C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-97, subsec. 144-101-II-97.07

Current through 2024-51, December 18, 2024

Subsection 144-101-II-97.07 - POLICIES AND PROCEDURES

97.07-1Setting

Services shall be delivered in the Private Non-Medical Institution or other settings appropriate to individual service needs in accordance with an individual service plan.

97.07-2Qualified Staff

A Private Non-Medical Institution may be reimbursed for services provided by the following staff and as set forth in the Chapter III, Principles of Reimbursement for that type of institution:

A.Professional Staff

All professional staff must be conditionally, temporarily, or fully licensed and approved to practice as documented by written evidence from the appropriate governing body.

MaineCare may reimburse a PNMI for covered services as defined in Section 97.04 if they are provided by the following professional staff members: dentist, licensed alcohol and drug counselor, licensed clinical professional counselor, licensed professional counselor, nurse practitioner, occupational therapist registered, physician, physician assistant, licensed practical nurse, psychiatrist, psychiatric nurse, psychologist, psychological examiner, registered nurse, social worker, or speech language pathologist. All providers must hold appropriate licensure in the state or Province in which services are provided and must practice within the scope of these licensing guidelines. See Appendix D of Section 97, Chapter III, for PNMI covered services.

B.Other Qualified Mental Health Staff

Other staff may be considered qualified for purposes of this Section if they meet the following requirements:

1. They have education, training, or experience that qualifies them to perform certain specified mental health functions;

2. They receive certification from the Department, or its designee, that they are qualified to perform such functions and such verification is recorded in writing and kept in the files of the Department, or its designee; and

3. They perform such functions under the supervision of a licensed, certified, or registered health professional with the supervisory relationship having been described to and approved by the Department in accordance with its licensing and certification regulations.

C.Other Qualified Medical and Remedial Services Staff

Medical and remedial services and personal care services staff members may be considered qualified for purposes of this Section if they meet the following requirements:

1. The services they provide are prescribed by a physician and are in accordance with the member's plan of care.

2. The facility has written documentation that each staff person has received orientation or is currently in orientation in keeping with the licensing regulations for medical and remedial services facilities cited in Section 97.01-1(D) and is adequately performing medical and remedial services according to minimum standards set by the Office of MaineCare Services identified in the regulations cited above.

3. The medical and remedial services staff person is not a member of the member's family as defined in the Chapter III, Principles of Reimbursement for Medical and Remedial Service Facilities.

D.Other Qualified Alcohol and Drug Treatment Staff

Other qualified alcohol and drug treatment staff are staff members, other than professional staff defined above, who have appropriate education, training and experience in substance use treatment services, related disciplines as approved by the Office of Behavioral Health, or behavioral sciences; who work under a substance use treatment professional, consisting of at least one (1) hour per week for each twenty (20) hours of covered services rendered; and who are approved by the State Board of

Alcohol and Drug Counseling as documented by written evidence on file with that office pursuant to Section 4.19 of the Regulations for Licensing/Certifying Substance Use Treatment Facilities in the State of Maine. A Certified Alcohol and Drug Counselor is considered to be an other qualified substance use staff member.

E.Personal Care Service Staff

Personal care service staff may be considered qualified for purposes of this Section if they meet the following requirements:

1. The personal care services provided by all PNMIs are prescribed by a physician upon or within thirty (30) days of admission, are in accordance with the member's plan of care, are supervised by a registered nurse at least every ninety (90) days, and are not provided by a member of the member's family as described in Section 97.01-6 or the pertinent Appendix of Chapter III, Principles of Reimbursement.

2. The following facilities shall have written documentation that each staff person has received orientation in keeping with the licensing regulations for:

a) community residences for people with mental illness, cited in Section 97.01-1(C) or,

b) as outlined in the residential services agreement required by the Department of Health and Human Services licensing requirements cited in Section 97.01-1(E); or

c) in accordance with licensing regulations for residential substance use treatment PNMIs as cited in Section 97.01-1(A).

Alcohol and drug treatment PNMIs shall maintain documentation that each staff member providing such services has received forty (40) hours of orientation and training in personal care procedures appropriate to residents.

Areas of training must include introduction to chemical addictions, assistance in self-administration of medication, infection control, bowel and bladder care, nutrition, methods of moving patients, and health-oriented record keeping.

Personal care service staff shall adequately perform personal care services according to minimum standards set by the Department when providing services in community residences for people with mental illness.

F.Other Qualified Child Care Facility Staff

Other qualified child care facility staff are those individuals who have appropriate education, training, attributes, and experience as approved by the Office of Child and Family Services (OCFS). The PNMI shall submit to the OCFS for approval, names and qualifications of personnel defined as other qualified child care staff in the format provided by that Office.

1. In order to qualify for reimbursement for other qualified child care facility staff, the PNMI shall provide written evidence on file with the provider that other qualified child care facility staff shall meet the standards outlined in the certification requirements established by the OCFS as documented by written evidence on file with that Office.

2. Other qualified child care staff, when performing PNMI reimbursable services, shall receive regular, documented supervision by appropriately licensed or certified staff in accordance with the Rules for Licensure of Residential Child Care Facilities, (or in the case of facilities also licensed by the Office of Behavioral Health, Licensed Alcohol and Drug Counselors).

