C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-21, subsec. 144-101-II-21.02

Current through 2024-51, December 18, 2024

Subsection 144-101-II-21.02 - DEFINITIONS

21.02-1Abuse means the infliction of injury, unreasonable confinement, intimidation or cruel punishment that causes or is likely to cause physical harm or pain or mental anguish; sexual abuse or sexual exploitation; or the intentional, knowing or reckless deprivation of essential needs as defined in 22 MRSA §3472.

21.02-2Activities of Daily Living (ADLs) is a term used to collectively describe fundamental skills that are required to independently care for oneself including:

A.Bed Mobility: How a person moves to and from lying position, turns side to side, and positions body while in bed;

B.Transfer: How a person moves between surfaces to/from: bed, wheelchair, standing position (excluding to/from bath/toilet);

C.Locomotion: How a person moves between locations, in room and other areas. If in wheelchair, self-sufficiency once in chair;

D.Eating: How a person eats and drinks (regardless of skill);

E.Toilet Use: How a person uses the toilet room (or commode, bedpan, urinal), transfers on/off toilet, cleanses, changes pad, manages ostomy or catheter, adjusts clothes;

F.Bathing: How a person takes full-body bath/shower, sponge bath and transfers in/out of tub/shower (exclude washing of back and hair); and

G.Dressing: How a person puts on, fastens, and takes off all items of street clothing, including donning/removing prosthesis.

21.02-3Administrative Oversight Agency means a provider agency that

a. Is approved by DHHS-Office of Aging and Disability Services (OADS).

b. Enters into a contractual agreement with the Shared Living Provider for oversight and monitoring services.

c. Bills and receives MaineCare reimbursement; and

d. Satisfies the Provider Qualifications and Requirements set forth in this rule.

21.02-4Agency Home Support means a provider Managed Service Location that routinely employs direct support staff to provide Direct Support Services.

21.02-5Autism Spectrum Disorder (ASD) means a diagnosis that meets diagnostic criteria set forth in the current edition of the Diagnostic and Statistical Manual of Mental Disorders, (American Psychiatric Association), that manifested during the developmental period..

21.02-6Authorized Entity is the organization authorized by the Department of Health and Human Services (DHHS) to perform specified functions pursuant to a signed contract or other approved signed agreement.

21.02-7Case Manager is a person responsible for assuring the timely convening of the service planning team, developing the Person-Centered Plan (PCP), monitoring the planned services received by the Member, and assuring that those services meet the requirements set forth in the Member's Person-Centered Plan.

21.02-8Clinical Review Team (CRT) is a multi-disciplinary team of qualified professionals that have work experience with adults with Intellectual Disabilities or Autism Spectrum Disorder. The CRT will partner with the resource coordinators to review and approve the following: Increased level of support for Shared Living and Family-Centered Support; Medical Add-On; all initial classifications to the waiver; and home support service requests. The CRT will also be responsible for systematic reviews to determine that Members are authorized at an appropriate level of service in accordance with the Member's Person-Centered Service Plan.

21.02-9Competitive Integrated Employment is employment that occurs in a competitive integrated setting, and which meets the specific requirements outlined in the Workforce Innovation and Opportunity Act (See34 C.F.R. § 361.5) , including:

(1) receiving compensation that is the higher of the federal, state or locally established minimum wage where the Member works, as well as being eligible for the level of benefits provided to other, non-disabled employees doing similar work and working similar hours;

(2) occurring in location(s) typically found in the community that are not disability-specific settings;

(3) enabling the Member to interact with co-workers and customers to the same extent as a person without a disability filling a similar position;

(4) for wage employment, having the employer of record be the business or organization ultimately benefitting from the work done by the Member;

(5) offering the Member an individualized position in which the Member does not work side-by-side with one or more other individuals with disabilities on the same schedule; and

(6) presenting, as appropriate, opportunities for advancement that are similar to those for other employees who are not individuals with disabilities and who have similar positions.

21.02-10Correspondent is a person designated by the Maine Developmental Services Oversight and Advisory Board (MDSOAB), to act as a next friend of a person with Intellectual Disabilities or Autism Spectrum Disorder.

21.02-11Designated Representative means the DHHS staff or Authorized Entity authorized by DHHS to perform specified functions.

