Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 419.000 - Day Habilitation Center Services
Section 419.402 - Definitions
Current through Register 1531, September 27, 2024
The following terms used in 130 CMR 419.000 have the meanings given in 130 CMR 419.402, unless the context clearly requires a different meaning.
Activities of Daily Living (ADLs) - fundamental personal care tasks performed daily as part of an individual's routine self-care. ADLs include, but are not limited to, eating, toileting, dressing, bathing, transferring, and mobility or ambulation.
Clinical Assessment - the screening process of cataloging a member's need for DH using a tool designated by the MassHealth agency and that forms the basis for prior authorization.
Day Habilitation (DH) - a service, for individuals with an intellectual disability (ID) or a developmental disability (DD), that is based on a day habilitation service plan that sets forth measurable goals and objectives, and prescribes an integrated program of activities and therapies necessary to reach the stated goals and objectives.
Day Habilitation Provider (DH Provider) - the entity with responsibility for the day-to-day operation of services and programs subject to 130 CMR 419.000.
Day Habilitation Leveling Tool - a clinical assessment tool that is completed based on the results of the Service Needs Assessment. The DH Leveling Tool indicates whether the member is in the Low-Need, Moderate-Need, or High-Need category.
Day Habilitation Service Manager (DHSM) - individual who manages cases, ensuring that members' service plans are implemented, reviewed, updated as appropriate, and maintained.
Day Habilitation Service Plan (DHSP) - a written plan of care for each member that sets forth realistic and measurable member-driven goals that prescribe an integrated program of individually designed activities and/or therapies necessary to achieve these goals. The objective of the plan is to help the member reach his or her optimal level of physical, cognitive, psychosocial, occupational capabilities, and wellness.
Department of Developmental Services (DDS) - an agency of the Commonwealth of Massachusetts established under M.G.L. c. 19B.
Department of Public Health (DPH) - an agency of the Commonwealth of Massachusetts, established under M.G.L. c. 17, § 1.
Developmental Disability - a severe, chronic disability that
(1) is attributable to other conditions found to be closely related to ID, apart from mental illness, which results in the impairment of general intellectual functioning or adaptive behavior similar to that of persons with ID, and which requires treatment or services similar to those required for such persons;
(2) is manifested before a person reaches 22 years of age;
(3) is likely to continue indefinitely; and
(4) results in substantial functional limitations in three or more of the following major areas:
Developmental Skills Training - a series of planned, coordinated, goal-oriented services that are designed to maintain or improve the functional abilities of a person with an intellectual or developmental disability. Such services include, but are not limited to, self-help skills, sensorimotor skills, communication skills, independent living skills, affective development skills, social development skills, behavioral skills, and wellness.
EOHHS - the Executive Office of Health and Human Services established under M.G.L. c. 6A.
Functional Level - the degree to which individuals can perform daily living activities and manage their lives independently. Functional level is measured through professional clinical assessments.
Health Care Professional - an individual accredited by a professional body upon completing a course of study, and usually licensed by a government agency, to practice a health-related profession such as dentistry, medicine, nursing, occupational health, or physical therapy.
Hospital - a facility that is licensed or operated as a hospital by the Massachusetts Department of Public Health or the Massachusetts Department of Mental Health that provides diagnosis and treatment on an inpatient or outpatient basis for patients who have any of a variety of medical conditions.
Individualized Staffing Supports (ISS) - one-to-one staff supports provided to a member to enable the member to participate in a DH; this includes direct care and nursing. MassHealth determines medical necessity through a prior authorization process which identifies the total units of one-to-one services the member requires to participate in DH. Individualized staffing supports must not be used to enhance general staffing in a DH program.
Instrumental Activities of Daily Living (IADLs) - activities related to independent living that are incidental to the care of the member and that include, but are not limited to, household-management tasks, laundry, shopping, housekeeping, meal preparation and cleanup, transportation, care and maintenance of medical equipment and adaptive devices, medication management or any other need determined by the DH provider as being instrumental to the health care and general well-being of the member.
