C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-102, app 144-101-II-102-I
PROVISIONAL ACCREDITATION PROCESS
The purpose of this Appendix is to describe the initial eighteen (18) month approval process for providers who are not ready to undergo the Rehabilitation Accreditation Commission (CARF) survey and certification and are requesting MaineCare reimbursement under this Section. The initial approval process is intended to assure the Maine Department of Health and Human Services that the applicant agency has a thorough understanding of the requirements of this Section, has sufficient clinical and administrative capability to carry out the intent of this Section, and has taken steps to assure the safety, quality, and accessibility of the service.
The Department will administer the initial approval process.
Step #1 - Identification of Provider and Verification of the Provider's Intent to Undergo the Provisional Accreditation Process
A. The director or administrator of the applicant agency must contact the Department to request the initiation of the process. The applicant agency's request must be accompanied by the following information:
1. Name of the agency (and the legal entity sponsoring the facility if different);
2. Address of the agency;
3. Name of agency contact person;
4. Telephone number of agency contact person; and
5. Estimated number of individuals to be served (service capacity).
B. The Department will start the review process. A representative of the Department will contact the agency within ten (10) working days of receipt of the identification information in order to:
1. Identify the Department's representative assigned to carry out the review process;
2. Provide clarification regarding the process; and
3. Request written information to use in the document review phase of the process.
Step #2 - Document Review
This part of the process must be initiated at least thirty (30) days prior to the date when the agency proposes to provide services for MaineCare reimbursement under this Section. If the agency satisfies the requirements of this review, the Department will provisionally certify the agency for ninety (90) days from the first date of service for which MaineCare reimbursement is requested. In order to continue certification beyond this period, the agency must (during the ninety (90) day period) have undergone the on-site survey described in Step #3 of this Appendix and been granted continued approved status as a result of that review.
The following requirements must be satisfied to gain ninety (90) day provisional certification. Additionally, the provider must show it will be in compliance with the MaineCare Benefits Manual requirements.
A. Compliance with applicable legal requirements and regulations of all governmental and legally authorized agencies under whose authority the agency operates. These include, but are not limited to, those regulations regarding equal employment opportunity, state and federal wage hour regulations, health and safety codes, and affirmative action. The applicant must submit documents demonstrating compliance with such regulations.
B. Provision of documents providing the legal basis for the organization and identifying the members of the governing body or, in the case of a proprietary organization, the designated authority. The documents must identify the chief executive of the organization.
C. Provision of by-laws, or other applicable documentation, describing and governing the purpose, scope and activities of the organization.
D. A narrative history of the organization, which provides a brief history of the agency's activities.
E. A description of the agency's services, with particular attention to those governed by Section 102 of the MBM. Service descriptions must include the purpose of each service and be written so as to govern the direction and character of each service.
F. The agency's criteria for admission/entrance to the service being reviewed.
G. Policies and procedures that address activities associated with member intake, assessment, individual planning, case coordination, and record keeping.
H. The agency's actual or projected staffing plan. This plan must identify staff providing covered services. There must be clear indication of which staff are actually employed by the agency at the time of Document Review.
I. Qualifications of all staff, consultants, independent contractors, trainees/interns, and volunteers.
J. Policies that address member rights and preserve confidentiality. These policies must meet the requirements of Chapter I of the MaineCare Benefits Manual.
K. Policies and procedures regarding quality assurance.
L. Proof of liability insurance covering the services reimbursed under this Section.
Within thirty (30) days of receipt of all information required by Step #2, the Department will issue a decision regarding the findings of the Document Review to the agency and to the Office of MaineCare Services. The finding will document all areas found to be non-compliant with the requirements of Step #2 and will stipulate corrective action, which must be accomplished to obtain 90-day provisional certification.
The agency must request an application for MaineCare enrollment from Provider File at the Office of MaineCare Services. Provider File will then process the agency application in order to begin MaineCare reimbursement after receiving the ninety (90) day provisional certification.
Step #3 - On-Site Review
Within ninety (90) days of the first date of service provided under this Section, the agency must have undergone an On-Site Review.
