Provider Responsibilities

In addition to meeting all of the qualifications set forth in 130 CMR 438.000 and 130 CMR 450.000: Administrative and Billing Regulations, CSN agencies must meet all of the following requirements. (A) Policies and Procedures. Each CSN agency must develop comprehensive policies and procedures governing the delivery of CSN agency services. The agency must maintain the policies and procedures, review/update them, comply with them, and make them available to members, in part or in their entirety, on request. At a minimum, the policies and procedures 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) CSN agency staff evaluation and supervision; (f) emergencies including fire, safety and disasters, including notifying the fire department and police in emergencies; (g) MassHealth 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) emergency services and plans for members; (n) recognizing and reporting abuse (physical, sexual, emotional, psychological), neglect, self-neglect, and financial exploitation; (o) Health Insurance Portability and Accountability Act (HIPAA); (p) procedures to be followed if a member is missing or lost; and (q) member complaint resolution protocol. (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 CSN agency services with other services the member is receiving, including co-vending; (h) coordination of CSN agency services with other CSN providers. CSN providers must include how the provider ensures documentation is accessible to family and other providers; (i) medical record management in the member’s home; (j) first aid and cardiopulmonary resuscitation requirements; and (3) any additional administrative or clinical policies the agency chooses to implement. (B) Nurse Teaching Activities. During a CSN services visit, the nurse may teach the member, family member, or unpaid caregivers how to manage the member’s treatment regimen as applicable. Ongoing teaching should occur when there is a change in the procedure or the member’s condition. All teaching activities must be documented in the member’s record. (C) Complex Care Assistant Service Delivery. (1) Complex Care Assistant Qualifications. CSN agencies providing complex care assistants and submitting reimbursement to the MassHealth agency for complex care assistant services must ensure complex care assistants meet the following qualifications: (a) be legally authorized to work in the United States; (b) be at least 18 years old; (c) not be on the List of Excluded Individuals and Entities as provided by the Office of Inspector General of the U.S. Department of Health and Human Services, or other applicable lists excluding individuals or entities from participating in MassHealth under state or federal law; (d) meet reading and writing comprehension standards sufficient to effectively communicate and report on the member’s complex care assistant services; and (e) complete training requirements for complex care assistant services as described at 130 CMR 438.415(C)(3). (2) Complex Care Assistant Payment and Assignment. (a) Payment. The CSN agency is required to directly pay complex care assistants at least 65% of the reimbursement rate established for complex care assistant services under 101 CMR 361.00: Rates for Continuous Skilled Nursing Agency and Independent Nursing Services. (b) Member Assignment. Complex care assistants are assigned to serve a specific member by the CSN agency. Complex care assistants may only serve members they have been specifically trained to care for. (3) Complex Care Assistant Training Requirements. (a) CSN agencies providing complex care assistant services and submitting reimbursement to the MassHealth agency for these services must ensure all complex care assistants complete a competency training and comprehension program that: 1. meets the home health aide qualification standards set forth in 42 CFR 484.80(a); and 2. provides, through hands-on practical training, education on how to perform the following activities that do not require the skills of a nurse, as ordered for a specific complex care member the assistant is being trained to serve: a. enteral G-tube/J-tube feedings b. skin care including application of OTC products or routine G-tube/J-tube care c. oxygen therapy d. oral (dental) suction to remove superficial oral secretions e. ostomy and catheter care f. modified meal preparation g. equipment management and maintenance (wheelchair, CPAP/BiPAP, oxygen and respiratory) and paperwork h. braces, splints, and/or pressure stockings i. transportation to medical providers / pharmacy (by driving the member or going alone) j. incidental services (b) The training and comprehension program must document the training provided and evaluate the complex care assistant’s proficiency in safely performing the activities listed in 130 CMR 438.415(C)(3)(a)2. (c) Complex care assistants who are evaluated and have documented competency and proficiency in safely performing the activities listed in 438.415(C)(3)(a) are exempt from completing the full training program. They are, however, required to complete any elements for which they are evaluated and not determined to be competent and proficient. (4) Member Care Instructions. The RN supervisor must prepare written member care instructions that are specific to the complex care member’s needs and follow the member’s plan of care as ordered by their physician or non-physician ordering practitioner. (5) Complex Care Assistant Service Supervision. Complex care assistant services must be assessed regularly by the RN supervisor described at 130 CMR 438.415(C)(4) to ensure quality and safe care delivery. (a) Biweekly RN Supervisory Visits. The RN supervisor must make a supervisory visit no less frequently than every 14 days to assess the quality and safety of the complex care assistant services provided. The supervisory visit may take place on site in the member’s home or with two-way audio-video telecommunication technology that allows for real- time interaction between the RN and the patient, and the representative, as needed. The complex care assistant does not need to be present during these biweekly supervisory visits. The supervisory visit must be documented and maintained in the member’s medical record and be clearly identified as a complex care assistant supervisory visit note. (b) Identifying Deficiencies. If the RN supervisor notes an area of concern in complex care assistant services during a biweekly supervisory visit, then the RN must make an onsite visit to the location where the patient is receiving care to observe and assess the complex care assistant while they are performing care. (c) 60-day Supervisory Visits. The RN supervisor must make an onsite visit to the member’s home no less frequently than every 60 days to observe and assess the assistant while they are performing care. The visit may be concurrent with the CSN agency’s recertification of the plan of care. (d) Addressing Deficiencies. If the RN supervisor verifies a deficiency in complex care assistant services during an onsite visit, then the CSN agency must conduct, and the