Subsection 144-101-II-2.07 - POLICIES AND PROCEDURES2.07-1Assessments for Service PlanningA.Assessment: Providers shall conduct an assessment, with the Department's assessment tool to determine each member's level of functioning and general health status, regardless of eligibility or source of payment. The results of the assessment shall be the basis for the development of the individual service plan described in Section 2.07-2. Providers must submit a copy of the completed assessment to the Department's authorized representative within 14 days of the assessment. A copy must be maintained in the member's record. 1. A person trained in the use of the MDS-ALS must conduct the initial assessment within 30 days of admission. Providers must use the Department-approved tool (MDS-ALS) according to the instructions in the training manual for the MDS-ALS tool.2. The member, or his or her legally responsible representative, will provide input into and be an integral part of the assessment process. The member's family or significant other also may be involved, unless such involvement is not feasible or contrary to the wishes of the member or legally responsible representative.3.Re-assessments. After the initial assessment, the member shall receive an assessment using MDS-ALS at least once every six months, or sooner in the event of a significant change, either an improvement or decline, in his or her functional status. The provider must revise the service plan based upon the needs identified at the re-assessment. Providers shall submit a copy of the completed assessment to the Department's agent within 14 days of the assessment. The assessments will be sequenced from the date in Section S.2.B. of the MDS-ALS, assessment completion date. Providers must complete subsequent assessments within 180 days from the date in S.2.B. Providers must complete significant change assessments within 14 days after determination is made of a significant change in resident status as defined in the training manual for the MDS-ALS tool. Providers must complete a resident tracking form within 7 days of the discharge, transfer or death. The provider must maintain all completed assessments within the previous 12 months in the member's active record.4.Accuracy of AssessmentsThe accuracy of the MDS-ALS will affect coverage of services outlined in individual service plans as well as payment to the provider. The Department will aggregate results of the assessment to give the provider feedback on critical quality indicators. Therefore, the following requirements must be met:
a. Only staff trained in completion of the MDS-ALS by the Department may conduct or coordinate assessments.b. Each individual who completes a portion of the assessment must sign and date the form to certify the accuracy of that portion of the assessment.c. The Department requires documentation to support the time periods and information coded on the MDS-ALS.d. The Department may sanction a provider whenever the provider willfully and/or knowingly certifies (or causes another individual to certify) a material and false statement in an assessment. This may be in addition to any other penalties provided by statute, including but not limited to, 22 M.R.S.A. §15.e. The Department has the right to review all forms, documentation and evidence used for completion of the MDS-ALS at any time. The Department will undertake quality review periodically to ensure that assessments are completed accurately, correctly, and on a timely basis.f. Facilities shall submit completed assessments to include admissions, semi-annuals, annuals, significant change, and other required assessments and MDS-ALS tracking forms within 30 days of completion to the Department of its designated agent.5.Quality Review of the MDS-ALS process: Definitions The Department conducts MDS-ALS assessment reviews. The process includes a review of assessments, documentation and evidence used in completion of the assessments, in accordance with this Section to ensure that assessments accurately reflect the member's characteristics and condition.
Assessment review error rate is the percentage of unverified resource-adjusted price group records in the drawn sample. The Department will draw samples from resource-adjusted group records completed for MaineCare members.
A verified resource-adjusted group record is an MDS-ALS assessment form completed by the provider that has been determined to accurately represent the member's characteristics during the MDS-ALS assessment review process. Verification activities include reviewing assessment forms and supporting documentation, conducting interviews and observing members.
An unverified resource-adjusted group record is one that cannot be verified for payment purposes, since the Department has determined it may not accurately represent the member's characteristics and condition and, therefore, may result in an inaccurate classification of the member into a resource-adjusted grouping that increases the MaineCare weight assigned to the member.
An unverified MDS-ALS record is one that does not accurately reflect the member's condition.