It will be the responsibility of the applicant agency to contact the Department's representative who conducted the Document Review to arrange for the On-Site Review. The agency must request the On-Site Review at least thirty (30) days prior to the requested date of the Review.
The On-Site Review Team will consist of at least two (2) representatives of the Department of Health and Human Services. The team may also include a licensed practitioner of the medical profession with expertise in the area of brain injury rehabilitation. In the event the Department requires such a clinician as a member of the review team the costs of the clinician's services must be reimbursed by the agency being reviewed.
The On-Site Review will be scheduled for up to four (4) days. The reviewers will, through the inspection of the agency documents, interviews and observation, determine the extent to which the agency is in compliance with the policies and procedures previously submitted by the agency as well as the agency's compliance with all requirements of this Section of the MaineCare Benefits Manual. Particular attention will be given to items identified as requiring correction in the Document Review report.
The following represents the On-Site Review Team activities:
1. Orientation Session. The On-Site Review Team meets with agency staff and representatives of the governing body to clarify the purpose of the survey and explain each team member's role in the review. This is an opportunity for agency staff and representatives to ask questions about the process and provide files and records necessary to carry out the review. At this time the review team must be assigned a secure work space (where confidential material can be safely stored) and a separate area where interviews can be held. Staff interviews shall be arranged at this time.
2. A tour of the physical plant.
3. Record reviews, interviews with staff, board members, members, family members, representatives, or others, and program observation. The agency must post signs on a readily viewed area that the review is being performed and reviewers are available to meet with members in private, if requested.
4. On-Site Review Team meeting to coordinate findings and clarify questions requiring more attention.
5. Information gathering.
6. Exit interview with representatives of administration, the governing body, and staff. This is the agency's opportunity to question interpretations or findings of the Review Team. Any member or legal guardian who requests to attend the exit interview shall be allowed to do so.
The On-Site Review Team will write a report of its findings, including strengths and areas requiring improvement. The report will make recommendations regarding the continuation of provisional certification as well as listing corrective action the Team deems necessary. The report will be submitted to the Director of the Office of MaineCare Services and to Provider File at the Office of MaineCare Services within twenty (20) days of the completion of the On-Site Review. A copy of the report will be sent to the contact person at the applicant agency.
The Department will notify the agency of the decision regarding continuation or revocation of the agency's provisional certification status within ten (10) days of the receipt of the On-Site Review Team report. Agencies that fail to substantially meet the requirements outlined in Step #3 will have their provisional certification revoked. In the event of revocation, the Office of MaineCare Services will stop MaineCare reimbursement as of the date of revocation. Any agency that is denied the continuation of provisional certification may appeal this decision. The appeal process is defined in Chapter I of the MaineCare Benefits Manual.
All three (3) steps defined in this Appendix must be completed in order for the agency to receive the eighteen (18) month provisional certification.
The provisional certification will be awarded one time only, for a total of eighteen (18) months from the first date of service, including the ninety (90) day certification defined in Step #2 of this Appendix.
Complaints made to the Department regarding an agency that has a provisional certification or is in the process of receiving a provisional certification will be investigated. The Department must determine the validity of the complaint and must withdraw the provisional certification or discontinue the process of reviewing the agency for provisional certification; whichever is appropriate, if the Department determines that the health or safety of a member receiving services is in jeopardy.
In the event that the Department determines the applicant is out of compliance with the requirements of any applicable policy, or when non-compliant items represent a threat to the health, safety, or rights of members to be served under this policy, the Department must refuse or withdraw provisional certification to the applicant. In the event the provisional certification is refused or withdrawn, the Department's decision may be appealed. Requests for hearings must be made, in writing, within ten (10) days of agency notification of an adverse decision. The appeal process is defined in Chapter I of the MaineCare Benefits Manual.
Each eligible program is allowed one eighteen (18) month provisional certification only. CARF accreditation must be obtained by the end of the eighteen (18) month provisional certification, or MaineCare will stop reimbursement until CARF accreditation is obtained.
If the application for CARF accreditation has been submitted and a review is scheduled, one three (3) month extension of the provisional certification will be granted by the Department.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-102, app 144-101-II-102-I