Current through Register 1531, September 27, 2024
(A)
Direct Care. The AFC provider must ensure the delivery
of direct care to members in a qualified setting, as described in
130
CMR 408.435, by a qualified AFC caregiver, as
described in
130
CMR 408.434, who lives in the residence and
paid by the AFC provider. AFC must be ordered by a PCP and delivered by a
qualified AFC caregiver under the oversight of the registered nurse and the MDT
in accordance with each member's written plan of care. Direct care includes
24-hour supervision, and daily assistance with ADLs and IADLs as defined in
130
CMR 408.402.
(B)
Nursing
Oversight. The AFC provider must provide nursing oversight by a
registered nurse or licensed practical nurse under the supervision of a
registered nurse who meets the qualifications as described in130 CMR
408.433(C)(2)(a) and
130
CMR 408.433(E)(1), who is
not related to the member, and who is licensed in Massachusetts. Nursing
oversight services must be individualized to meet the needs of each member in
accordance with the member's AFC plan of care and must include all of the
following activities:
(1) completing or
coordinating all applicable clinical assessments and clinical evaluations,
provided that only a registered nurse can complete such assessments and
evaluations;
(2) developing the
member's interim and final AFC plan of care, with input from the member or
responsible party, all members of the MDT, and other individuals designated by
the member;
(3) completing a
semi-annual health status report for each member;
(4) ensuring implementation of the AFC plan
of care;
(5) coordinating the
delivery of AFC with any other health services or supportive services the
member is receiving from MassHealth or other agencies or organizations
including, but not limited to, visiting nurse services, therapy services,
Department of Developmental Services (DDS) services, Department of Mental
Health (DMH) services, and Massachusetts Rehabilitation Commission (MRC)
services;
(6) conducting on-site
visits with each member at the qualified setting:
(a) for members authorized for AFC level I
service payment, the nurse must conduct on-site visits every other month, or
more often as the member's condition warrant where such visits alternate with
the required visits by the care manager to ensure the member receives one visit
by the nurse or care manager every month, as determined by the MDT in
accordance with
130
CMR 408.433(B), a community
support specialist may conduct up to three non-consecutive on-site visits per
12-month period in place of the nurse; and
(b) for AFC level II service payment, the
nurse must conduct on-site visits every month, or more often as the member's
condition warrants, to ensure the member receives one visit by the nurse and
one visit by the care manager every month, if determined appropriate by the MDT
in accordance with
130
CMR 408.433(B), a community
support specialist may conduct up to six non-consecutive on-site visits per
12-month period in place of the nurse;
(7) completing a nursing progress note for
each on-site visit or encounter and upon significant change;
(8) monitoring each member's health status
and documenting those findings in the member's medical record for each on-site
visit or encounter, or more often as the member's condition warrants;
(9) educating the member about hygiene and
health concerns;
(10) reporting
changes in the member's condition to the member's PCP;
(11) coordinating and implementing the PCP
form and approval for AFC with the member, AFC caregiver, and AFC provider
personnel;
(12) developing, in
conjunction with the MDT the AFC caregiver, and the member or responsible
party, an emergency backup and personal care contingency plan for each member
receiving AFC that includes an alternative plan for the member if the AFC
caregiver is temporarily unable to provide care; and
(13) overseeing, monitoring, supporting,
training, and evaluating AFC caregivers.
(C)
Care Management.
Care management must be provided by a qualified AFC care manager, as described
in 130 CMR
408.433(C)(3)(a), who is not
related to the member, and who is responsible for coordinating care and
monitoring the needs of the member in conjunction with the registered nurse.
Care management performed by the AFC care manager must include the following
activities:
(1) conducting initial and ongoing
psychosocial evaluation of a member's appropriateness for AFC;
(2) evaluating, supporting, and training AFC
caregivers;
(3) assisting with the
development of the member's interim and final AFC plan of care with input from
the member or responsible party, all members of the MDT, and other individuals
designated by the member.
(4)
ensuring implementation of the AFC plan of care;
(5) conducting on-site visits with each
member at the qualified setting:
(a) for AFC
level I service payment, the care manager must conduct on-site visits every
other month, or more often as the member's condition warrants, where such
visits alternate with the required visits by the nurse to ensure the member
receives one visit by the nurse or care manager every month, provided that, as
determined by the MDT in accordance with
130
CMR 408.433(B), a community
support specialist may conduct up to three non-consecutive on-site visits per
12-month period in place of the AFC care manager;
(b) for AFC level II service payment, the
care manager must conduct on-site visits every month, or more often as the
member's condition warrants, to ensure the member receives one visit by the
nurse and one visit by the care manager every month. If determined appropriate
by the MDT in accordance with
130
CMR 408.433(B), an AFC
community support specialist may conduct up to six non-consecutive on-site
visits per 12-month period in place of the care manager;
(6) assisting with coordination of AFC with
any other health services or supportive services the member is receiving from
MassHealth, a managed care organization, an accountable care organization or
other agencies or organizations including, but not limited to, visiting nurse
services, therapy services, Department of Developmental Services (DDS)
services, Department of Mental Health (DMH) services, and Massachusetts
Rehabilitation Commission (MRC) services;
(7) completing a care manager progress note
corresponding with each on-site visit or encounter, or more often as the
member's condition warrants;
(8)
reporting changes in the member's condition to the member's AFC
nurse;
(9) assisting with making
referrals to appropriate service providers if the member requires services
other than those provided by the AFC provider;
(10) conducting regular, periodic
evaluations, at least annually, to ensure that each qualified setting where AFC
is provided meets the requirements of
130
CMR 408.435;
(11) providing timely assistance and
responding to urgent or emergency needs of the member; and
(12) developing, in conjunction with the MDT,
the AFC caregiver, and the member or responsible party, an emergency backup and
personal care contingency plan for each member, receiving AFC that includes an
alternative plan for the member if the AFC caregiver is temporarily unable to
provide care.
(D)
AFC Community Support Specialist On-site Visits. An
AFC community support specialist who is qualified as described in
130
CMR 408.433(D)(1), who is
not related to the member, and who has the responsibilities described in
130
CMR 408.433(D)(2) may
conduct on-site visits of the member at the qualified setting in place of the
nurse or care manager if determined appropriate by the MDT in accordance with
130
CMR 408.433(B).
