Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL)
Chapter III - Allowances for Services
Section 144-101-III-97 - Private Non-Medical Institution Services
Appendix 144-101-III-97-C - MEDICAL AND REMEDIAL SERVICE FACILITIES
Section 144-101-III-97-C-7000 - RESIDENT ASSESSMENTS

Universal Citation: 10 ME Code Rules § 144-101-III-97-C-7000

Current through 2024-38, September 18, 2024

7010 Purpose of Resident Assessments

The provider shall assess each resident, regardless of payment source utilizing an assessment tool on which provider staff will base a service plan designed to assist the resident to reach his/her highest practicable level of physical, mental, and psychosocial functioning. The MDS-RCA is the Department's approved resident assessment instrument.

7020 Schedule of Resident Assessments

The provider must complete the MDS-RCA within 30 days of admission and at least every 180 days thereafter during a resident's stay. The provider will sequence the assessments from the date in Section S.2.B of the MDS-RCA, Assessment Completion Date. The provider will complete subsequent assessments within 180 days from the date in S.2.B. Providers must complete a significant change MDS-RCA assessment within 14 calendar days after determination is made of a significant change in resident status as defined in the Training Manual for the MDS-RCA Tool. Providers must complete a Resident Tracking Form within 7 days of the discharge, transfer, or death of a resident. Providers must maintain all resident assessments completed within the previous 12 months in the resident's active record.

7030 Accuracy of Assessments

7030.1 Each assessment must be conducted or coordinated by staff trained in completion of the MDS-RCA.

7030.2 Certification: 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.

7030.3 Documentation: Documentation is required to support the time periods and information coded on the MDS-RCA.

7030.4 Penalty for Falsification: The provider may be sanctioned whenever an individual willfully and knowingly certifies (or causes another individual to certify) a material and false statement in a resident assessment. This may be in addition to any other penalties provided by statute, including but not limited to, 22 MRSA §15. The Department's R.N. assessors will review the accuracy of information reported on the MDS-RCA instruments. If the Department determines that there has been a knowing and willful certification of false statements, the Department may require (for a period specified by the Department) that the resident assessments under this Appendix be conducted and certified by individuals who are independent of the provider and who are approved by the Department.

7030.5 Review of Assessment Forms: The Department may review all forms, documentation and evidence used for completion of the MDS-RCA at any time. The Department will undertake quality review periodically to ensure that assessments are completed accurately, correctly, and on a timely basis.

7030.6 Facilities shall submit completed assessments to include Admissions, Semi-Annuals, Annuals, Significant Change, other required assessments and MDS Tracking Forms within 30 days of completion to the Department or the Department's designated agent.

7030.7 Providers must submit all claims on electronic media to be specified by the Department. Failure to submit on electronic media on or after this date may result in the provider being paid the DCP adjusted by the default classification (not classified) weight of 0.731.

7030.8 Providers must use the MDS-RCA Correction Form in order to request modification or inactivation of erroneous data previously submitted as part of the MDS record (assessment or tracking forms). The MDS-RCA Correction Form is for corrections of two types:

1) Modification, which should be requested when a valid MDS-RCA record (assessment or tracking form) is in the State MDS-RCA database, but the information in the record contains errors; or

2) Inactivation, which should be requested when an incorrect reason for assessment has been submitted under item "Reason for Assessment." Providers must then resubmit the record with the correct reason for assessment. An inactivation should also be used when an invalid record has been accepted into the State MDS-RCA database. A record may considered invalid for the following reasons:

1) the event did not occur;

2) the record submitted identifies the wrong resident;

3) the record submitted identifies the wrong reason for assessment; or

4) it was an inadvertent submission of a non-required record.

7040 QUALITY REVIEW OF THE MDS-RCA PROCESS

7040.1 Definitions

7040.1.1 MDS-RCA assessment review is conducted at residential care facilities (RCFs) by the Department, and consists of review of assessments, documentation and evidence used in completion of the assessments, in accordance with Section 7000, to ensure that assessments accurately reflect the resident's clinical condition.

7040.1.2 Assessment review error rate is the percentage of unverified Case Mix Group Records in the drawn sample. Samples shall be drawn from Case Mix Group Records completed for residents who have MaineCare reimbursement. MDS-RCA Correction forms received in the central repository or included in the clinical record will be the basis for review when completed before the day of the review and included as part of the resident's clinical record.

7040.1.3 Verified Case Mix Group Record is an MDS-RCA assessment form completed by the provider, which has been determined to accurately represent the resident's clinical condition during the MDS-RCA assessment review process. Verification activities include reviewing resident assessment forms and supporting documentation, conducting interviews, and observing residents.

7040.1.4 Unverified Case Mix Group Record is one which, for payment purposes, the Department has determined does not accurately represent the resident's condition and, therefore, results in an inaccurate classification of the resident into a case mix group that increases the case mix weight assigned to the resident. If the Department identifies any such record, it will require providers to follow appropriate clinical guidelines for completion and submission. Correction forms received prior to calculating the rate setting quarterly index will be used in the calculation of that index.

7040.1.5 Unverified MDS-RCA Record is one that, for clinical purposes, does not accurately reflect the resident's condition.

7050 CRITERIA FOR ASSESSMENT REVIEW

7050.1 Providers may be selected for an MDS-RCA assessment review by the Department based upon but not limited to any of the following:

(a) The findings of a licensing survey conducted by the Department indicate that the provider is not accurately assessing residents;

(b) An analysis of a provider's case mix profile of RCFs indicates changes in the frequency distribution of the residents in the major categories or a change in the facility average case mix score; or

(c) Resident assessment performance of the provider, including but not limited to, on-going problems with assessment completion and timeliness, untimely submissions and high assessment error rates.

7050.2 Assessment Review Process

7050.2.1 Assessment reviews shall be conducted by staff or designated agents of the Department.

7050.2.2 Providers selected for assessment reviews must provide reviewers with reasonable access to residents, professional and direct care staff, the provider assessors, clinical records, and completed resident assessment instruments as well as other documentation regarding the residents' care needs and treatments.

7050.2.3 Samples shall be drawn from MDS-RCA assessments completed for residents who have MaineCare coverage.

7050.2.4 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 residents where assessments are in error.

7060. SANCTIONS

7060.1 The Department will sanction providers for failure to complete assessments completely, accurately and on a timely basis.

7060.2 When a sanctionable event occurs, the Department shall base the sanctions on the total MaineCare payment received by the provider during the 4th through 6th months preceding the month in which the sanctionable event occurred. (For example, if the sanctionable event occurred in May, the sanction would be calculated by multiplying the sanction rate times the total MaineCare Case Mix payments to the provider during the preceding November, December and January).

7060.3 The amount of the sanction will be based on an application of the percentages below multiplied by the MaineCare Case Mix 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 case mix weight equal to 0.731. The sanctions shall be calculated 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.

e) 10% of MaineCare payments if the provider fails to complete reassessments within 7 days of a written notice/request by the Department.

Disclaimer: These regulations may not be the most recent version. Maine may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.

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