Current through Register Vol. 54, No. 12, March 23, 2024
(a) Ongoing responsibilities of providers are
established in §
1101.51 (relating to ongoing
responsibilities of providers).
(b)
In addition to the requirements set forth under subsection (a), a case manager
shall comply with the following recordkeeping requirements:
(1) A case manager shall maintain an activity
log on each recipient that includes, at a minimum:
(i) The case manager's name.
(ii) The recipient's name and MA
identification number.
(iii) The
time, date, place and a description of each targeted case management
service.
(iv) Information relating
to the services provided.
(2) The case manager's recipient's file shall
include a copy of the medical treatment plan or other documentation obtained
from the recipient's physician no later than 30 days from the initial contact
with the recipient. The case manager shall obtain an updated medical treatment
plan from the recipient's physician at least every 6 months.
(3) Case managers shall develop a service
coordination plan (SCP) for each recipient that:
(i) Is based on the medical treatment plan
developed by the recipient's physician.
(ii) Incorporates social and other
interventions needed to promote the well-being of the recipient.
(iii) Is developed within 30 days of
notification by the Department that the recipient is eligible for the targeted
case management program.
(iv)
Includes active participation by the recipient or the recipient's
representative during the development and updating of the SCP.
(v) Is updated monthly to document and
certify the effectiveness of services included in the plan and the recipient's
need for continuation of services.
(vi) Is submitted to the Department or its
representative upon request or as designated by the Department.
(c) Services provided by
a case manager are limited to the following:
(1)
Screening. The case
manager evaluates the recipient's medical, social, psychological and financial
condition as well as environmental factors by reviewing related documentation
and interviewing the recipient to determine if the recipient is an appropriate
candidate for targeted case management services under the MA Program.
(2)
Assessing service needs.
Based on the medical treatment plan, the case manager, in conjunction with the
recipient or the recipient's representative, will:
(i) Identify the recipient's needs.
(ii) Identify targeted case management
services that are appropriate based on the recipient's health
condition.
(iii) Establish
realistic goals.
(3)
Developing and implementing the SCP. The SCP will specify
activities which serve as a means for the case manager and recipient to achieve
the established goals. The plan will include appropriate referrals, service
providers and community resources to be used. The plan will follow a format
developed by the Department.
(4)
Identifying, linking and coordinating services. Based on the
SCP, the case manager shall locate resources and make referrals or arrangements
for treatments and support services.
(5)
Facilitating access to
services. When necessary, the case manager shall intervene on behalf
of the recipient to obtain needed services from appropriate agencies, private
individuals or other service providers. The case manager shall provide support
to the recipient and encourage the recipient to use services in accordance with
the service coordination plan.
(6)
Monitoring the effectiveness of services. To ensure
appropriate quantity, quality and effectiveness of services in accordance with
the SCP, the case manager shall monitor services on an ongoing basis.
(7)
Reassessing the service
needs. The case manager shall confer with the recipient and review the
SCP periodically for changes in the recipient's needs as determined by the
Department. These changes shall be reflected by appropriate revisions to the
SCP followed by changes in targeted case management services as indicated in
the plan.
(d) The case
manager shall meet with the recipient and, when appropriate, the recipient's
representative in the recipient's place of residence within 30 days of the
determination that the recipient is eligible for targeted case management
services. Follow-up meetings with the recipient and, when appropriate, the
recipient's representative shall occur at least every 6 months. Exceptions to
the requirements relating to meetings in the recipient's place of residence
will be made at the discretion of the Department taking into consideration
unusual circumstances encountered.
(e) The case manager shall act promptly in
situations that may jeopardize the goal of a recipient's SCP.
(f) The case manager shall complete training
programs developed or required, or both, by the Department within specified
time frames.