D.C. Mun. Regs. tit. 29, r. 29-8807

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-8807 - PARTICIPANT ASSESSMENT AND PLAN OF CARE

8807.1

The interdisciplinary team shall conduct an initial in-person comprehensive assessment of each participant following enrollment. The assessment shall be completed in a timely manner in order to comply with the plan of care development requirements at § 8807.7. As part of the initial comprehensive assessment, each of the following members of the interdisciplinary team shall evaluate the participant in person and develop a discipline-specific assessment of the participant's health and social status:

(a) Primary care provider;

(b) Registered nurse;

(c) Master's-level social worker;

(d) Physical therapist;

(e) Occupational therapist;

(f) Recreational therapist or activity coordinator;

(g) Dietitian; and

(h) Home care coordinator.

8807.2

At the recommendation of the interdisciplinary team, other professional disciplines (e.g., speech-language pathology, dentistry, or audiology) may be included in the initial comprehensive assessment process.

8807.3

The initial comprehensive assessment shall at a minimum include the evaluation of:

(a) Physical and cognitive function and ability;

(b) Medication use;

(c) Participant and caregiver preferences for care;

(d) Socialization and availability of family support;

(e) Current health status and treatment needs;

(f) Nutritional status;

(g) Home environment, including home access and egress;

(h) Participant behavior;

(i) Psychosocial status;

(j) Medical and dental status; and

(k) Participant language.

8807.4

At least once every six (6) months, or more often if a participant's condition dictates, the following members of the interdisciplinary team shall conduct an inperson reassessment:

(a) Primary care provider;

(b) Registered nurse;

(c) Master's-level social worker; and

(d) Other team members actively involved in the development or

implementation of the participant's plan of care, as determined by the primary care provider, registered nurse, and Master's-level social worker.

8807.5

If the health or psychosocial status of a participant changes, the members of the interdisciplinary team listed at § 8807.4 shall conduct an in-person reassessment.

8807.6

If a participant, or his or her authorized representative, makes a request to initiate, eliminate, or continue a particular service, the appropriate members of the interdisciplinary team, as identified by the interdisciplinary team, shall conduct a reassessment in accordance with the following:

(a) The reassessment may be conducted via remote technology when the interdisciplinary team determines that the use of remote technology is appropriate and the service request will likely be deemed necessary to improve or maintain the participant's overall health status and the participant, or his or her authorized representative, agrees to the use of remote technology.

(b) An in-person reassessment must be conducted:

(1) When the participant, or his or her authorized representative, declines the use of remote technology; and

(2) Before a PACE organization can deny a service request.

(c) The PACE organization must have explicit written procedures for timely resolution of requests by a participant, or his or her authorized representative, to initiate, eliminate, or continue a particular service.

(d) Except as permitted under § 8807.6(e), the interdisciplinary team must notify the participant, or his or her authorized representative, of its decision to approve or deny the request as expeditiously as the participant's condition requires, but no later than seventy-two (72) hours after the date the interdisciplinary team receives the request for reassessment.

(e) The interdisciplinary team may extend the seventy-two (72) hour timeframe for notifying the participant, or his or her authorized representative, of its decision to approve or deny the request by no more than five (5) additional days for either of the following reasons:

(1) The participant, or his or her authorized representative, requests the extension; or

(2) The interdisciplinary team documents its need for additional information and how the delay is in the interest of the participant.

(f) For any denial of a request to initiate, eliminate, or continue a particular service, the PACE organization must take the following actions:

(1) Explain the denial to the participant, or his or her authorized representative, orally and in writing;

(2) Provide the specific reasons for the denial in understandable language;

(3) Inform the participant, or his or her authorized representative, of the right to appeal the decision as specified in 42 CFR § 460.122;

(4) Describe both the standard and expedited appeals processes, including the right to, and conditions for, obtaining expedited consideration of an appeal of a denial of services as specified in 42 CFR § 460.122; and

(5) Describe the right to, and conditions for, continuation of appealed services through the period of an appeal as specified in 42 CFR § 460.122(e).

(g) If the interdisciplinary team fails to provide the participant with timely notice of the resolution of the request or does not furnish the services required by the revised plan of care, this failure constitutes an adverse decision, and the participant's request must be automatically processed by the PACE organization as an appeal in accordance with 42 CFR § 460.122.

8807.7

The interdisciplinary team shall develop a plan of care for each PACE participant in accordance with the following requirements:

(a) Within thirty (30) days of the date of enrollment in PACE, the interdisciplinary team must consolidate discipline-specific assessments into a single plan of care for the participant through team discussions and consensus of the entire interdisciplinary team;

(b) If the interdisciplinary team determines that certain services are not necessary to the care of the participant, the reasoning behind this determination must be documented in the plan of care;

(c) The plan of care must include all of the following:

(1) Specify the care needed to meet the participant's medical, physical, emotional, and social needs, as identified in the initial comprehensive assessment;

(2) Identify measurable outcomes to be achieved;

(3) Utilize the most appropriate interventions for each care need that advances the participant toward a measurable goal and outcome; and

(4) Identify each intervention, how it will be implemented, and how it will be evaluated to determine progress in reaching specified goals and desired outcomes.

(d) Female participants must be informed that they are entitled to choose a qualified specialist for women's health services from the PACE organization's network to furnish routine or preventive women's health services;

(e) The interdisciplinary team must implement, coordinate, and monitor the plan of care, whether the services are furnished by PACE employees or contractors. The team must continuously monitor the participant's health and psychosocial status, as well as the effectiveness of the plan of care, through the provision of services, informal observation, input from participants, and/or participants' authorized representatives, and caregivers, and communications among members of the interdisciplinary team and other providers;

(f) At least once every six (6) months, the interdisciplinary team must reevaluate the plan of care, including defined outcomes, and make changes as necessary;

(g) The interdisciplinary team must develop, review, and reevaluate the plan of care in collaboration with the participant, and/or his or her authorized representative, and caregiver, to ensure that there is agreement with the plan of care and that the participant's concerns are addressed; and

(h) The interdisciplinary team must document the plan of care, and any changes made to it, in the participant's medical record.

D.C. Mun. Regs. tit. 29, r. 29-8807

Final Rulemaking published at 69 DCR 6400 (6/3/2022)