Provider Responsibilities

In addition to meeting all of the qualifications set forth in 130 CMR 403.000 and 450.000: Administrative and Billing Regulations, home health agencies must meet all of the following requirements. (A) Policies and Procedures. Each home health agency must develop, maintain, review, update, and comply with comprehensive policies and procedures governing the delivery of home health services which at a minimum must contain the following as applicable for the services the agency delivers: (1) administrative policies and procedures, including but not limited to: (a) human resource and personnel; (b) staff and staffing requirements; (c) backup staff in the event coverage is required due to illness, vacation, or other reasons; (d) staff education and training; (e) home health agency staff evaluation and supervision; (f) emergencies including fire, safety and disasters, including notifying the fire department and police in emergencies; (g) member rights; (h) human rights and nondiscrimination; (i) incident and accident reporting; (j) staff and member grievances; (k) staff cultural competency; (l) quality assurance and improvement; (m) home health aide training; (n) emergency services and plans; (o) recognizing and reporting abuse (physical, sexual, emotional, psychological), neglect, self-neglect and financial exploitation; (p) Health Insurance Portability and Accountability Act (HIPAA); and (q) procedures to be followed if a member is missing or lost. (2) clinical policies and procedures, including, but not limited to: (a) clinical evaluations; (b) privacy and confidentiality; (c) documentation of visits and progress notes; (d) medication management; (e) infection control and communicable disease; (f) discharge criteria; (g) coordination of home health with other services the member is receiving; and (h) first aid and cardiopulmonary resuscitation requirements. (B) Teaching Activities. During a home health nursing or therapy treatment visit, the nurse or therapist must teach the member, family member, or caregivers how to manage the member’s treatment regimen as applicable. Ongoing teaching is required when there is a change in the procedure or the member’s condition, and all teaching activities must be documented in the member’s record. (C) Visit Verification. Home health agencies that provide home health aide services must: (1) ensure the member completes home health aide visit verification, which must minimally include: (a) the date of service rendered; (b) the number of hours provided; and (c) the signature of the member or the member’s legal representative. (2) Store the completed visit verification in the member’s record. (D) Recordkeeping. (1) Administrative Records. Home health agencies must maintain administrative records in compliance with the record retention requirements set forth in 130 CMR 450.205: Recordkeeping and Disclosure. All records, including but not limited to the following, must be accessible and made available on site for inspection by the MassHealth agency: (a) payroll and staff records, including evidence of completed staff orientation and training; (b) financial records; (c) staffing levels; (d) complaints and grievances; (e) contracts for subcontracted services, including a description of how the home health agency will supervise the subcontracted services; (f) contracts for independent contractor services, including a description of how the home health agency will supervise the independent contractors and their services; and (g) job descriptions that include titles, reporting authority, qualifications, and responsibilities. (2) Incident and Accident Records. Home health agencies must maintain an easily accessible record of member and staff incidents and accidents. The record may be kept within the individual member medical record or employee record or within a separate, accessible file. (a) The home health agency must submit to the MassHealth Program Manager or their designee an incident or accident report within five days of having knowledge of the incident and under the following circumstances. 1. An incident or accident that occurred during a home health service visit that results in serious injury to the member. 2. An incident or accident resulting in the member’s death even if the home health agency was not involved in the incident or accident. 3. An incident of abuse or neglect involving a staff member of the home health agency and the member. 4. An incident of abuse or neglect committed by another provider supporting the member concurrently as the home health agency (if known). (b) The incident or accident report must include at least the following information. 1. general information including but not limited to member name and member identification; 2. general nature of incident or accident; and 3. any action that was taken as a result of the incident or accident including all outcomes. (3) Member Records. In order for a medical record to completely document a service to a member, the record must describe fully the nature, extent, quality, and necessity of the care furnished to the member. When the information contained in a member’s record does not provide sufficient documentation for the service, the MassHealth agency may disallow payment (see 130 CMR 450.205: Recordkeeping and Disclosure). (a) The record maintained by a home health agency for each member must conform to130 CMR 450.000: Administrative and Billing Regulations. Payment for any service listed in 130 CMR 403.000 requires complete documentation in the member’s medical record. The home health agency must maintain records for each member to whom services are provided. (b) The home health agency must maintain an up-to-date medical record of services provided to each member. The medical record must contain at least the following in addition to the information defined at 130 CMR 403.402: 1. the member’s name, address, phone number, date of birth, and MassHealth ID number; 2. the name and phone number of the member’s ordering physician or ordering non- physician practitioner prescribing home health services; 3. the primary caregiver’s name, phone number, and relationship to the member; 4. the name and phone number of the member’s emergency contact person; 5. a copy of all verbal orders, properly authenticated; 6. accessible and legible progress notes for each visit, signed by the person providing the service that includes the following information: a. the full date of service and time that each visit began and ended; b. for nursing and therapy visit notes, treatments and services ordered by the physician or ordering non-physician practitioner that were provided by the clinician during the visit and the member’s response; c. for home health aide visit notes, documentation of which treatments and services in the plan of care or directed/supervised by a nurse/therapist that were provided during the visit and the member’s response, including documentation of medication administration as described in 130 CMR 403.419(D)(3)(b)8.; d. any service or treatment the member declined during visit and explanation of denial; e. the member’s vital signs and any other required measurements as appropriate; f. when applicable, progress toward achievement of goals as specified in the plan of care, including an explanation of why goals are not achieved as expected; g. a pain assessment, as appropriate; h. the status of any equipment maintenance and management, as appropriate; and i. any contacts with physicians or other health-care providers about the member’s needs or change in plan of care, as applicable; 7. a current medication-administration list or other documentation, such as nursing notes, and as applicable, that includes the timing of administration as ordered, drug identification and dose, route of administration, the member’s response to the medication being administered, and the signature of the person administering the medication; 8. documentation on the teaching provided to the member, member’s family, or caregiver by the nurse or therapist on how to manage the member’s treatment regimen, any ongoing teaching required due to a change in the procedure or the member’s condition, and the response to the teaching; or as applicable, documentation indicating that teaching was unsuccessful or unnecessary and why further teaching is not reasonable; 9. visit verification as described in 130 CMR 403.419(C); 10. any clinical tests and their results, as applicable; and 11. a signed medical records release form, as applicable. (4) Copies of Records. Upon the request of the member or the member’s representative, the home health agency must provide a copy of the medical record to the person or entity that the member or the member’s representative designates. (E) Statement of Fiscal Soundness. (1) Submission requirements. Under 130 CMR 403.405(E), home health agencies must submit annually and at enrollment to MassHealth or its designee a statement of fiscal soundness attesting to the financial viability of the home health agency. To satisfy the fiscal soundness requirement, the home health agency must demonstrate a cash reserve sufficient to meet one month of financial obligations in the operation of the provider’s home health program, including but not limited to timely payment of staff wages and the agency’s general and professional liability insurance coverage and workers’ compensation insurance coverage. If using a line of credit to meet the cash reserve requirement, the agency must demonstrate the line of credit has been approved by a financial institution. (2) Submission Due Date. The home health agency must submit to MassHealth or its designee a statement of fiscal soundness annually and by the end of May each year. (3) Attestation. The home health agency must attest that its available cash reserve will meet the average monthly cost at all times during the subsequent year. (4) Noncompliance. For home health agencies that fail to meet the fiscal soundness requirement pursuant to 130 CMR 403.405(E) and 130 CMR 403.419(E), MassHealth may take further action, such as imposing sanctions in accordance with 130 CMR 450.238: Sanctions: General including but not limited to termination of the organization as a MassHealth home health agency.