C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-97, subsec. 144-101-II-97.08
Requirements identified in this Section shall be the responsibility of direct care staff. Direct care services include supervisory and training activities necessary to accomplish the provisions described in this Section. It also includes personal supervision or being aware of members' general whereabouts, observing or monitoring members to ensure their health and safety, assisting with or reminding members to carry out activities of daily living, and assisting members in adjusting to the facility and community.
Clinical responsibility for implementation of each member's overall specific treatment plan shall rest with a treatment team, which shall be chosen from the qualified professional staff as defined in Section 2400 of the pertinent Chapter III, Principles of Reimbursement.
All services must be provided pursuant to a written service plan based upon an individual assessment made in accordance with the Regulations for Licensing/Certifying Substance Use Treatment Programs in the State of Maine.
Service plans must be reviewed and signed by a physician, psychiatrist, psychologist, social worker, licensed clinical professional counselor, registered nurse or licensed alcohol and drug counselor as defined in Chapter II, Section 97.07-2. Such qualified professional staff shall be responsible for the provision of direct services to members, and for direct supervision of all other staff in the implementation of the service plan through the various elements of the comprehensive treatment described in this Section. The qualified professional staff shall ensure that a full range of formal treatment services is provided to each member in conjunction with the structured set of activities routinely provided by the PNMI and in accordance with the individual member's needs. The range of formal treatment services provided tomembers by the PNMI shall aid the member, through non hospital based detoxification, type I residential rehabilitation, type II residential rehabilitation, halfway house services, extended care, adolescent residential rehabilitation, or personal care substance use services (shelter based), toward the primary goal of recovery for the chemically dependent person.
PNMI staff shall assess members for unmet mental health needs and complement the substance use plan of care with appropriate referrals for mental health care.
PNMIs approved and funded by Office of Behavioral Health in licensed facilities must also provide necessary personal care services for the promotion of ongoing treatment and recovery. MaineCare does not cover personal care services provided by a family member.
Personal care services shall be prescribed by a physician, provided by qualified staff, and will occur in the substance use treatment PNMI where the member receiving services resides.
Personal care services shall consist of, but are not limited to, the following
- Assistance or supervision of activities of daily living that include bathing, dressing, eating, toileting, ambulation, personal hygiene activities, grooming, and the performance of incidental household tasks essential to the activities of daily living and to the maintenance of the member's health and safety within the substance use treatment PNMI;
- Supervision of or assistance with administration of physician-ordered medication;
- Personal supervision or being aware of the member's general whereabouts, observing or monitoring the member while on the premises to ensure their health and safety, reminding the member to carry out activities of daily living, and assisting the member to carry out activities of daily living, and assisting the member in adjusting to the group living facility;
- Arranging transportation and making phone calls for medical or treatment appointments as recommended by medical providers, or as indicated in the member's plan of care;
- Observing and monitoring member's behavior and reporting changes in the member's normal appearance, behavior, or state of health to medical providers or supervisory personnel as appropriate;
- Arranging or providing motivational, diversionary, and behavioral activities that focus on social interaction to reduce isolation or withdrawal and to enhance communication and social skills necessary for ongoing treatment and recovery, as described in the member's plan of care;
- Monitoring and supervising member's participation in the treatment; and
- Psychosocial treatment including assisting members to adjust to the substance use treatment PNMI, to live as independently as possible, to cope with personal problems during periods of stress, to accept and adjust to their personal life situations, to accept and cope with their chemical addictions and to decrease unhealthy behaviors leading to possible relapse into active addiction, in addition to providing services and a supportive environment which promotes feelings of safety and freedom from danger, fear or anxiety.
MaineCare limits non hospital-based detoxification services to seven (7) days for each admission episode, with no limit on the number of admissions or covered days on an annual basis. The facility may provide detoxification services for a longer period if medical necessity is substantiated and ordered by the medical director, and documented in the member's clinical file by the facility's designated medical staff.
