GAFC Provider Responsibilities

In addition to meeting all of the qualifications set forth in 130 CMR 408.000 and 130 CMR 450.000: Administrative and Billing Regulations, the GAFC provider must meet all of the following requirements. (A) Policies and Procedures Manual. Each GAFC provider must develop, maintain, annually review, and update a comprehensive policies and procedures manual governing the delivery of GAFC services. Each manual at a minimum must contain a mission statement; the goals and objectives of the program; an organizational chart describing the lines of authority and communication needed to manage the GAFC program, including the lines of authority for delegation of responsibility down to the member care level; job descriptions that include titles, reporting authority, qualifications and responsibilities; and a description of the governing body. Additionally, each policy and procedure manual must contain the following: (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) GAFC provider staff evaluation and monitoring; (f) emergencies, including fire, safety and disasters, including notifying the fire department and police in emergencies, relocating members during an emergency, and coordinating alternative GAFC providers when a member is relocated; (g) MassHealth basics and member rights; (h) human rights and nondiscrimination; (i) incident and accident reporting; (j) staff and member grievances; (k) cultural competency; (l) quality assurance and improvement; (m) direct care aide training; (n) emergency services and plans; (o) first aid and cardiopulmonary resuscitation requirements; (p) Health Insurance Portability and Accountability Act (HIPAA); (q) coordination of GAFC with other services the member is receiving; and (r) procedures to be followed if a member is missing or lost; and (2) clinical policies and procedures including, but not limited to: (a) clinical evaluations; (b) privacy and confidentiality; (c) 24-hour emergency coverage, including medical and other emergencies; (d) documentation of visits and progress notes; (e) medication management; (f) universal precautions; (g) infection control and communicable disease; (h) recognizing and reporting abuse (physical, sexual, emotional, psychological) neglect, self- neglect and financial exploitation; (i) discharge criteria; and (j) member counseling. (B) Clinical Assessment and Clinical Evaluations. If required by MassHealth, the GAFC provider’s MDT must perform a clinical assessment by completing a clinical assessment screening tool designated by the MassHealth agency as well as all other applicable clinical evaluations for each member (1) before admission to GAFC; (2) upon significant change; and (3) annually on the anniversary date of the member’s admission to GAFC. (C) GAFC Plan of Care. The plan of care must be based upon clinical evaluations and contain the following elements: prioritized goals and objectives that consider and document the needs, goals and preferences of the member; the resources to be utilized; and a plan for continuity of care. The goals and actions of the plan of care must be measurable and reflect the member’s desired outcomes for GAFC and address medical, social, and other services needed and chosen by the member. The plan of care must reflect the member’s needs, current care and treatment, problem identification with appropriate follow-up, and implementation with interventions and evaluation. The plan of care must be in language that is understandable to the member, and to the individuals important in supporting the member. (1) Within five working days of a member’s admission to GAFC, the GAFC provider’s MDT, the member, and others as designated by the member must design an interim GAFC plan of care. The interim plan must be signed by the registered nurse and include, at a minimum, an outline of a temporary schedule of care provided that will be used until the final GAFC plan of care is completed. (2) Within 30 calendar days of a member’s admission to GAFC, the GAFC provider’s MDT, the member or responsible party, and others designated by the member must develop the final GAFC plan of care. The final plan of care must be signed by the member, the registered nurse, and the care manager. The final signed plan of care must be sent to the PCP. The final plan of care must include: (a) a treatment plan describing how, and by whom, the member’s service needs will be met seven days a week that is based on the member's PCP’s summary, physical examination, and all applicable clinical evaluations; and (b) documentation of any other health services or supportive services the member is receiving from MassHealth or other agencies or organizations (for example, adult day health, visiting nurse services, therapy services, services provided by DDS, DMH, and MRC, or counseling services, including behavioral health). (3) The plan of care must be based upon: (a) the member’s strengths, preferences, and member identified goals and desired outcomes for GAFC; (b) clinical evaluation; (c) the GAFC direct care aide’s care log; (d) the nursing progress notes; (e) the care manager’s progress notes; (f) the PCP Summary Form and approval to participate in GAFC; (g) documentation of the member’s PCP annual visit and the member’s physical examination; and (h) the member’s discharge and transition plan. (4) For members who meet the requirements for GAFC service payment, the GAFC provider must annually review the plan of care and send a copy of the