Current through Register Vol. 49, No. 9, September, 2024
Section II Program
of All-Inclusive Care for the Elderly (PACE)
202.200
Staff Oversight Responsibility
(42 CFR §
460.71)
A. The PACE Organization must ensure that all
employees and contracted staff providing care directly to participants
demonstrate the skills, licensure, and/or certifications necessary for
performance of their position.
1. The PACE
Organization must provide all staff with an orientation that includes, at a
minimum, the organization's mission, philosophy, policies on participant
rights, emergency plan, ethics, and the PACE Program and any policies related
to the job duties.
2. The provider
must develop a competency evaluation program that identifies those skills,
knowledge and abilities that must be demonstrated by direct participant care
staff.
3. The competency program
must be evidenced as completed before performing participant care and on an
on-going basis by qualified professionals. Certification of the satisfactory
completion of the competency program must be in the personnel files of all
staff.
B. The PACE
Organization must develop a program to ensure that all staff furnishing direct
participant care services:
1. Comply with any
state or federal requirements for direct patient care staff in their respective
settings;
2. Comply with the
requirements of
42 CFR §
460.68(a) regarding persons
with criminal convictions;
3. Have
verified current certifications or licenses for their respective
positions;
4. Are free of
communicable diseases and are up to date with immunizations before performing
direct patient care;
5. Have been
oriented to the PACE Program; and
6. Agree to abide by the philosophy,
practices and protocols of the PACE Organization.
204.200
Medical Criteria
PACE participants must meet one of the following criteria: The
individual is unable to perform either of the following:
A. At least one (1) of the three (3)
activities of daily living (ADL) of transferring and/or locomotion, eating or
toileting without extensive assistance from or total dependence upon another
person; or,
B. At least two (2) of
the three (3) activities of daily living (ADL) of transferring and/or
locomotion, eating or toileting without limited assistance from another
person;
C. Medical assessment
results in a score of three or more on Cognitive Performance Scale;
D. Medical assessment results in a Changes in
Health, End-Stage Disease and Symptoms and Signs (CHESS) score of three or
more;
E. Individuals diagnosed with
a serious mental illness or mental retardation are not eligible for the Living
Choices Assisted Living program unless they have medical needs unrelated to the
diagnosis of mental illness or mental retardation and meet the other qualifying
criteria.
A diagnosis of severe mental illness or mental retardation must
not bar eligibility for individuals having medical needs unrelated to the
diagnosis of serious mental illness or mental retardation when they meet the
other qualifying criteria.
205.100 Retention of Records
All medical records of PACE participants must be completed
promptly, filed and retained for a minimum of six (6) years from the date of
service or until all audit questions, appeal hearings, investigations or court
cases are resolved, whichever is longer. The records must be available upon
request for audit by an authorized representative of the Arkansas Division of
Medical Services, the State Medicaid Fraud Control Unit and representatives of
the National Department of Health and Human Services.
205.200 Documentation Requirements
(42 CFR §
460.210)
All services provided to the PACE participant must be properly
documented in the PACE participant's record and signed by the service provider
at the time the service is delivered. At a minimum, the medical record must
contain appropriate identifying information and documentation of all services
furnished including the following:
1.
A summary of emergency care and other inpatient or long-term care
services
2. Services furnished by
employees of the PACE Organization
3. Services furnished by contractors and
their reports
4. Interdisciplinary
assessments, reassessments, plans of care, treatment and progress notes that
include the participant's response to treatment
5. Laboratory, radiological and other test
reports
6. Medication
records
7. Hospital discharge
summaries, if applicable; continuance of follow up care post
hospitalization
8. Reports of
contact with informal support (for example, caregiver, legal guardian, or next
of kin)
9. Enrollment
agreement
10. Physician
orders
11. Discharge summary and
Disenrollment justification, if applicable
12. Advance directives, if
applicable
13. A signed release
permitting disclosure of personal information
14. Accident and incident reports
215.100 Composition of the PACE
Interdisciplinary Team (42 CFR §
460.102)
The PACE interdisciplinary team must be composed of at least
the following members:
A. Primary care
physician (PCP)
B. Registered nurse
(RN)
C. Master Social worker
(MSW)
D. Physical therapist
(PT)
E. Occupational therapist
(OT)
F. Recreational therapist
(RT)/activity coordinator
G.
Dietician
H. PACE center
manager
I. Home care
coordinator
J. Personal care
attendant/aide
K. Transportation
staff/driver
215.200
Assessment/Treatment Plan
An interdisciplinary team is responsible for assessment,
treatment planning and care delivery after the DHS-RN has completed the initial
eligibility assessment for nursing facility level of care. The team must meet
the following assessment requirements:
A. An initial in-person comprehensive
assessment must be completed promptly following enrollment by the:
1. Primary care physician,
2. Registered nurse,
3. Master's-level social worker,
4. Physical therapist,
5. Occupational therapist,
6. Recreational therapist or activity
coordinator,
7. Dietitian
and
8. Home care
coordinator.