Detoxification services provide immediate diagnosis and care to members having acute physical problems related to substance use. Providers of detoxification services shall make and maintain arrangements with external clinicians and facilities for referral of the member for specialized services beyond the capability of the PNMI.
Each member shall receive a complete physical examination by a physician within forty-eight (48) hours of admission and the results shall be entered in the member's record. Admissions resulting from a direct physician referral by telephone may be sufficient to meet this requirement so long as the orders are taken by an RN or an LPN who has been trained to take telephone orders. The referring physician shall sign these orders within forty-eight (48) hours.
PNMIs shall provide medical evaluation and diagnosis upon intake. Designated areas suitable (1) for the provision of general medical services, and (2) to control and administer drugs prescribed by the PNMI's legally qualified staff, shall be maintained by the PNMI so as to assure the appropriate treatment of physical illness and maintenance of good general health among members. The member shall receive continuing medical supervision under the direction of a physician while in the PNMI that shall be documented in the member's case record. The PNMI shall establish procedures for the prompt detection and treatment of physical health problems through surveillance, periodic appraisals and physical examinations.
The PNMI's qualified staff shall teach attitudes, skills, and habits conducive to good health and enabling the member to sustain a substance free lifestyle. The treatment mode may vary with the member's needs and may be in the form of individual, group or family counseling.
The PNMI shall maintain a medical staffing pattern, which enables it to meet the physical care requirements delineated above. The PNMI shall provide for twenty-four (24) hour, on-premises medical coverage by a registered nurse or licensed practical nurse who is experienced in the disease process of chemical dependency. Physician back up and on-call staff shall be provided to deal with medical emergencies.
MaineCare limits residential rehabilitation type I to thirty (30) days for any single admission, with a limit of two (2) admissions and thirty (30) covered days on an annual basis per member. These limits allow some clinical flexibility should additional treatment be required, or should a member drop out very early in treatment and are admitted at a later date.
Any continuous stay in excess of twenty-eight (28) days requires documented need in the member's treatment plan.
Residential rehabilitation shall provide scheduled therapeutic treatment consisting of diagnostic and counseling services designed to enable the member to develop a substance free lifestyle.
Each member shall receive a complete physical examination by a physician within seventy-two (72) hours of admission and the results shall be entered in the member's record. Admissions resulting from a direct physician referral by telephone may be sufficient to meet this requirement so long as the orders are taken by an RN or an LPN who has been trained to take telephone orders. The referring physician shall sign these orders within forty-eight (48) hours.
PNMIs shall provide medical evaluation upon intake and laboratory examinations as deemed appropriate by the physician as soon as practicable after admission. The PNMI shall establish procedures for the prompt detection and treatment of physical health problems through surveillance, periodic appraisals, and physical examinations. Arrangements with external clinicians and facilities for referral of the member for specialized services beyond the capability of the PNMI shall be made and maintained by the PNMI.
The PNMI's qualified staff shall teach attitudes, skills, and habits conducive to good health and the maintenance of a substance free lifestyle. The treatment mode may vary with the member's needs and may be in the form of individual, group or family counseling at a minimum of ten (10) hours per week.
The PNMI shall maintain a medical staffing pattern, which enables it to meet the physical care requirements delineated above. The PNMI shall provide for twenty-four (24)-hour staff coverage. Physician back-up and on-call staff shall be provided to deal with medical emergencies. The PNMI shall not subcontract any of its obligations and rights pertaining to medical services described in this Section. For the purposes of this Section, physician consultant services are not considered subcontracting.
Adolescent residential rehabilitation PNMIs provide the opportunity for recovery through modalities, which emphasize personal growth through family and group support and interaction. The PNMI's qualified staff shall teach attitudes, skills, and habits, conducive to facilitating the member's transition back to the family and community. Adolescent residential rehabilitation PNMIs are designed to last at least three (3) months and are limited to twelve (12) months per single admission.
