Scope of Group Adult Foster Care Services

(A) Direct Care. Direct care includes daily assistance with ADLs and IADLs as defined in 130 CMR 408.502. The GAFC provider must ensure the delivery of direct care to members by a qualified GAFC direct care aide, as described in 130 CMR 408.524(C), who is supervised by the GAFC provider. GAFC must be ordered by a PCP and delivered by a qualified GAFC direct care aide under the supervision of the registered nurse and the MDT in accordance with each member’s written plan of care. Direct care includes daily assistance with ADLs and IADLs as defined in 130 CMR 408.502. (B) Nursing Oversight. The GAFC 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 408.524(B)(2)(a) and 130 CMR 408.524(D)(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 GAFC plan of care and must include all of the following activities: (1) completing or coordinating all applicable clinical assessments and clinical evaluations, provided that a licensed practical nurse may complete clinical assessments and evaluations only under the supervision of a registered nurse; (2) developing the member’s interim and final GAFC 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 GAFC plan of care; (5) coordinating the delivery of GAFC 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), Department of Mental Health (DMH) services, Executive Office of Elder Affairs, and Massachusetts Rehabilitation Commission (MRC) services; (6) conducting on-site visits with each member at the member’s home 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; (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 GAFC with the member and GAFC provider personnel; (12) developing, in conjunction with the MDT, the GAFC direct care aide, and the member or responsible party, an emergency backup and personal care contingency plan for each member receiving GAFC that includes an alternative plan for the member if the GAFC provider is temporarily unable to provide care; and (13) overseeing, monitoring, supporting, training, and evaluating GAFC direct care aides. (C) Care Management. Care management must be provided by a qualified GAFC care manager, as described in 130 CMR 408.524(B)(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 GAFC care manager must include the following activities: (1) conducting initial and ongoing psychosocial evaluation of a member’s appropriateness for GAFC; (2) evaluating, supporting, and training GAFC direct care aides; (3) assisting with the development of the member’s interim and final GAFC 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 GAFC plan of care; (5) conducting on-site visits with each member at the member’s home every other month, or more often as the member’s condition warrants, where such visits alternate with the required visits by the nurse or care manager to ensure the member receives one visit by the care manager or nurse every month; (6) assisting with coordination of GAFC 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), 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 GAFC nurse; (9) assisting with making referrals to appropriate service providers if the member requires services other than those provided by the GAFC provider; (10) providing timely assistance and responding to urgent or emergency needs of the member; and (11) developing, in conjunction with the MDT, the GAFC direct care aide, and the member or responsible party, an emergency backup and personal care contingency plan for each member receiving GAFC that includes an alternative plan for the member if the GAFC provider is temporarily unable to provide care.