6.Criteria for Quality ReviewThe Department will select providers for an MDS-ALS quality review based upon but not limited to any of the following:
a. The findings of a licensing survey conducted by the Department indicating that the provider is not accurately assessing persons receiving assisted living services;b. An analysis of a provider's resident resource group profile indicating changes in the frequency distribution of members in the major categories or a change in the average resource adjusted groupings; orc. Performance of the provider, including but not limited to, on-going problems with assessment completion and timeliness, untimely submissions and high assessment error rates.7.Quality Review Processa. Department staff or designated agent(s) shall conduct reviews.b. Providers selected for review must coordinate access to members, and provide access to professional and direct care staff, the provider assessors, member records, and completed assessment tools, as well as documentation regarding the member's service needs and services delivered.c. The Department shall draw samples from MDS-ALS assessments completed for MaineCare members.d. At the conclusion of the on-site portion of the review process, the reviewers shall hold an exit conference with provider representatives. Reviewers will share written findings for reviewed records. The reviewer may also request reassessment of members where assessments are in error.8.SanctionsThe Department will sanction providers who fail to accurately complete assessments in a timely manner. Effective July 1, 2004, when a sanctionable event occurs, the Department shall base the sanctions on the total MaineCare payment to the provider from the 4th through the 6th months preceding the month in which the sanctionable event occurred. (For example, if the sanctionable event occurred in July, the sanction would be calculated by multiplying the sanction rate times the total MaineCare payments to the provider during the preceding January, February and March.) The amount of the sanction will be based on an application of the percentages below multiplied by the MaineCare payments to the provider during the 4th through 6th months preceding the event. In no event will the payment to the provider be less than the price that would have been paid with an average resource-adjusted price equal to 0.551. The Department will calculate sanctions as follows:
a. 2% of MaineCare payments when the assessment review results in an error rate of 34% or greater, but is less than 37%;b. 5% of MaineCare payments when the assessment review results in an error rate of 37% or greater, but is less than 41%;c. 7% of MaineCare payments when the assessment review results in an error rate of 41% or greater, but is less than 45%;d. 10% of MaineCare payments when the assessment review results in an error rate of 45% or greater; ore. 10% of MaineCare payments if the provider fails to complete reassessments within 7 days of a written notice/request by the Department.2.07-2Individual Service PlanA. Providers must develop and implement an individual service plan for each member. This plan must be based upon the results of the assessment described in Section. 2.07-1. The plan must contain long- and short-range goals (as appropriate), and identify the resources and strategies necessary to meet the goals. The plan must describe the specific personal care services and other services required and specify who will perform each service and how frequently. The provider must also include other items, as appropriate, such as orders for medications and treatments, safety measures to protect against injury, nutritional requirements and therapeutic diets, and discharge plans, etc. The plan must include the use of the member's natural support system. Additionally, for cognitively impaired residents, providers must include activities, safeguards for wandering, and behavior management approaches in the individual service plan. The individual service plan must summarize any other "in home" services the member is receiving (including: Section 96, "Private Duty Nursing and Personal Care Services"; Section 40, "Home Health Services"; Section 19, "Home and Community-based Benefits for the Elderly and Adults with Disabilities"; Section 43, "Hospice Services"; or Section 22, "Waiver Services for the Physically Disabled") and how these services will be coordinated with Adult Family Care Services. The plan must describe the services and frequency delivered by each provider (see also Section 2.05-1).
B. The member, or legally responsible representative, and others chosen by the member, shall have an integral role in the development of the service plan, in reviewing its effectiveness, and in revising the plan.C. The provider shall coordinate AFC services with any other services the member may utilize. The provider shall assist the member to access other services that are needed.D. The individual service plan shall be reviewed and modified as necessary, based upon the needs identified during reassessments or significant changes in functioning.E. The individual service plan must be reviewed and initialed by a professional R.N. every 90 days, and copies must be maintained in the member's record.2.07-3RecordsThe AFC provider must maintain an individual record for each member including the following:
A. Name, birthdate, and MaineCare identification number;B. Pertinent personal information such as names and addresses of nearest relatives, guardian, power of attorney, and physician or primary care provider;D. Resident assessments (MDS-ALS);E. Monthly summaries of services delivered, frequency of delivery, and identity of the person(s) who delivered the service;F. Progress notes written regularly and at least monthly which state the progress the member has made;G. Medication Administration Record (MAR), if any;H. Copies of all orders for medications and treatments;I. Record of physician or primary care provider visits, if any;J. Record of rehabilitation or therapy visits, if any;K. Documentation of any incidents or accidents; and L. Other information, as necessary.2.07-4Professional And Other Qualified StaffA.Professional Staff may include the following: 1. A registered nurse (RN) who is currently licensed to practice nursing in the State or Province in which services are provided.B.Other Qualified Staff include the following: 1. A provider who meets the qualifications set forth under the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level III - Residential Care Facilities, as evidenced by a valid license issued by the Department; and2. Other caregivers who meet the qualifications set forth under the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level III Residential Care Facilities.2.07-5Surveillance And Utilization Review Requirements for Surveillance and Utilization Review are included in Chapter I of the MaineCare Benefits Manual (MBM).
2.07-6ConfidentialityDisclosure of Information- The disclosure of information regarding individuals participating in the MaineCare program is strictly limited to purposes directly connected with the administration of the MaineCare program.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-2, subsec. 144-101-II-2.07