MaineCare does not cover in-house, accredited, individualized schooling, weekly vocational exploration groups, and structured recreational activities.
Services must include but are not limited to:
- Medical evaluation;
- Physical examination within seventy-two (72) hours following admission or no more than thirty (30) days prior to admission, and laboratory examinations as appropriate and as soon as practicable after the member's admission;
- Individual and group counseling at a minimum of ten (10) hours per week for each member;
- Arrangements for needed health care services; and
- Planning for and referral to further treatment.
The PNMI shall document that all persons providing services are legally qualified through licensure, certification, and/or registration as required to provide the service. PNMIs shall have qualified (as described in Section 2400 of these principles) staff coverage twenty-four (24) hours a day, including weekend coverage and shall include weekly clinical supervision to the staff to ensure the well-being of the members and to provide for the growth and development of the staff.
The PNMI shall not subcontract any of its obligations and rights pertaining to medical services described in this Section. For the purposes of this Section, physician consultant services are not considered subcontracting.
MaineCare limits halfway house services to a single admission of one hundred eighty (180) covered days on an annual basis per member. Any stay in excess of one hundred eighty (180) days requires documented need in the member's service plan.
A halfway house shall provide scheduled therapeutic and rehabilitative treatment consisting of transitional services designed to enable the member to sustain a substance free lifestyle in an unsupervised community living situation.
Counseling staff of the PNMI shall perform an assessment of the member's medical and social/psychological needs, as required by the Office of Behavioral Health, within five (5) days of admission unless the member can show evidence of such examination within the last thirty (30) days. Such assessment may be completed prior to admission by the substance use treatment facility referring the member. This assessment may additionally include, but not be limited to an examination for contagious or infectious disease, determination of the status of chronic physical disease and examination of nutritional deficiencies. Arrangements with external clinicians and facilities for referral of the member for specialized services beyond the capability of the PNMI shall be made and maintained by the PNMI.
The PNMI's qualified staff shall teach attitudes, skills, and habits conducive to facilitating the member's transition back to the community. The treatment mode may vary with the member's needs and may be in the form of individual, group or family counseling.
The PNMI shall have a written agreement with an ambulance service to assure twenty-four (24)-hour access to transportation to emergency medical care facilities for members requiring such transport. Physician back-up and on-call staff shall be provided to deal with medical emergencies.
The PNMI shall not subcontract any of its obligations and rights pertaining to medical services described in this Section, with the exception of physician consultant services.
MaineCare limits extended care services to a single admission of two hundred seventy (270) covered days on an annual basis per member. Any stay in excess of two hundred seventy (270) days requires documented need in the member's treatment plan.
Extended care services shall provide scheduled therapeutic plan consisting of treatment services designed to enable the member to sustain a substance free lifestyle within a supportive environment.
Each member shall receive a complete physical examination by a physician within seventy-two (72) hours of admission and the results shall be entered in the member's record. Physical examinations performed more than thirty (30) days before admission are not acceptable. If the member's admission was based on the results of a physical examination performed thirty (30) or fewer days before admission, the PNMI's physician must approve the prior examination or re-examine the member within forty-eight (48) hours after admission.
PNMIs shall provide medical evaluation upon intake and laboratory examinations as deemed appropriate by the physician as soon as practicable after admission. The PNMI shall establish procedures for the prompt detection and treatment of physical health problems through surveillance, periodic appraisals, and physical examinations. The PNMI is responsible for referring the member to external clinicians and facilities for specialized services beyond the capability of the PNMI.
The PNMI's qualified staff shall teach attitudes, skills, and habits conducive to facilitating the member's transition back to the community. The treatment mode may vary with the member's needs and may be in the form of individual, group or family counseling.
The PNMI shall have a written agreement with an ambulance service to assure twenty-four (24)-hour access to transportation to emergency medical care facilities for members requiring such transport. Physician back-up and on-call staff shall be provided to deal with medical emergencies.
