016.06.12 Ark. Code R. 032

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.12-032 - Program of All-Inclusive Care for the Elderly (PACE) Update Transmittal PACE 2-12

Section II Program of All-Inclusive Care for the Elderly (PACE)

202.200 Staff Oversight Responsibility (42 CFR § 460.71)

A. The PACE Organization must ensure that all employees and contracted staff providing care directly to participants demonstrate the skills, licensure, and/or certifications necessary for performance of their position.

1. The PACE Organization must provide all staff with an orientation that includes, at a minimum, the organization's mission, philosophy, policies on participant rights, emergency plan, ethics, and the PACE Program and any policies related to the job duties.

2. The provider must develop a competency evaluation program that identifies those skills, knowledge and abilities that must be demonstrated by direct participant care staff.

3. The competency program must be evidenced as completed before performing participant care and on an on-going basis by qualified professionals. Certification of the satisfactory completion of the competency program must be in the personnel files of all staff.

B. The PACE Organization must develop a program to ensure that all staff furnishing direct participant care services:

1. Comply with any state or federal requirements for direct patient care staff in their respective settings;

2. Comply with the requirements of 42 CFR § 460.68(a) regarding persons with criminal convictions;

3. Have verified current certifications or licenses for their respective positions;

4. Are free of communicable diseases and are up to date with immunizations before performing direct patient care;

5. Have been oriented to the PACE Program; and

6. Agree to abide by the philosophy, practices and protocols of the PACE Organization.

204.200 Medical Criteria

PACE participants must meet one of the following criteria: The individual is unable to perform either of the following:

A. At least one (1) of the three (3) activities of daily living (ADL) of transferring and/or locomotion, eating or toileting without extensive assistance from or total dependence upon another person; or,

B. At least two (2) of the three (3) activities of daily living (ADL) of transferring and/or locomotion, eating or toileting without limited assistance from another person;

C. Medical assessment results in a score of three or more on Cognitive Performance Scale;

D. Medical assessment results in a Changes in Health, End-Stage Disease and Symptoms and Signs (CHESS) score of three or more;

E. Individuals diagnosed with a serious mental illness or mental retardation are not eligible for the Living Choices Assisted Living program unless they have medical needs unrelated to the diagnosis of mental illness or mental retardation and meet the other qualifying criteria.

A diagnosis of severe mental illness or mental retardation must not bar eligibility for individuals having medical needs unrelated to the diagnosis of serious mental illness or mental retardation when they meet the other qualifying criteria.

205.100 Retention of Records

All medical records of PACE participants must be completed promptly, filed and retained for a minimum of six (6) years from the date of service or until all audit questions, appeal hearings, investigations or court cases are resolved, whichever is longer. The records must be available upon request for audit by an authorized representative of the Arkansas Division of Medical Services, the State Medicaid Fraud Control Unit and representatives of the National Department of Health and Human Services.

205.200 Documentation Requirements (42 CFR § 460.210)

All services provided to the PACE participant must be properly documented in the PACE participant's record and signed by the service provider at the time the service is delivered. At a minimum, the medical record must contain appropriate identifying information and documentation of all services furnished including the following:

1. A summary of emergency care and other inpatient or long-term care services

2. Services furnished by employees of the PACE Organization

3. Services furnished by contractors and their reports

4. Interdisciplinary assessments, reassessments, plans of care, treatment and progress notes that include the participant's response to treatment

5. Laboratory, radiological and other test reports

6. Medication records

7. Hospital discharge summaries, if applicable; continuance of follow up care post hospitalization

8. Reports of contact with informal support (for example, caregiver, legal guardian, or next of kin)

9. Enrollment agreement

10. Physician orders

11. Discharge summary and Disenrollment justification, if applicable

12. Advance directives, if applicable

13. A signed release permitting disclosure of personal information

14. Accident and incident reports

215.100 Composition of the PACE Interdisciplinary Team (42 CFR § 460.102)

The PACE interdisciplinary team must be composed of at least the following members:

A. Primary care physician (PCP)

B. Registered nurse (RN)

C. Master Social worker (MSW)

D. Physical therapist (PT)

E. Occupational therapist (OT)

F. Recreational therapist (RT)/activity coordinator

G. Dietician

H. PACE center manager

I. Home care coordinator

J. Personal care attendant/aide

K. Transportation staff/driver

215.200 Assessment/Treatment Plan

An interdisciplinary team is responsible for assessment, treatment planning and care delivery after the DHS-RN has completed the initial eligibility assessment for nursing facility level of care. The team must meet the following assessment requirements:

