218 R.I. Code R. 218-RICR-40-00-5.4

Current through December 26, 2024

Section 218-RICR-40-00-5.4 - Service Delivery of Home and Community Care

5.4.1Intake and Assessment

A. The agency must respond by telephone to a request for assessment by the end of the first business day after day of the request.

B. The agency must conduct and document:

1. An initial screening of each potential consumer; and

2. An assessment of each potential consumer to: identify consumer's care/service needs and concerns in physical, cognitive, social, emotional, financial, nutritional, environmental domains; and lead to the development of an individualized plan of care and/or service by the case management agency and to a determination of the required level of care by the Rhode Island Department of Human Services.

C. The agency must utilize the current Division assessment tool(s) and Confidential Release of Information Form(s).

D. The agency must schedule the assessment within the following time lines:

1. Schedule an assessment within five (5) business days;

2. Conduct an assessment within 10 business days.

E. In the event that the agency is unable to meet one of the above time lines in a specific instance, the reasons shall be documented.

5.4.2Care and Service Coordination

A. The agency must provide and document these components of care/service coordination:

1. Information on services to meet consumer's needs;

2. Regular follow up contact with consumer, service and support providers, and others to ensure continued care per care plan, identification of problems and needs, working with health plans, and further coordination with state and local public agencies to support development of unified plan;

3. An attempt by telephone or in person to reach each consumer must be made by the consumer's case manager at least once each month;

4. If contact is not made at the monthly attempt, after the second consecutive month of inability to talk with the consumer, the case manager shall contact a representative of an agency scheduled to deliver services to the consumer;

5. Conduct an evaluation of care plan at least once every six (6) months, including the annual re-assessment prescribed by the Division;

6. Help consumers gain access to identified needed health and support services; and

7. Ensure services are delivered in timely fashion as determined by the service team, consumer and referring agency/agencies.

B. The agency must designate a case manager for each consumer. The case manager is responsible for at least:

1. Initial and monthly contact(s) with consumer;

2. Coordination of assessment;

3. Coordination of services;

4. Being available/accessible to be contacted by the consumer or his/her representative;

5. Implementation of the care plan.

6. Follow-up and re-evaluation.

C. The agency must establish and implement a policy and procedure to encourage continuity of care/service; and take steps to avoid interruptions of care/service, minimize transitions for the consumer; and provide a stable, positive relationship for the consumer.

D. The agency must coordinate care with the Division, in the case of protective services clients, so as to assure that social, health and psychological service needs and protective service needs are addressed in an integrated manner.

E. The agency must provide advocacy, as follows:

1. Support consumer's efforts to have his/her voice heard and to get needed services;

2. Offer advocacy on consumer's or family's behalf when needed services are not being adequately provided by an organization within community's service delivery system and;

3. Recognize potential conflicts of interest and refer consumers to next appropriate service so advocacy needs are met.

5.4.3Care Plan Development and Implementation

A. The agency must utilize the current Division care plan documents to develop a care plan in collaboration with the consumer and in coordination with existing community resources within thirty (30) days after an individual is referred to the case management agency.

1. A person-centered care plan is developed with the consumer which facilitates individual choice regarding services and supports and who provides them. The consumer identifies other members they wish to participate in the care planning process.

B. The agency must:

1. Document the process for getting consumer input into his/her care plan;

2. Include in the care plan a listing of all services recommended for the consumer; and

3. Demonstrate that the plan development is done in conjunction with other agencies that provide services to the consumer.

C. The agency must document and provide a copy of the care plan to the consumer.

D. Implementation of the care plan must begin immediately upon approval of the consumer and the Division

5.4.4Care Plan Monitoring, Revision and Reassessment

A. The case manager must monitor the care plan according to the following schedule:

1. Community Waiver monthly;

2. Co-Pay as needed, but at least every six (6) months.

B. In the event that the agency is unable to meet one of the above time lines in a specific instance, the reasons shall be documented.

C. The case manager must review care plans at least twice a year. The case manager must gather relevant information and involve clinical specialists to consult on case reviews as needed.

D. The agency must have plans and procedures for all consumer reassessments:

1. Conduct a first reassessment at six (6) months for all consumers. After that, use the Division tool to complete a reassessment for all consumers every six (6) months and whenever there is a significant change in consumer's status, as defined in the agency's policy and procedure relating to reassessments.

2. Visit consumer in the appropriate setting and conduct face-to-face interview to review established goals and progress in meeting those goals.

E. The agency must track number of referrals, sources, and other information needed to report to the Division in the format and at intervals specified by the Division.

5.4.5Service Denial and Consumer Appeal Procedures

If a service is still denied after discussion between the consumer and the case manager, the agency must provide written notice to the consumer that includes the reason(s) for the denial, and the consumer's right to appeal the decision to the agency. Any applicant, certificate holder, or the state acting through the Attorney General, who is aggrieved by the decision may appeal the decision to the Executive Office of Health and Human Services, as outlined under "Medicaid Code of Administrative Rules, Section #0110, 'Complaints and Appeals'".

5.4.6Discharge/Transition

A. Discharge/transition plans must be developed for consumers with changes in service needs and changes in functional status that prompt another level of care.

B. The agency must develop a discharge protocol that includes criteria and notification procedures.

C. The agency must document the reason for discharge and all related information in the individual consumer record.

D. The agency must give the consumer and family/caregiver written notice if he/she is to be discharged from the program and:

1. Advise the consumer of his/her right to appeal a service decision, and

2. Review appeal procedure with consumer or representative.

218 R.I. Code R. 218-RICR-40-00-5.4