21.02-12Direct Supports are a range of activities that contribute to the health and well-being of the Member and his or her ability to live in or be part of the community. Direct Support activities may include personal assistance or activities that support personal development, or activities that support personal well-being. The emphasis and purpose of the Direct Support provided may vary depending on the type of service.

Direct Support activities include the following:

Personal Assistance is assistance provided to a Member in performing tasks the Member would normally perform if the Member did not have his or her disability. Personal assistance may include guiding, directing, or overseeing the performance of self-care and self-management of activities.

Self-Care includes assistance with eating, bathing, dressing, mobility, personal hygiene, and other Activities of Daily Living; assistance with light housework, laundry, meal preparation, transportation, grocery shopping, and assistance with health and nutrition maintenance, including assessing well-being and identifying need for medical assistance; complying with nutritional requirements as specified in the Person-Centered Service Plan; administration of non-prescription medication that are ordinarily self-administered; and administration of prescription medication, when provided by a person legally authorized to assist with the administration of medication.

Self-Management includes assistance with managing safe and responsible behavior; exercising judgment with respect to the Member's health and well-being; communication, including conveying information, interpreting information, and advocating in the Member's interests; managing money including paying bills, making choices on how to spend money, keeping receipts, and expending funds with the permission of a Member's representative payee. Self-management also includes teaching coping skills, giving emotional support, and guidance to other resources the Member may need to access.

Activities that support personal development include teaching or modeling for a Member's self-care and self-management skills, physical fitness, behavior management; sensory, motor and psychological needs; interpersonal skills to cultivate supportive personal, family, work and community relationships; resources and opportunities for participation in activities to promote social and community engagement; participation in spiritual activities of the Member's choice; motivating the pursuit of personal development and opportunities; teaching or modeling informed choice by gathering information and practicing decision making; and learning to exercise.

Activities that support personal well-being include directly or indirectly intervening to promote the health and well-being of the Member. This may include identifying risks such as risk of abuse, neglect or exploitation; participating in a Member's risk assessment; identifying and reporting to an immediate supervisor changes in health status and behavior; anticipating or preventing unsafe or destructive behavior; and safely intervening against undesirable behavior according to an intervention plan. In the absence of a plan, intervention must be consistent with DHHS's Regulations Governing Behavioral Support, Modification and Management for People with Intellectual Disabilities or Autism in Maine (14-197 C.M.R. ch. 5). It may also be necessary to seek emergency medical or safety assistance when needed and comply with incident reporting requirements.

21.02-13Employment Setting for either Work Support-Individual or Work Support-Group must be one with the highest level of integration possible. The job must be one that is available to a non-disabled employee with the same expectations for the Member's job performance and attendance. The Member works under similar work conditions as others without disabilities in similar positions; including access to lunchrooms, restrooms, and breaks. The Member performs work duties with ongoing interaction with other workers without disabilities, and has contact with customers, suppliers and the public to the same degree as workers without disabilities in the same or comparable occupations. The Member cannot be excluded from participation in company-wide events such as holiday parties, outings and social activities. Provider owned/controlled businesses are subject to the same integration standards as other businesses. Staff providing employment services at the worksite are not considered non-disabled employees in determining the level of integration. For those agencies that currently operate under an award from Ability One, the federal workforce guidelines associated with this funding source will apply to the services funded by the contract. The Member can be on the employer's payroll or the provider agency payroll.

Members may receive additional employment supports from a provider agency. A Member must be supervised in a manner identical to other employees. It is permissible, on a case by case basis to have the support provider offer and provide this supervision as long as the above conditions are met.

21.02-14Exploitation means the illegal or improper use of an incapacitated or dependent Member or that Member's resources for another's profit or advantage as defined in 22 M.R.S. §3472.

21.02-15Family-Centered Support is a model designed to provide home support to a Member in a family environment, with the family and the Member sharing a home that is not owned by the Member or Member's family. No more Family-Centered Support will be approved after December 30, 2007. The Family-Centered Provider must be a Certified Direct Support Professional (DSP) who meets all the requirements to provide this service.

21.02-16Habilitation is a service that is provided in order to assist a Member to acquire a variety of skills, including self-help, socialization and adaptive skills. Habilitation is aimed at raising the level of physical, mental, and social functioning of a Member. Habilitation is contrasted to rehabilitation which involves the restoration of function that a person has lost.