Intellectual Disability (ID) - a disability characterized by significant limitations in both intellectual functioning and adaptive behavior as expressed in conceptual, social, and practical skills and that originates before the individual attains age 22. The meaning of ID is consistent with the standard contained in the 12th edition of the American Association on Intellectual and Developmental Disabilities' Intellectual Disability: Definition, Classification, and Systems of Supports (2021) or any subsequent publication.
Interdisciplinary Team (IDT) - the team consists of the Registered Nurse (RN)/health care supervisor, developmental specialist, DHSM, and program director. The IDT must also include the following clinical members: a physical therapist, speech and language pathologist, occupational therapist, and behavioral professional. Other health care professionals may be included, as applicable.
Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/ID) - a facility, or distinct part of a facility, that provides intermediate care facility (ICF) services as defined under 42 CFR § 440.150, and that meets federal conditions of participation, and is licensed by the Commonwealth primarily for the diagnosis, treatment, or rehabilitation for individuals with intellectual disabilities; and provides, in a protected residential setting, ongoing evaluation, planning, 24-hour supervision, coordination, and integration for health or rehabilitative services to help individuals function at their greatest ability.
Level II Preadmission Screening and Resident Review (Level II PASRR) - a comprehensive evaluation and determination performed by DDS for any individual seeking admission or continued stay in a Medicaid nursing facility, in accordance with 42 CFR 483.100, to determine whether an individual suspected of having intellectual or other developmental disability has such a condition and if so, whether the individual requires the level of services provided by a nursing facility, and if so, whether specialized services are required.
MassHealth - the medical assistance and benefit programs administered by EOHHS pursuant to Title XIX of the Social Security Act (42 U.S.C. 1396), Title XXI of the Social Security Act (42 U.S.C. 1397), M.G.L. c. 118E, and other applicable laws and waivers to provide and pay for medical services to eligible members.
Member - a person determined by the MassHealth agency to be eligible for MassHealth.
Nursing Facility (NF) - an institution (or a distinct part of an institution) which is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care, rehabilitation services for the rehabilitation of injured people, people with disabilities, or sick persons, or on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services that meets the requirements of Sections 1919 (a), (b), (c), and (d) of the Social Security Act and is licensed under and certified by the Massachusetts Department of Public Health.
Primary Care Provider (PCP) - a physician, physician assistant, or nurse practitioner who operates under the supervision of a physician.
Resident Integrated Service Plan (RISP) - a comprehensive service plan developed by an interdisciplinary team consisting of the DDS service coordinator where applicable, the member (or authorized representative), NF staff representatives, the specialized services provider, and other relevant professionals (such as physical therapists, speech pathologists, occupational therapists, dieticians, and medical staff). The purpose is to address care in all settings for persons with ID or DD who reside in NFs and receive specialized services.
Semi-annual Review - a review of the member's overall progress conducted by the IDT at least every six months. Components of the review can be found at 130 CMR 419.419(C)(3).
Service Needs Assessment (SNA) - a compilation of evaluations by the clinical members of the IDT (Registered Nurse, OT, PT, SLP, Behavior Professional). The SNA determines a member's level of functioning, needs, and strengths, and makes specific recommendations for DH to address identified needs.
Significant Change - a major change in the member's status that
(1) impacts one or more areas of the member's health status; and
(2) requires the professional interdisciplinary team's review or revision of the DHSP.
Specialized Services - services specified by EOHHS for an NF resident with ID or DD which, combined with services provided by the nursing facility or other service providers, result in treatment that meets the requirements of 42 CFR 483.440 (a)(1).
Transportation - the method by which a member is brought from their home to the day habilitation provider or from the day habilitation provider to the member's home. Transportation service includes assisting the member while they enter and exit the vehicle, as appropriate.