B. At least
semi-annually, an in-person assessment and treatment plan must be completed by
the:
1. Primary care physician,
2. Registered nurse,
3. Master's-level social worker and
4. Recreational therapist/activity
coordinator.
C.
Annually, an in-person assessment and treatment plan must be completed by the:
1. Physical therapist,
2. Occupational therapist
3. Dietitian and
4. Home care coordinator.
PACE organizations consolidate discipline specific plans into a
single plan of care semi-annually through discussion and consensus of the
interdisciplinary team. The consolidated plan is then discussed and finalized
with the PACE participant and/or his or her significant others.
Reassessments and treatment plan changes are completed when the
health or psychosocial situation of the participant changes.
215.300
PACE
Participant Appeal Process
When an adverse decision is received, the PACE participant may
appeal. The appeal request must be in writing and received by the Appeals and
Hearing Section of the Department of
Human Services within thirty (30) days of the date on the
letter explaining the decision.
View or print Appeals and Hearings Section
contact information.
220.000
Quality Assurance and
Monitoring Activities
The Department of Human Services will conduct site visits
annually during the trial period in conjunction with CMS or as needed to review
the quality of service provision by the PACE Organization. The annual site
visit review will include a clinical and administrative component and a review
of compliance with life safety codes. The annual on-site review will include
but not be limited to a review of the PACE Organization's compliance with
requirements in 42 CFR § 460, or its successor, in the following
compliance areas:
1.
Administrative,
2. PACE
Services,
3. Participant
Rights,
4. Quality Assessment and
Performance Improvement,
5.
Participant Enrollment and Disenrollment,
6. Payment,
7. Federal and State Monitoring,
8. Data Collection,
9. Record Maintenance and
10. Reporting, which includes a review of the
marketing materials, financial reports, samples of documentation of proper
licensure for PACE Organization staff, current contract arrangements to ensure
the PACE Organization has the capability to provide all federally and state
required services, and other items as deemed necessary to ensure compliance
with state and federal requirements.
At the conclusion of the trial period, CMS, in cooperation with
the State administering agency, continues to conduct reviews of a PACE
organization, as appropriate, taking into account the quality of care furnished
and the organization's compliance with all of the requirements.
DHS will be responsible for conducting an exit conference with
the PACE Organization to discuss any review findings, provide technical
assistance in developing corrective action plans and to assist the PACE
Organization in their efforts to implement the required corrections.
220.100
Monitoring by the
Office of Long Term Care
Due to the requirement that PACE Organizations be licensed as
Arkansas Adult Day Health Care Centers, the Office of Long Term Care will be
conducting monitoring and oversight of the PACE Center operations.
220.200
Reserved
220.300
Monitoring
by RN Supervisor
The DHS RN Supervisor attends the PACE organization's weekly
Interdisciplinary Team Meetings (IDT). The DHS RN Supervisor contributes to the
IDT meetings as necessary to ensure the health, welfare and safety needs of the
beneficiaries are met.
220.400
Monitoring by the Centers for
Medicare and Medicaid Services
(CMS) and the State Administering Agency
(SAA)
In compliance with federal requirements, each PACE Organization
will enter required information for nine (9) key indicators into the Health
Plan Management System (HPMS), or any successor data elements or data system on
a quarterly basis. Both CMS and the State Administering Agency (SAA) will use
the data entered into HPMS or its successor system to monitor the ongoing
operations of the PACE Organization and identify potential problems or unusual
events that may be the first indication of problems in patient care, site
operations or financial solvency. These reviews will also be used to determine
if further onsite monitoring will be necessary.
A. The nine (9) key indicators are as
follows:
1. Routine Pneumococcal
Immunizations
2. Grievances &
Appeals
3. Enrollments
4. Disenrollments
5. Prospective Enrollees
6. Unscheduled Hospitalizations
7. Emergency (Unscheduled) Care
8. Unusual Incidents for participants and the
PACE site (such as falls, attempted suicides, staff criminal records,
infectious diseases, food poisoning, participant injury, Medication errors,
lawsuits, any type of restraint use, etc.)
9. Participant Deaths
B. Other Required DHS Monitoring Reports:
1. 45 day report - tracks all applications
pending more than 45 days
2.
Monthly Reports - tracks all assessments, reassessments, monitoring contacts,
mileage associated with home visits, and pending applications
3. Average Days for Assessment Completion -
tracks statewide average and each RNs length of time between receiving referral
and completing home visit.