The PNMI shall not subcontract any of its obligations and rights pertaining to medical services described in this Section, with the exception of physician consultant services.
Residential Rehabilitation Type II will provide a structured therapeutic environment for members who are on a waiting list for treatment, or who have either completed detoxification treatment, or are otherwise not in need of detoxification services. The primary objectives of Residential Rehabilitation Type II are; to stabilize the substance user in order to provide continuity of treatment, to enable the member to develop an appropriate supportive environment, to remain substance free and to develop linkages with community services.
The term of residency shall not exceed forty-five (45) days. The PNMI shall provide a daily structured sequence of individual and/or group counseling for the treatment of substance use provided by qualified staff members (listed in Section 2400 of the pertinent Chapter III, Principles). MaineCare does not cover other educational and vocational counseling required by the Office of Behavioral Health Regulations for Extended Care Shelters.
Services provided will depend upon the therapeutic needs of individual members and must include but are not limited to:
- Evaluation of the member's medical and psychosocial needs;
- A medical examination by a physician within five (5) days of admission unless the member can show evidence of such examination within the last thirty (30) days;
- Opportunities for learning basic living skills, such as personal hygiene skills, knowledge of proper diet and meal preparation, constructive use of leisure time, money management and interpersonal relationship skills, all of which are considered non-covered services by MaineCare;
- Clinical services, including individual and group counseling; and
- Opportunity for family involvement.
The PNMI shall have twenty-four (24)-hour coverage by on-site trained staff (as required by Office of Behavioral Health) and include weekend coverage.
Each PNMI shall provide at least one (1) hour per week of professional consultation to the clinical staff to ensure the wellbeing of the members and to provide for the growth and development of the staff. This consultation may be either on a group or individual basis.
The PNMI shall assure the availability of a transportation support system twenty-four (24)-hours a day, and shall maintain a written agreement for the provision of transportation between the facility and emergency care facilities.
Responsibility for implementation of each member's individual service plan shall rest with a licensed or certified clinical personnel or staff person operating within the scope of his/her license or certification under Maine law. Such clinical personnel or staff is responsible for the provision of direct services and for documented supervision of other qualified staff involved in implementing the service plan. Supervisory arrangements must be made in accordance with licensing and certification regulations. The health professional may be employed by the facility or engaged through a consultant contract or agreement.
PNMIs must provide all services pursuant to a written service plan based on an individualized assessment of the member made in accordance with the Rules for the Licensure of Residential Child Care Facilities or the Rules for Licensure of Child Placing Agencies, whichever is applicable.
Service plans must be developed, approved and signed in accordance with the Rules for Licensure of Residential Child Care Facilities or Rules for Licensure of Child Placing Agencies. The plan shall specify the treatment and rehabilitative services to be provided. The plan shall be reviewed and documented according to the applicable licensing requirements.
Providers must maintain records in accordance with Chapter I and Chapter II, Sections 97.07-4, and 5 of the MaineCare Benefits Manual. Discharge summaries shall be consistent with the Rules for the Licensure of Residential Child Care Facilities and Rules for Licensure of Child Placing Agencies.
Rehabilitative services are designed to improve member's instrumental functioning in daily living, emotional and physical capability in areas of daily living, community integration and interpersonal functioning. These services include, but are not limited to:
- Group therapy aimed at improving a member's emotional integration, self-awareness, and environment;
- Emotional development skills training aimed at promoting behaviors that affect a member's relations with other people and the member's attitudes, interest, values, and emotional expression;
- Daily living skills training, aimed at addressing member dysfunction in areas necessary to maintain independent living;
- Interpersonal skills training, such as structured learning therapy, which are aimed at addressing member dysfunction in areas of social appropriateness and social integration;
- Community skill training, such as modeling therapy that is aimed at ameliorating member dysfunction in the awareness and appropriate use of community resources; and
- Collateral contacts, which mean a face-to-face contact on behalf of the member by clinical personnel or qualified staff to seek information, or discuss the member's case with other professionals, caregivers, or others included in the treatment plan in order to achieve continuity; of care, coordination of services, and the most appropriate mix of services for the member. Discussions or meetings with staff of the PNMI provider on behalf of the same member are not considered to be collateral contacts.
