Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 422.000 - Personal Care Attendant Services
Section 422.438 - Transitional Living Program: Operating Procedures

Universal Citation: 130 MA Code of Regs 130.422

Current through Register 1531, September 27, 2024

(A) Assessment. The assessment identifies the member's needs and functional capabilities, including the ability to manage PCA services independently. For an individual who cannot manage PCA services independently, the assessment must identify a surrogate or administrative proxy; if a surrogate or administrative proxy is not available, the agency must refer the member to an appropriate service provider. The assessment process must include the member and may include participation of family members and advocates. The product of an assessment is either an evaluation or a referral to an appropriate service provider.

(B) Evaluation.

(1) An evaluation team consisting of a registered nurse and an occupational therapist must conduct an initial evaluation under the supervision of a registered nurse. The evaluation team must consider the member's physical and cognitive condition to determine the member's ability to benefit from PCA services. All evaluations are subject to the approval of the member's physician.

(2) The evaluation must take place in the member's actual or proposed place of residence in the community, or in the following locations, if these situations apply:
(a) at the transitional living program site where the member lives if the member has completed functional skills training, but is unable to find housing; or

(b) at a hospital or institution if the member has been hospitalized or institutionalized for an extended period.

(C) Reevaluations. At least annually, and when necessary in the event of a significant change in the member's physical condition or living situation, the registered nurse or LPN must conduct a reevaluation, including a review of the PCA services plan. For plans designating a surrogate or administrative proxy, see 130 CMR 422.439(B). The reevaluation must conform to the requirements in 130 CMR 422.438(B). If appropriate, the occupational therapist must be involved.

(D) Processing Services. The transitional living provider must process MassHealth agency payments for PCA services. The MassHealth agency pays the agency, which transmits the funds to the member or the surrogate, who pays the PCA.

(1) The organization's administrator and the member both must sign an agreement on a form designated by the MassHealth agency. This agreement states the member's and the agency's legal responsibilities in the transitional living program.

(2) Each pay period, not to exceed a month, the transitional living provider must collect activity forms from each member, signed by both the member and the PCA. The organization may claim payment from the MassHealth agency only for services actually provided by the PCA as documented by the activity forms, plus the processing fee.

(3) Within four working days after receiving payment from the MassHealth agency for PCA services, the transitional living provider must pay the member or the surrogate the amount owed to the PCA for these services.

(4) The agency must maintain a separate account exclusively for PCA payments. All such payments must be maintained in such account until disbursed to the member or surrogate.

(E) Nursing Supervision. The transitional living provider must provide nursing supervision of transitional living services as authorized in the service agreement and at least annually as part of an evaluation or reevaluation.

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