Current through Register 1531, September 27, 2024
All CSN agency services must be provided under an
individualized plan of care developed for the member. The physician or ordering
non-physician practitioner must sign the plan of care before services are
provided to the member.
(A)
Providers Qualified to Establish a Plan of Care.
(1) The member's physician or ordering
non-physician practitioner in consultation with the CSN agency must establish a
written plan of care and the physician or ordering non-physician practitioner
must recertify, sign, and date the plan of care every 60 calendar
days.
(2) The CSN agency may
establish an additional nursing plan of care, when appropriate, that may be
incorporated into the physician or ordering non-physician practitioner's plan
of care, or be prepared separately. The additional plan of care does not
substitute for the physician or ordering non-physician practitioner's plan of
care.
(3) If a CSN agency is
co-vending a case with other CSN providers or home health agency providers,
each provider is responsible for establishing a separate plan of care signed by
the member's physician or ordering non-physician practitioner.
(B)
Content of the
Plan of Care. The orders on the plan of care must specify the
total number of CSN hours and complex care assistant hours, as applicable, that
the MassHealth agency or its designee has authorized to be provided to the
member. The physician or ordering non-physician practitioner must sign and date
the plan of care before the CSN agency submits its claim for those services to
the MassHealth agency for payment. Alternatively, the physician or ordering
non-physician practitioner must comply with the verbal order provisions at
130
CMR 438.416(D). Any increase
in the total number of CSN hours and complex care assistant hours, as
applicable, must be requested in advance by the physician or ordering
non-physician practitioner with verbal or written orders and authorized by the
MassHealth agency or its designee. If the member is enrolled in the Primary
Care Clinician (PCC) Plan, the CSN agency must communicate with the member's
PCC both when the goals of the care plan are achieved and when there is a
significant change in a member's health status. The plan of care must also
include
(1) the member's name and date of
birth;
(2) all pertinent diagnoses,
including the member's mental, psychosocial, and cognitive status;
(3) types of medical supplies and DME
required;
(4) the member's
prognosis, rehabilitation potential, functional limitations, permitted
activities, nutritional requirements, medications, and treatments;
(5) the total number of nursing hours
requested by the CSN agency, if different from the total number of CSN hours
authorized by the MassHealth agency or its designee;
(6) the total number of complex care
assistant hours requested by the CSN agency, if different from the total number
of complex care assistant hours authorized by the MassHealth agency or its
designee, as applicable;
(7) any
teaching activities to be conducted by the nurse to teach the member, family
member, or caregiver how to manage the member's treatment regimen (ongoing
teaching may be necessary where there is a change in member's condition or
treatment);
(8) a description of
the patient's risk for emergency department visits and hospital readmission,
and all necessary interventions to address the underlying risk
factors;
(9) a plan for medical
emergencies;
(10) goals toward
discharge planning from CSN agency services when appropriate; and
(11) any additional items the CSN agency or
physician or ordering non-physician practitioner chooses to include.
(C)
Certification
Period. The plan of care required under
130
CMR 438.416(A)(1) must be
reviewed, signed, and dated by a physician or ordering non-physician
practitioner at least every 60 days, unless the provider follows the verbal
order provisions at
130
CMR 438.416(D).
(D)
Verbal Orders.
(1) Notwithstanding the requirements of
130
CMR 438.416(A), services
that are provided from the beginning of the certification period
(
see
130
CMR 438.416(C)) and before
the ordering physician or ordering non-physician practitioner signs the plan of
care are considered to be provided under a plan of care established and
approved by the physician or ordering non-physician practitioner if
(a) the clinical record contains a documented
verbal order from the ordering physician or ordering non-physician practitioner
for the care before the services are provided; or
(b) the physician or ordering non-physician
practitioner signature is on the 60-day plan of care either before the claim is
submitted or within 90 days after submitting a claim for that period.
(2) If the member has other health
insurance (whether commercial or Medicare), the provider must comply with the
other insurer's regulations for physician or ordering nonphysician practitioner
signature before billing the MassHealth agency.
(E)
Corrections to the Plan of
Care. When correcting errors on a paper plan of care before it is
signed by the physician or ordering non-physician practitioner, the CSN agency
staff must cross out the error with a single line and place their initials and
the date next to the correction. The use of correction fluid or correction tape
on a plan of care is not permitted.
(F)
Face-to-face Encounter
Requirements.
(1) A face-to-face
encounter between the member and an authorized practitioner is required for
initial orders for CSN agency services. A face-to-face encounter is not
required when the plan of care is reviewed and revised as required at
130
CMR 438.416(C) or at
resumption of CSN agency services.
(2) Authorized practitioners include
(a) the ordering physician. In order to be an
ordering physician, the physician must be enrolled in MassHealth;
(b) the physician who cared for the member in
an acute or post-acute care facility (acute/post-acute care attending
physician) from which the member was directly admitted to the CSN agency;
or
(c) certain authorized
non-physician practitioners, which include one of the following in a CSN agency
context:
1. an ordering non-physician
practitioner; or
2. a certified
nurse midwife.
(3)
Documenting the Face-to-face
Encounter in the Member's Record.
(a) The face-to-face encounter must be
documented in the member's record either on the plan of care or in other
medical notes sufficient to make the link between the individual's health
conditions, the services ordered, an appropriate face-to-face encounter, and
actual service provision.
(b) The
ordering or acute/post-acute care attending physician or ordering non-physician
practitioner may serve as the physician writing the plan of care. When the
acute/post-acute care attending physician or ordering non-physician
practitioner writes the plan of care, such attending practitioners must
document that the face-to-face encounter is related to the primary reason the
patient requires CSN agency services and that the encounter with an authorized
practitioner occurred within the required timeframes. The plan of care or the
medical notes must include which authorized practitioner conducted the
encounter and the date of the encounter.
(c) If the face-to-face encounter was not
provided by the ordering physician or ordering non-physician practitioner, the
authorized practitioner who did conduct the face-to-face encounter is required
to communicate the clinical findings of the face-to-face encounter to the
ordering physician or ordering non-physician practitioner. This requirement is
necessary to ensure that the ordering physician or ordering non-physician
practitioner has sufficient information to determine the need for CSN agency
services in the absence of conducting the face-to-face encounter himself or
herself.
(d) The CSN agency must
maintain a copy of the face-to-face documentation.
(G)
MassHealth Members
Enrolled in the Primary Care Clinician (PCC) Plan. If a member is
enrolled in the PCC Plan, the CSN agency must provide the PCC with a copy of
the member's plan of care for each certification period.
