Code of Massachusetts Regulations
651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS
Title 651 CMR 3.00 - Home Care Program Regulations
Section 3.05 - Home Care Service Plan Development and Reassessment

Universal Citation: 651 MA Code of Regs 651.3

Current through Register 1531, September 27, 2024

(1) Service Plan. After determining an Applicant's eligibility and need for Home Care Services pursuant to 651 CMR 3.04, a Comprehensive Service Plan will be developed. The Home Care Service Plan will identify the services to be provided to the Applicant or Caregiver to meet his or her identified needs and the date on which services shall commence. The ASAP shall initiate the provision of the appropriate service(s) in accordance with the time lines outlined in 651 CMR 3.04(2). Circumstances resulting in exceptions to this time requirement shall be documented in the Consumer's electronic record.

(2) Service Authorization. The ASAP shall issue a service authorization to all providers in order to initiate, change, or terminate any Home Care Program Service according to procedures mandated by Elder Affairs.

(3) Follow-up and Reassessment. The ASAP shall provide ongoing Interdisciplinary Case Management services to the Consumer to:

(a) Assess whether the services provided to the Consumer are meeting his or her needs;

(b) Ascertain whether the services are being provided by the provider in a manner acceptable to the Consumer and appropriate for his or her needs;

(c) Determine and make necessary changes in the level, amount, and/or type of services deemed appropriate by the ASAP;

(d) Reassess each Consumer's current health and functional status, need for services, service level, and service type by conducting in-home reassessments and communicating with the elder, family members, other care givers, informal supports and/or formal supports as necessary. A home visit to reassess the Consumer's needs shall be conducted according to specific Elder Affairs Program Instructions; and

(e) Document any changes in the service pattern, including an increase, reduction, termination, or suspension of services made as a result of this ongoing reassessment process. A Long Term Care Assessment is required to be completed a minimum of every six months and more frequently as required by changes in the Consumer's circumstances, functional impairments, or service needs.

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