The population served by child-care facilities tends to manifest a wide variety of physical problems in addition to those mental health or behavioral disorders that are the primary presenting problems. For this reason, it is imperative that the provider provides physical care for members that is integral rather than adjunctive. In this sense, the provider shall assure that physical care exists that meets the primary care needs of members. The provider shall coordinate and collaborate with other physical health care providers to assure the appropriate treatment of physical illness and the maintenance of good general health among members. The provider shall also maintain arrangements with external clinicians and facilities for the provision of specialized medical, surgical, and dental services to members.
Direct member services performed by clinical personnel refers to mental health treatment, substance use treatment, rehabilitative services and/or personal care services performed as deemed medically necessary and described in an authorized plan of care with the member present and participating. These services are provided within the scope of their licensure or certification by physicians, psychiatrists, psychologists, social workers, psychiatric nurses, psychological examiners, occupational therapists, other qualified mental health staff, personal care service staff, licensed substance use staff, licensed clinical professional counselors, licensed professional counselors or other qualified alcohol and drug treatment staff as defined in Chapter II, Section 97.07-2.
Mental health treatment and rehabilitative services refer to direct member services provided for reduction of a mental illness and restoration of a member to his/her best possible functional level. These services focus on the establishing or regaining of functional skills; the increase of self-understanding, crisis prevention and self management; socialization and leisure skill development; the development and enhancement of social roles within the context of natural supports, the consumer's community, and others within the residential treatment facility; and other activities connected with the rehabilitation goals and objectives identified in the plan of care.
These services are deemed medically necessary and described in an authorized plan of care and are provided with the member present and participating. The individualized rehabilitation plan shall include sequential steps developed with the consumer. Treatment planning will include, when possible, community staff providing services outside the facility as well as residential treatment facility staff. Planning will also include any other individuals that the member chooses. The plan will reflect individualized goals and objectives identifying the tailored services to be provided. Services provided are based on a well defined, time-limited plan that focuses on the member's particular strengths, needs, and choices and which is developed through a regularly scheduled, individualized planning process on a quarterly basis. One of the key elements reflected in the services provided by the facility is that of the expectation of growth and recovery. Mental health treatment and rehabilitative services are provided by physicians, psychiatrists, psychologists, social workers, licensed clinical professional counselors, licensed professional counselors, certified interpreters, psychiatric nurses, psychological examiners, occupational therapists, and other qualified mental health staff, as defined in Chapter II, Section 97.07-2, operating within their competence in accordance with state law.
MaineCare does not cover personal care services provided by a family member. Personal care services must be prescribed by a physician, are provided by other qualified mental health staff, in accordance with their
respective plans of care, as defined in Section 97.07-2(E) and include, but are not limited to, the following:
- Assistance or supervision of activities of daily living including bathing, dressing, eating, toileting, ambulation, personal hygiene activities, grooming, and the performance of incidental household tasks essential to the activities of daily living and to the maintenance of the member's health and safety;
- Supervision of or assistance with administration of physician-ordered medication;
- Personal supervision or being aware of the member's general whereabouts, observing or monitoring the member to ensure their health and safety, reminding the member to carry out activities of daily living, and assisting the member in adjusting to the facility and the community;
- Arranging transportation and making phone calls for appointments as recommended by medical providers or as indicated in the member's plan of care; and
- Observing and monitoring member's behavior and reporting changes in the member's normal appearance, behavior, or state of health to medical providers or supervisory personnel as appropriate.