G.Other Qualified Licensed Treatment Foster Care Providers

Other qualified licensed treatment foster care providers are licensed treatment foster care homes/parents who hold a contract to provide treatment foster care services to State agency clients.

H.Interpreter Services

See Chapter I for provider rules regarding Interpreter Services.

I.Clinical Consultant Services

Clinical consultant services must be provided by licensed or certified professionals as described in Chapter II, Section 97.07-2, of these rules, and working within all State and Federal regulations specific to the services provided.

For those facilities covered under Chapter II, Appendix B, substance use facilities, clinical consultants may include substance use services including methadone maintenance services.

97.07-3Assessment and Individual Service Plan

Qualified staff must provide reimbursable services following a written individual service plan. The service plan must be developed and reviewed in accordance with these rules for either substance use treatment facilities, child care facilities, community residences for persons with mental illness, medical and remedial services facilities, non-case mixed medical and remedial facilities, or ITRT facilities. PNMI staff must assess members for unmet physical and mental health needs, and complement the individual service plan with appropriate referrals for health care.

97.07-4Member's Record

The provider must keep a record for each member that includes, as applicable, but is not necessarily limited to:

A. The member's name, address, and birthdate;

B. The member's medical and social history, as appropriate;

C. The member's diagnosis. The attending physician or psychiatrist, if applicable;

D. Long and short range medical and other goals, as appropriate;

E. A description of any tests ordered by the PNMI and performed and results;

F. A description of treatment, counseling, or follow-up care;

G. Notation of any medications and/or supplies dispensed or prescribed;

H. Plans for coordinating the services with other agencies, if applicable;

I. The discharge plan of the member;

J. Written and signed progress notes as appropriate and frequency for each type of facility orPNMI, weekly or daily depending upon the type of facility, which shall identify the services provided and progress toward achievement of goals.

97.07-5Program Integrity

See Program Integrity (formerly Surveillance and Utilization Review) in the MBM Chapter I.

97.07-6Review of the Individual Service Plan

A review of the individual service plan shall be conducted by the appropriate case review team and/or professional of the following facilities in accordance with the following:

A. for substance use treatment facilities, the rules and regulations cited in Section 97.01-1(B);

B. for child care institutions, the rules and regulations cited in Section 97.01-1(D); and

C. for community residences for persons with mental illness, the rules and regulations cited in Section 97.01-1(E);

Reviews for community residences for persons with mental illness must be made at least every ninety (90) days;

D. for medical and remedial services facilities, the regulations cited in Section 97.01-1(C); and

E. for non-case mixed medical and remedial facilities, the rules cited in Section 97.01-1(F) and the Chapter III, Principles of Reimbursement for Non-Case Mixed Medical and Remedial Facilities.

F. for ITRT facilities, the rules cited in Section 97.01-1(F); and the Chapter III, Appendix D, Principles of Reimbursement for Child Care Facilities.

97.07-7Discharge Summary

A discharge summary shall summarize the entire case in relationship to the plan of care.

97.07-8Time Studies

A. The Department requires time studies for educational staff performing duties as described in Section 97.06 to determine if a percentage of the time can be applied to direct service staff and is an allowable cost under Chapter III, Principles of Reimbursement for Private Non-Medical Institutions, Section 2400. The percentage of time determined in the time study that is applicable to academic services listed in MBM Chapter I, Section 1.06-4, Non-Covered and Non-Reimbursable Services will not be allowable time (and the costs related to that time) under Chapter III, Section 2400.

B. The Department requires time studies of direct time for staff who perform both covered direct services and other non-covered services for facilities covered under Appendices B, D, and E. The percentage of time determined from the time study spent in duties as described in Section 97.04 is an allowable cost under Chapter III, Principles of Reimbursement for Private Non-Medical Institutions, Section 2400.

C. Facilities must complete time studies in accordance with procedures prescribed by the Office of MaineCare Services.

97.07-9Continuing Stay Requirements

Members must continue to meet the eligibility criteria set forth in each Section above for provider reimbursement in the PNMI setting.

97.07-10Termination

For members receiving Appendix E services under this Section, providers must:

A. Obtain written approval from the Director of the Office of Behavioral Health (OBH)or designee prior to terminating services to that member;

B. If approved by OBH, issue a thirty (30) day advanced written termination notice to the member prior to termination of the member's services. In cases where the member poses a threat of imminent harm to persons employed or served by the provider, the Director of OBH may approve a shorter notification for termination of services; and

C. Assist the member in obtaining clinically necessary services from another provider prior to discharge or termination.

97.07-11Referrals

Providers must acknowledge receipt of Department referrals within three (3) business days for members deemed eligible for Appendix E services. Providers must accept or request permission to decline referrals in accordance with a Department-defined process within five (5) business days of receipt of the referral. Only in cases where providers have received written approval from OBH may a referral be declined; otherwise, providers must admit members within thirty (30) days of receipt of the referral.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-97, subsec. 144-101-II-97.07