall be provided by the following staff:

A. Professional Staff

The following professional staff must be fully licensed, which license must be documented by written evidence from the appropriate governing body. All professional staff must provide services only to the extent permitted by licensure and approval to practice conditions. If the professional is not acting as an independent contractor, he/she must be employed directly by or through a contractual relationship with a MaineCare provider.

1. Registered Professional Nurse: A registered professional nurse may provide nursing services within the scope of his or her licensure.

2. Practical Nurse: A licensed practical nurse may provide nursing services within the scope of his or her licensure provided they are supervised by a registered professional nurse.

3. Master's Social Worker: A social worker must hold a Master's Degree from a school of social work accredited by the Council on Social Work Education.

4. Physical Therapist: A physical therapist who meets the requirements and the qualifications set forth in the MaineCare Benefits Manual (MBM), Chapter II, Section 85- Physical Therapy Services, may provide physical therapy services.

5Occupational Therapist: A registered occupational therapist who meets the requirements and the qualifications set forth in the MaineCare Benefits Manual (MBM), Chapter II, Section 68- "Occupational Therapy Services", may provide occupational therapy services.

6. Speech-Language Pathologist: A speech-language pathologist meeting the requirements and qualifications set forth in the MaineCare Benefits Manual (MBM), Chapter II, Section 109- Speech and Hearing Services, may provide speech and language therapy services.

B. Other Qualified Staff:

Other qualified staff members, other than professional staff defined above, must have appropriate education, training, certification, and experience, as verified by the employing agency that is enrolled as a MaineCare provider.

1. Assessor

In order to determine medical Eligibility for services under this section the assessor must:

a. Hold a valid registered nurse (RN) license in the State of Maine

b. Must be employed with the contracted Assessing Services Agency

2. Care Coordinator

In order to provide Care Coordination Services under this section, a care coordinator must be employed by an enrolled Service Coordination Agency and attend annual mandated reporter and fraud/waste/abuse trainings.

Prior to employment, the care coordinator must provide written evidence of the following:

a. Status as a licensed social service or health professional: or

b. Four years of education in the health or social services field and one year of community experience: or

c. Status as a registered occupational therapist who is licensed to practice occupational therapy in the State of Maine; or

d. Status as a certified occupational therapy assistant who is licensed to practice occupational therapy in the State of Maine under the documented supervision of a licensed occupational therapist.

3. Home Health Aide

A home health aide must be listed on the Maine Registry of Certified Nursing Assistants and Direct Care Workers and must not be prohibited from employment under 22 M. R. S. § 1812(G). Home health aides employed by a home health agency must be in compliance with the Regulations Governing the Licensing and Functioning of Home Health Care Services. A home health aide shall work under the direct supervision of a registered nurse.

4. Certified Nursing Assistant (CNA)

A CNA must be listed on the Maine Registry of Certified Nursing Assistants or Direct Care Workers and must not be prohibited from employment under 22 M. R. S. § 1812(G). A CNA shall work under the direct supervision of an RN.

5. Personal Support Specialist (PSS)

A PSS must be employed by, or acting under a contractual relationship with, a licensed home health agency or by a registered personal care agency. A family member who meets the requirements of this Section may be a PSS and receive reimbursement for delivering personal support services, with the exception of the MaineCare member's spouse, or the parent (including stepparent) of a minor child who is a MaineCare member.

Effective July 1, 2020, the spouse of an eligible member may be reimbursed as a PSS for the provision of Personal Care Services when the member requires Extraordinary Care. Extraordinary Care means care exceeding the range of activities that a spouse would ordinarily perform in the household on behalf of a person without a disability or chronic illness of the same age, and which are necessary to assure the health and welfare of the member and avoid institutionalization. Extraordinary services include Activities of Daily Living (ADLs), but do not include Instrumental Activities of Daily Living (IADLs).

The need for Extraordinary Care must be identified, documented, and regularly evaluated within the Person-Centered Planning process and authorized by the Service Coordination Agency (SCA). The spouse must meet the qualifications herein for a Personal Support Specialist and work for a Personal Care Agency in order to provide Personal Care Services to the member. The SCA and PCA are responsible for ensuring that a spouse acting as a PSS is only submitting instances of Extraordinary Care for MaineCare reimbursement.

a. All individuals employed as a PSS must:

i. Undergo criminal background checks, and checks on the Maine Registry of Certified Nursing Assistants and Direct Care Workers. PSSs may not be employed by the provider agency if they are prohibited from employment under 22 M. R. S. § 1717.