Integrated treatment services for persons with coexisting disorders (chronic mental illness and substance use) shall include mental health and substance use rehabilitative services. These services assist members in confronting their addiction history (alcohol and drug abuse) and develop motivation for long-term compliance and plans for ongoing recovery and treatment. Such rehabilitation services include individual counseling, family therapy, group therapy, and other services necessary to enhance a member's successful transition to housing and services in the community and promote the ability to function as independently as possible in the community.
Integrated treatment services shall also include independent living skills and social skills services, necessary to promote ongoing recovery and treatment.
Specific treatment goals and objectives of such services shall be documented in each member's individual service plan.
MaineCare does not reimburse for services that are primarily academic, vocational, socialization or recreational in nature, as described in Chapter I of the MaineCare Benefits Manual. MaineCare does not reimburse self-help supportive meetings.
Clinical responsibility for implementation of each member's individual service plan shall rest with a licensed or certified mental health professional operating within the scope of his/her license or certification under Maine law. Such mental health professional shall be responsible for the provision of direct services and for documented supervision of other qualified mental health staff involved in implementing the service plan. The Department, in accordance with its licensing and certification regulations, must approve supervisory arrangements. The mental health professional may be employed by the facility or engaged through a consultant contract or agreement.
Within thirty (30) days of the entry of the member in the facility, all services must be provided pursuant to a written service plan based on an individualized assessment of the member made by a psychiatrist, psychologist, physician, licensed clinical social worker, psychiatric nurse, licensed master social worker conditional I, licensed master social worker conditional II, licensed clinical professional counselor or licensed clinical professional counselor conditional. The plan shall specify the treatment and rehabilitative services to be provided at the facility site. The plan shall be reviewed and documented every ninety (90) days.
Records must be maintained and reviewed in accordance with Sections 97.07-4, 5, and 7. Progress notes must be entered into the record and signed at least daily, at a minimum addressing specific goals indicated in the individual treatment plan.
Only services provided at the facility for the diagnosis, assessment, treatment, rehabilitation, or provision of personal care services are reimbursable. It is recognized that many elements of a comprehensive plan of services to mentally ill members are not reimbursable by MaineCare. Services reimbursable under Section 97, Chapter III may complement, but must not duplicate, services provided outside of the facility, regardless of the actual provider of services. Each member's comprehensive individual service plan shall assure the most appropriate non-duplicative mix of services.
PNMIs approved and funded by Office of Behavioral Health in licensed facilities must also provide personal care services necessary for the promotion of ongoing treatment and recovery.
Medical and remedial facilities, whether they are case-mix reimbursed or non-case mix reimbursed facilities, include services provided at the facility for the diagnosis, assessment, treatment, rehabilitation, or provision of personal care services. These services must be provided within the scope of licensure or certification by staff as defined in Section 97.07-2.
MaineCare does not cover personal care services provided by a family member. A physician must prescribe personal care services. Other qualified personal care staff must provide services in accordance with respective plans of care, which include, but are not limited to, the following:
- Provision of personal care and nursing services;
- Assistance with or supervision of activities of daily living including bathing, dressing, eating, toileting, ambulation, personal hygiene activities, grooming, and the performance of incidental household tasks such as food preparation, laundry, and housekeeping essential to the activities of daily living and to the maintenance of the member's health and safety;
- Supervision of or assistance with the administration of physician-ordered medication;
- Personally supervising or being aware of the member's general whereabouts, observing or monitoring the member to ensure his or her health and safety, reminding the member to carry out activities of daily living, and assisting the member in adjusting to the facility and the community; and
- Arranging transportation for appointments as recommended by medical providers or as indicated in the member's plan of care.
Providers must include at least four family meetings per month as part of the treatment process unless documentation in the treatment plan indicates that such meetings are counterproductive to the child's progress. Each child must have an initial plan developed within the first seventy-two (72) hours of admission, and a comprehensive treatment plan developed within twenty (20) working days after admission.
Providers must meet all of the following requirements:
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-97, subsec. 144-101-II-97.08