A. An initial in-person comprehensive assessment must be completed promptly following enrollment by the:

1. Primary care physician,

2. Registered nurse,

3. Master's-level social worker,

4. Physical therapist,

5. Occupational therapist,

6. Recreational therapist or activity coordinator,

7. Dietitian and

8. Home care coordinator.

B. At least semi-annually, an in-person assessment and treatment plan must be completed by the:

1. Primary care physician,

2. Registered nurse,

3. Master's-level social worker and

4. Recreational therapist/activity coordinator.

C. Annually, an in-person assessment and treatment plan must be completed by the:

1. Physical therapist,

2. Occupational therapist

3. Dietitian and

4. Home care coordinator.

PACE organizations consolidate discipline specific plans into a single plan of care semi-annually through discussion and consensus of the interdisciplinary team. The consolidated plan is then discussed and finalized with the PACE participant and/or his or her significant others.

Reassessments and treatment plan changes are completed when the health or psychosocial situation of the participant changes.

215.300 PACE Participant Appeal Process

When an adverse decision is received, the PACE participant may appeal. The appeal request must be in writing and received by the Appeals and Hearing Section of the Department of

Human Services within thirty (30) days of the date on the letter explaining the decision.

View or print Appeals and Hearings Section contact information.

220.000 Quality Assurance and Monitoring Activities

The Department of Human Services will conduct site visits annually during the trial period in conjunction with CMS or as needed to review the quality of service provision by the PACE Organization. The annual site visit review will include a clinical and administrative component and a review of compliance with life safety codes. The annual on-site review will include but not be limited to a review of the PACE Organization's compliance with requirements in 42 CFR § 460, or its successor, in the following compliance areas:

1. Administrative,

2. PACE Services,

3. Participant Rights,

4. Quality Assessment and Performance Improvement,

5. Participant Enrollment and Disenrollment,

6. Payment,

7. Federal and State Monitoring,

8. Data Collection,

9. Record Maintenance and

10. Reporting, which includes a review of the marketing materials, financial reports, samples of documentation of proper licensure for PACE Organization staff, current contract arrangements to ensure the PACE Organization has the capability to provide all federally and state required services, and other items as deemed necessary to ensure compliance with state and federal requirements.

At the conclusion of the trial period, CMS, in cooperation with the State administering agency, continues to conduct reviews of a PACE organization, as appropriate, taking into account the quality of care furnished and the organization's compliance with all of the requirements.

DHS will be responsible for conducting an exit conference with the PACE Organization to discuss any review findings, provide technical assistance in developing corrective action plans and to assist the PACE Organization in their efforts to implement the required corrections.

220.100 Monitoring by the Office of Long Term Care

Due to the requirement that PACE Organizations be licensed as Arkansas Adult Day Health Care Centers, the Office of Long Term Care will be conducting monitoring and oversight of the PACE Center operations.

220.200 Reserved

220.300 Monitoring by RN Supervisor

The DHS RN Supervisor attends the PACE organization's weekly Interdisciplinary Team Meetings (IDT). The DHS RN Supervisor contributes to the IDT meetings as necessary to ensure the health, welfare and safety needs of the beneficiaries are met.

220.400 Monitoring by the Centers for Medicare and Medicaid Services

(CMS) and the State Administering Agency (SAA)

In compliance with federal requirements, each PACE Organization will enter required information for nine (9) key indicators into the Health Plan Management System (HPMS), or any successor data elements or data system on a quarterly basis. Both CMS and the State Administering Agency (SAA) will use the data entered into HPMS or its successor system to monitor the ongoing operations of the PACE Organization and identify potential problems or unusual events that may be the first indication of problems in patient care, site operations or financial solvency. These reviews will also be used to determine if further onsite monitoring will be necessary.

A. The nine (9) key indicators are as follows:

1. Routine Pneumococcal Immunizations

2. Grievances & Appeals

3. Enrollments

4. Disenrollments

5. Prospective Enrollees

6. Unscheduled Hospitalizations

7. Emergency (Unscheduled) Care

8. Unusual Incidents for participants and the PACE site (such as falls, attempted suicides, staff criminal records, infectious diseases, food poisoning, participant injury, Medication errors, lawsuits, any type of restraint use, etc.)

9. Participant Deaths

B. Other Required DHS Monitoring Reports:

1. 45 day report - tracks all applications pending more than 45 days

2. Monthly Reports - tracks all assessments, reassessments, monitoring contacts, mileage associated with home visits, and pending applications

3. Average Days for Assessment Completion - tracks statewide average and each RNs length of time between receiving referral and completing home visit.

016.06.12 Ark. Code R. 032

12/13/2012