ii. Meet one (1) of the training and examination requirements below. An individual without the required training may be hired and reimbursed for delivering personal support services as long as the individual enrolls in a certified training program within sixty (60) days of hire and completes training and examination requirements within nine (9) months of employment and meets all other requirements. If the individual fails to pass the examination within nine (9) months, reimbursement for his or her services must stop until such time as the training and examination requirements are met. A PSS must meet one (1) of the following:

aa. Hold a valid certificate of training for Certified Nursing Assistants and be listed on the Maine Registry of Certified Nursing Assistants; or

bb. Hold a valid certificate of training, issued within the past three (3) years, for nurse's aide or home health aide training that meets the standards of the Maine State Board of Nursing nursing assistant training program; or

cc. If a CNA's status on the Maine Registry of Certified Nursing Assistants has become inactive, or an individual holds a valid certificate of training meeting the standards of the Maine State Board of Nursing nursing assistant program issued more than three (3)years ago, the individual must pass the competency-based examination of didactic and demonstrated skills from the Department's approved Personal Support Specialist curriculum. A certificate of training as a personal careassistant/Personal Support Specialist will be awarded upon passing this examination; or

dd. Hold a valid certificate of training as a Personal Support Specialist issued as a result of completing the Department approved Personal Support Specialist training curriculum and passing the competency-based examination of didactic and demonstrated skills. The training course must include at least fifty (50) hours of formal classroom instruction, demonstration, return demonstration, and examination. Tasks covered under this Section must be covered in the training; or

ee. Be a Personal Support Specialist who successfully completed a Department-approved curriculum prior to September 1, 2003. Such individuals will be grandfathered as a qualified PSS.

b. New employee orientation must be provided as follows:

i. A PSS, newly hired to an agency, who meets the Department's PSS training requirements, must receive an agency orientation. The training and certification documents must be on file in the PSS's personnel file.

ii. A newly hired PSS who does not yet meet the Department's training and examination requirements must undergo an eight (8) hour orientation that reviews the role, responsibilities and tasks of the PSS. To meet the required eight hours for orientation an agency may choose to use job shadowing for a maximum of two (2) hours of the 8 hour time requirement. The orientation must be completed by the PSS prior to the start of delivering services. The PSS must demonstrate competency to the employing agency in all required tasks prior to being assigned to a member's home, with the exception of Health Maintenance Activities, whereby a PSS can demonstrate competency via on the job training once being assigned to a member's home.

c. Provider agency responsibilities include, but are not limited to the following:

i. Assuring that a PSS meets the training, competency, and other requirements of this Section, and maintaining documentation of how each requirement is met in the PSS's personnel file, including: evidence of orientation when applicable, check of the CNA and Direct Care Worker Registry, criminal background check, and the verification of credentials including the certificate of training and/or verification of competency.

ii. Supervisory visits

aa. Initial visit. A provider agency supervisor must make an initial visit to a member's home prior to the start of PSS services to develop and review with the member the Authorized Plan of Care as authorized by the ASA and as ordered by the care coordinator.

bb. Scheduled supervisory visits. An agency employer will provide a PSS on-site supervision at least every six (6) months in a member's residence to observe and verify PSS competency in the delivery of service . The documentation of supervisory visits shall be maintained in the PSS's employee file. More frequent or additional on-site supervision visits of the PSS occur at the discretion of the provider agency as governed by its personnel policies and procedures.

cc. A provider agency must develop and implement written policies and procedures that ensure a smoke-free environment. PSSs are not allowed to smoke, consume alcohol, or use controlled substances in the member's home or vehicle during work hours.

dd. A provider agency must develop and implement written policies and procedures that address abuse, neglect or misappropriation of a member's property and that includes information on mandated reporting requirements.

d. The Department has the authority to recover funds for services provided if the provider agency does not provide required documentation to support qualifications of the agency or staff or services billed.

e. The Office of MaineCare Services and the Office of Aging and Disability Services have the responsibility of ensuring the quality of services and the authority to determine whether a PSS agency has the capacity to comply with all service requirements. Failure to meet standards may result in non-approval, a plan of correction, or termination of the provider enrollment agreement.

f. An agency must provide documentation demonstrating compliance with these requirements upon request by the Department, including the OADS.

6. Attendants.

The following requirements apply to an Attendant employed under the Participant-Directed Option:

a. Effective July 1, 2020, an Attendant must be at least seventeen (17) years old;

b. The Attendant must demonstrate competency to the member or representative in all required tasks;

c. An Attendant will not be reimbursed for more than forty hours of service per week, except as provided in 19.05(M); and

d. The member must use a qualified Fiscal Intermediary as the payroll agent to pay the attendant.

The following individuals may not be reimbursed as Attendants under this Section:

aa. A member's guardian or conservator;

bb. A member's spouse;

cc. A member's Representative;

dd. An individual who has an annotation of abuse, neglect or misappropriate of property on the Maine Registry of Certified Nursing Assistants and Direct Care Workers;

ee. An individual who would be prohibited from being hired by an agency under 22 M. R. S. § 1717;

ff. An individual who receives Attendant or Personal Care Services as a member under this Section or other MaineCare or State funded long term care program.