member’s health status report to the member’s PCP. (5) Review of the plan of care will be conducted by the MDT with participation from the member or responsible party and others as designated by the member at a minimum of every six months, or more often as warranted by changes in the member’s condition or other significant changes. If a plan of care is modified, the GAFC provider must send a copy of the plan of care to the member’s PCP. (6) The member, health care proxy, or surrogate identified by a member with decisional capacity must be afforded the opportunity to attend all plan of care meetings. (7) The GAFC provider must establish emergency policy and procedures in writing and include them with the member’s plan of care including, at a minimum, an emergency file (such as an emergency fact sheet) on the member that must contain: (a) the name and telephone number of the member’s PCP; (b) the member’s diagnosis; (c) any special treatments or medications the member may need; (d) insurance information; (e) emergency contact information for notification of the family or legal guardian; (f) procedures to be followed in the event a member is missing or lost; and (g) procedures for handling medical emergencies. (D) Recordkeeping. The GAFC provider must maintain 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: (1) administrative records, including: (a) payroll and staff records, including evidence of completed staff orientation and training, members served per day, and timesheets; (b) financial records; (c) member utilization; (d) staffing levels; (e) complaints and grievances; (f) documents related to the member’s home; (g) contracts for subcontracted services; (h) contracts for independent contractor services, including a description of how the GAFC provider will supervise the independent contractors and their services; (i) documentation of the preadmission procedure described in 130 CMR 408.522(A); and (j) maintain job descriptions that include titles, reporting authority, qualifications and responsibilities. (2) member records, which must contain at a minimum all of the following: (a) initial admission information, including 1. the member information sheet; 2. the prior authorization by the MassHealth agency or its designee; and 3. clinical evaluations; (b) medical information, including: 1. a copy of the most recent physical examination (within the past 12 months); 2. the PCP’s authorization and summary; 3. the member’s semi-annual health-status reports and documentation that the health status reports were sent to the PCP; 4. the member’s medical history; 5. the member’s tuberculosis screening documentation; 6. list of the member’s known allergies; 7. information about the member’s dietary requirements; 8. a list of the member’s current medications; 9. if designated by the member, advance directives and the name of the healthcare proxy; and 10. the ADL needs as outlined in 130 CMR 408.506(B); (c) progress notes, including; 1. nursing notes; 2. care manager notes; and 3. service documentation (log of care received); (d) correspondence from family, therapists, PCP, other service providers, or others, including a managed care organization or an accountable care organization, about the care of the member in the GAFC program; (e) the GAFC plan of care, including any documentation forming the basis of the plan of care, and documentation that the signed final plan of care was sent to the PCP; (f) the discharge plan; (g) legal documentation, for example, signed authorizations for release of information; (h) critical incident reports in a form and format designated by the MassHealth agency; (i) the member’s post-discharge status; (j) documentation of the direct care aide’s daily schedule; and (k) documentation of the care required to be provided by the MDT; (3) records 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. (E) Reporting. (1) Incident Reporting. The GAFC provider must immediately notify the MassHealth agency of any of the following incidents and follow up in writing within three business days: (a) the death of a member; (b) a fire or other natural or unnatural disaster in either the qualified setting or the GAFC administrative office; (c) a life-threatening accident or incident; (d) a serious communicable disease contracted by GAFC staff or a member; (e) any allegation of abuse or neglect of or by the member; and (f) a member missing from a qualified setting. (2) Program Reporting. The GAFC provider must submit all of the following information in the format and time frames as requested by the MassHealth agency: (a) clinical and statistical information; (b) cost and expense information; (c) member satisfaction survey results, including the survey developed by the provider, and a description of how the findings will be addressed; (d) change in GAFC provider contact information; (e) any additional information requested by the MassHealth agency or its designee related to the provider’s provision of GAFC services; and (f) data necessary to measure the quality of the services delivered by the provider as required by the MassHealth agency. (F) Quality Improvement Plan. Each GAFC provider must conduct a biennial survey of members and staff and develop a quality improvement plan that addresses issues and concerns raised by the survey. The provider must maintain the survey and quality improvement plan. (G) Electronic Visit Verification (EVV). Each GAFC provider must use EVV in the form and format as required by EOHHS.