21.02-17Instrumental Activities of Daily Living (IADLs) are activities related to independent living, including preparing meals, managing money, shopping for groceries or personal items, performing light or heavy housework, and communication. The extent to which a person requires assistance in performing IADLs is often assessed in conjunction with the evaluation of medical eligibility.

21.02-18Intellectual Disability means a disorder as defined in 34-B M.R.S. §5001 and diagnosed in accordance with Diagnostic Criteria set forth in the current edition of the Diagnostic and Statistical Manual of Mental Disorders, (American Psychiatric Association), that manifested during the developmental period.

21.02-19Medical Add-On is an increase in the rate paid to address short or long-term medical needs and is reviewed and approved by the CRT. Medical Add-On is a component of Home Support, Community Support, Employment Specialist Services and Work Support-Individual and is included in the established authorization (as described in Section 21.04-1). It is not a separately billable activity.

Billing may not exceed the Home Support, Community Support, Employment Specialist Services or Work Support authorized units of service. It is not a separately billable activity. Documentation must clearly identify and support periods of such activity. Refer to Appendix II for more information.

21.02-20Member is a person determined to be eligible for MaineCare benefits by the Office for Family Independence (OFI) in accordance with the eligibility standards published by the OFI in the MaineCare Eligibility Manual. Some Members may have restrictions on the type and amount of services they are eligible to receive.

21.02-21Neglect means a threat to a Member's health or welfare by physical or mental injury or impairment, deprivation of essential needs or lack of protection from these as defined in 22 MRSA §3472.

21.02-22On Behalf Of is a billable activity that is provided for individual Members and is not necessarily a direct face-to-face service. On Behalf Of is a component of Home Support, Community Support, Employment Specialist Services and Work Support. It is included in the established authorization and is not a separately billable activity. Refer to Appendix III for more information.

21.02-23Person-Centered Service Plan (PCSP) is a Member's plan developed at least annually based on the effective plan date, that identifies the services required under the waiver benefit. The PCSP must also include services and supports not covered by the waiver but identified by the Member. Only covered services included on the PCSP are reimbursable. The PCSP may also be known as a Person-Centered Plan, a plan of care, or a service plan, as long as the requirements of Section 21.04 are met.

21.02-24Primary Caregiver: The Primary Caregiver is the adult who takes primary responsibility for the health and well-being of a Member who cannot fully care for himself/herself. This is unpaid assistance and support, typically provided by a family member.

21.02-25Prir Authorization is the process of obtaining written prior approval by the Department's Designated Representative as to the medical necessity and eligibility for a service.

21.02-26Qualified Intellectual Disability Professional (QIDP) is a person who has at least one year of experience working directly with persons with Intellectual Disabilities or other developmental disabilities and is one of the following:

1) a doctor of medicine or osteopathy;

2) a registered nurse; or

3) an individual who holds at least a bachelor's degree as specified in title 42C.F.R. § 483.430, (b)(5).

21.02-27Qualified Vendor is a provider approved by DHHS to provide waiver services to eligible Members receiving services under this Section. DHHS requires agencies to provide high quality services that, at a minimum, meet the expectations of the Members who utilize those services. DHHS may authorize agencies to provide services under this Section after an application, along with supporting documentation, has been submitted to a Designated Representative for review and approval. The Designated Representative will authorize only agencies that meet DHHS expectations in the areas of organization and operation, operation of individual programs or services, personnel administration, environment and safety, and quality management. Only Qualified Vendors will receive authorizations for reimbursement. Qualified Vendors are required to provide notice to the Department upon the need for agency closure or termination of services to Members.

21.02-28Shared Living (Foster Care-adult) is a model in which services are provided to a Member by a person who meets all of the requirements of a Direct Support Professional with whom that Member shares a home.

21.02-29Shared Living Provider is a provider who subcontracts with an agency to provide Direct Support to a Member, with whom they share a home.

21.02-30Utilization Review is a formal assessment of the medical necessity, efficiency and appropriateness of services on a prospective, concurrent or retrospective basis.

21.02-31Year: Services are authorized on the state fiscal year, July 1 through June 30.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-21, subsec. 144-101-II-21.02