After the completion of Skills Training instruction, the member or Representative shall train the Attendant on the job. Within a twenty-one (21) day probation period, the member or Representative will determine the competency of the Attendant on the job. At a minimum, based upon the Attendant's job performance, the member or Representative will certify competence in the following areas:

aa. ability to follow oral or signed and written instructions and carry out tasks as directed by the member or Representative;

bb. disability awareness;

cc. use of adaptive and mobility equipment;

dd. transfers and mobility; and

ee. ability to assist with Health Maintenance Activities.

Satisfactory performance in the areas above will result in a statement of Attendant competency for each Attendant. This statement must be completed on a Department-approved form signed by the member, submitted to the SCA, with a copy kept in the member's record. The SCA may require that the member or the Representative provide additional information or verification regarding the competency of an Attendant before or after hiring.

7. Skills Trainer

Skills Trainer must have a high school degree or equivalent, be an employee of the SCA, and have the ability to teach the skills required for a member to successfully utilize the Participant-Directed Option including information on: recruiting, interviewing, selecting, training, scheduling and supervising a competent Attendant. Requisite skills which must be documented by the SCA include the ability to effectively communicate with members or representatives, their families and other support staff; knowledge of program regulations and the principles of member direction; and knowledge of community resources.

8. Representative

A Representative may manage Attendant Services for a member under the Participant-Directed Option and shall not be compensated for the services provided under this Section. The Representative must be able to manage and direct program Attendant Services for the member in accordance with the member's preferences and meet all program requirements. The Representative may not actively manage the care for more than two members participating in the Participant-Directed Option under this Section or another MaineCare or state funded long term care program. Specifically, the Representative must:

a. Be at least 18 years of age;

b. Have the ability to understand and perform tasks required to manage an Attendant as determined by the SCA;

c. Have the ability to communicate effectively with the SCA, FMS and Attendant(s) in performing the tasks required to employ an Attendant;

d. Agree to visit the member in person at least once a month and contact the member in person, by phone or other means at least weekly; and

e. Not be an Attendant reimbursed for providing care to the member.

19.08-9Member's Record

A. SCA, Fiscal Intermediary and Direct Care Provider responsibilities. The SCA, Fiscal Intermediary and Direct Care Providers are responsible for maintaining a specific record for each member, which shall include, but is not limited to the member's name, address, birth date, MaineCare ID, pertinent medical history, and diagnosis.

All member records shall be kept current in accordance with the rules outlined under Chapter I, Section 1, "General Administrative Policies and Procedures" and available to the Department as documentation of services included on invoices. Records shall be retained for a period of not less than five(5) years from the date of service delivery, with the exception that, if an audit is initiated within the required retention period, the records must be retained until the audit is completed and a cost settlement has been finalized.

B. SCA responsibilities. In addition to the requirements elsewhere in this Section, the SCA shall maintain all notes, progress notes and documentation related to its responsibilities and requirements.

C. Provider agency responsibilities. Direct Care Provider must maintain documentation of the dates, type, amount and duration of services provided, progress notes, discharge summary, release of information authorization, and service approval issued by the SCA. A provider of Home Health Services must maintain the nursing plan of care signed by the physician.

Written progress notes shall contain:

1. Identification of the service provided, date, total hours, and by whom. Exclude travel time unless provided as a service as described in Sections 19.01 and 19.04;

2. Progress toward the achievement of long and short-range goals. Include explanation when goals are not achieved as expected;

3. Signature of the service provider; and

4. Full account of any unusual condition or unexpected event, dated and documented.

All entries shall be signed by the individual who performed the service.

D. Fiscal Intermediary responsibilities

In addition to the requirements set forth elsewhere in this Section, the Fiscal Intermediary shall maintain:

1. Attendant payroll records and employment forms;

2. Time sheets submitted by the member or the member's Representative; and

3. Evidence of all required background checks.

E. Representative responsibilities

In addition to the requirements set forth elsewhere in this Section, the Representative must maintain and provide documentation to the SCA, as requested, of monthly in person contact and other required contact with the member.

19.08-10Member Appeals

A member or applicant has the right to appeal as set forth in Chapter I of this Manual. An appeal for members must be requested in writing or verbally to:

Director

Office of Aging and Disability Services

c/o Hearings

11 State House Station

Augusta, ME 04333-0011 19.08-11

Program Integrity

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.

Ongoing monitoring shall be conducted by the Department of Health and Human Services, Office of Aging and Disability Services, which will include on-site visits to the ASA and the SCA, and visits to a sample of members. The Department will monitor the ASA's and SCAs' compliance with the Waiver document, regulations and contract performance.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-19, subsec. 144-101-II-19.08