Scope of Adult Foster Care Services

(A) Direct Care. The AFC provider must ensure the delivery of direct care to members in a qualified setting, as described in 130 CMR 408.435, by a qualified AFC caregiver, as described in 130 CMR 408.434, who lives in the residence and paid by the AFC provider. AFC must be ordered by a PCP and delivered by a qualified AFC caregiver under the oversight of the registered nurse and the MDT in accordance with each member’s written plan of care. Direct care includes 24-hour supervision, and daily assistance with ADLs and IADLs as defined in 130 CMR 408.402. (B) Nursing Oversight. The AFC provider must provide nursing oversight by a registered nurse or licensed practical nurse under the supervision of a registered nurse who meets the qualifications as described in 130 CMR 408.433(C)(2)(a) and 130 CMR 408.433(E)(1), who is not related to the member, and who is licensed in Massachusetts. Nursing oversight services must be individualized to meet the needs of each member in accordance with the member’s AFC plan of care and must include all of the following activities: (1) completing or coordinating all applicable clinical assessments and clinical evaluations, provided that only a registered nurse can complete such assessments and evaluations; (2) developing the member’s interim and final AFC plan of care, with input from the member or responsible party, all members of the MDT, and other individuals designated by the member; (3) completing a semi-annual health status report for each member; (4) ensuring implementation of the AFC plan of care; (5) coordinating the delivery of AFC with any other health services or supportive services the member is receiving from MassHealth or other agencies or organizations including, but not limited to, visiting nurse services, therapy services, Department of Developmental Services (DDS) services, Department of Mental Health (DMH) services, and Massachusetts Rehabilitation Commission (MRC) services; (6) conducting on-site visits with each member at the qualified setting: (a) for members authorized for AFC level I service payment, the nurse must conduct on-site visits every other month, or more often as the member’s condition warrants where such visits alternate with the required visits by the care manager to ensure the member receives one visit by the nurse or care manager every month, as determined by the MDT in accordance with 130 CMR 408.433(B), a community support specialist may conduct up to three non-consecutive on-site visits per 12-month period in place of the nurse; and (b) for AFC level II service payment, the nurse must conduct on-site visits every month, or more often as the member’s condition warrants, to ensure the member receives one visit by the nurse and one visit by the care manager every month, if determined appropriate by the MDT in accordance with 130 CMR 408.433(B), a community support specialist may conduct up to six non-consecutive on-site visits per 12-month period in place of the nurse; (7) completing a nursing progress note for each on-site visit or encounter and upon significant change; (8) monitoring each member’s health status and documenting those findings in the member’s medical record for each on-site visit or encounter, or more often as the member’s condition warrants; (9) educating the member about hygiene and health concerns; (10) reporting changes in the member’s condition to the member’s PCP; (11) coordinating and implementing the PCP form and approval for AFC with the member, AFC caregiver, and AFC provider personnel; (12) developing, in conjunction with the MDT the AFC caregiver, and the member or responsible party, an emergency backup and personal care contingency plan for each member receiving AFC that includes an alternative plan for the member if the AFC caregiver is temporarily unable to provide care; and (13) overseeing, monitoring, supporting, training, and evaluating AFC caregivers. (C) Care Management. Care management must be provided by a qualified AFC care manager, as described in 130 CMR 408.433(C)(3)(a), who is not related to the member, and who is responsible for coordinating care and monitoring the needs of the member in conjunction with the registered nurse. Care management performed by the AFC care manager must include the following activities: (1) conducting initial and ongoing psychosocial evaluation of a member’s appropriateness for AFC; (2) evaluating, supporting, and training AFC caregivers; (3) assisting with the development of the member’s interim and final AFC plan of care with input from the member or responsible party, all members of the MDT, and other individuals designated by the member. (4) ensuring implementation of the AFC plan of care; (5) conducting on-site visits with each member at the qualified setting: (a) for AFC level I service payment, the care manager must conduct on-site visits every other month, or more often as the member’s condition warrants, where such visits alternate with the required visits by the nurse to ensure the member receives one visit by the nurse or care manager every month, provided that, as determined by the MDT in accordance with 130 CMR 408.433(B), a community support specialist may conduct up to three non-consecutive on-site visits per 12-month period in place of the AFC care manager; (b) for AFC level II service payment, the care manager must conduct on-site visits every month, or more often as the member’s condition warrants, to ensure the member receives one visit by the nurse and one visit by the care manager every month. If determined appropriate by the MDT in accordance with 130 CMR 408.433(B), an AFC community support specialist may conduct up to six non-consecutive on-site visits per 12-month period in place of the care manager; (6) assisting with coordination of AFC with any other health services or supportive services the member is receiving from MassHealth, a managed care organization, an accountable care organization or other agencies or organizations including, but not limited to, visiting nurse services, therapy services, Department of Developmental Services (DDS) services, Department of Mental Health (DMH) services, and Massachusetts Rehabilitation Commission (MRC) services; (7) completing a care manager progress note corresponding with each on-site visit or encounter, or more often as the member’s condition warrants; (8) reporting changes in the member’s condition to the member’s AFC nurse; (9) assisting with making referrals to appropriate service providers if the member requires services other than those provided by the AFC provider; (10) conducting regular, periodic evaluations, at least annually, to ensure that each qualified setting where AFC is provided meets the requirements of 130 CMR 408.435; (11) providing timely assistance and responding to urgent or emergency needs of the member; and (12) developing, in conjunction with the MDT, the AFC caregiver, and the member or responsible party, an emergency backup and personal care contingency plan for each member, receiving AFC that includes an alternative plan for the member if the AFC caregiver is temporarily unable to provide care. (D) AFC Community Support Specialist On-site Visits. An AFC community support specialist who is qualified as described in 130 CMR 408.433(D)(1), who is not related to the member, and who has the responsibilities described in 130 CMR 408.433(D)(2) may conduct on-site visits of the member at the qualified setting in place of the nurse or care manager if determined appropriate by the MDT in accordance with 130 CMR 408.433(B).