Current through 2024-38, September 18, 2024
19.08-1
Home
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.
19.08-2
Living
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.
19.08-3
Matter 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.
19.08-4
Member 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.
19.08-5
Member Surveys: The ASA,
SCA, Fiscal Intermediary and WSP shall be responsible for conducting annual
member surveys as approved by the Department.
19.08-6
Reports 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.
19.08-7
Electronic 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.
19.08-8
Professional 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.
5
Occupational
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.
19.08-9
Member'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.
19.08-10
Member 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.