complex care assistant must complete, reeducation and training to address the specific deficiency. Documentation of satisfactory completion of reeducation and training must be maintained in the complex care assistant’s employment file and in accordance with 130 CMR 438.415(D). (D) Recordkeeping. (1) Administrative Records. CSN 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 any complex care assistant’s satisfactory completion of the competency training and comprehension program in the complex care assistant’s employment file, as well as any other 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 CSN agency will supervise the subcontracted services; (f) contracts for independent contractor services; and (g) job descriptions that include titles, reporting authority, qualifications, and responsibilities. (2) Incident and Accident Records. CSN 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 CSN agency must submit to the MassHealth agency or its designee an incident or accident report within five days under the following circumstances: 1. an incident or accident that occurred during a CSN agency service visit that results in serious injury to the member; 2. an incident or accident resulting in the member’s unexpected death even if the CSN agency was not involved in the incident or accident; 3. an incident of abuse or neglect involving a staff member of the CSN agency and the member; or 4. an incident of abuse or neglect committed by another provider supporting the member (if known). (b) The incident or accident report must include at least the following information: 1. general information including, but not limited to, member’s name and member’s MassHealth ID number; 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 CSN agency for each member must conform to 130 CMR 450.000: Administrative and Billing Regulations. Payment for CSN agency services described at 130 CMR 438.000 requires complete documentation in the member’s medical record. The CSN agency must maintain records for each member to whom services are provided and a copy of the member’s complete medical record must be maintained in the member’s home. (b) The CSN 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 438.415(D): 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 primary care physician or ordering non-physician practitioner; 3. the primary natural 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 include the following information: a. the full date of service and time that each visit began and ended; b. for CSN services, all treatments and services ordered by the physician or ordering non-physician practitioner included in the member’s plan of care and documentation of which treatments and services were provided during the visit and the member’s response; c. for complex care assistant services, documentation of the treatments and services in the plan of care, and written in the member care instructions described at 130 CMR 438.415(C)(4), that were provided during the visit, as well as the member's response; d. any additional treatment or service not included in the member’s plan of care provided, as well as the member’s response, including, for CSN services, documentation of medication administration as described at 130 CMR 438.415(D)(3)(b)7; e. any service or treatment the member may have declined during visit and explanation of denial; f. the member’s vital signs and any other required measurements, as appropriate; g. progress toward achievement of goals as specified in the plan of care including, when applicable, an explanation of why goals are not achieved as expected; h. a pain assessment, as appropriate; i. the status of any equipment maintenance and management, as appropriate; and j. 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, 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. any clinical tests and their results, as applicable; 9. a signed medical records release form, as applicable; 10. the number of authorized nursing hours for their agency per calendar week for the member; 11. the number of authorized complex care assistant hours for the CSN agency per calendar week for the member, as applicable; 12. the names and telephone numbers of all the providers involved in co-vending care; the number of nursing hours; and, as applicable, the number of complex care assistant hours approved for each provider by the MassHealth agency or its designee, to the best of the agency’s ability; and 13. a copy of the CSN agency’s current prior authorization. (4) Access to Records Maintained in Member’s Home. The CSN agency must maintain a copy of the member’s medical record in the member’s home as described at 130 CMR 438.415(D)(3). The copy of the member’s medical record maintained in the member’s home must be provided to the member, and also the CSN agency must make every attempt to coordinate care and/or change in shifts with other CSN providers and, as applicable, complex care assistants. (5) Copies of Records. Upon the request of the member or the member’s representative, the CSN agency must provide a copy of the medical record to the person or entity that the member or the member’s representative designates. Additionally, upon request of the MassHealth agency or its designee, the CSN agency must provide a copy of the member’s complete medical record. (E) Statement of Fiscal Soundness. (1) Submission Requirements. Under 130 CMR 438.404(I), CSN agencies must submit to the MassHealth agency or its designee annually and at enrollment a statement of fiscal soundness attesting to the financial viability of the CSN agency. To satisfy the fiscal soundness requirement, the CSN agency must demonstrate a cash reserve sufficient to meet one month of financial obligations in the operation of the provider’s CSN agency 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 CSN agency must submit to the MassHealth agency or its designee a statement of fiscal soundness annually and by the end of May each year. (3) Attestation. The CSN agency must attest that its available cash reserve will meet the average monthly cost at all times during the subsequent year. (4) Noncompliance. For CSN agencies that fail to meet the fiscal soundness requirement pursuant to 130 CMR 438.404(I) and 438.415(E), the MassHealth agency 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 provider as a MassHealth CSN agency. (F) Annual Staffing Report. (1) Submission Requirements. CSN agencies must annually submit to the MassHealth agency or its designee a record of the gross hourly wage the CSN agency paid to all employee nurses the previous calendar year. The staffing report must include the median, average, and range of all direct-care nurse salaries and account for all wage differentials paid, licensure, other factors the CSN agency uses to determine nurse wages, and additional requirements issued by the EOHHS. (2) Submission Due Date. The CSN agency must submit its staffing report to the MassHealth agency or its designee by the end of February each year. (3) Attestation. The staffing report must include an attestation confirming, under the penalty of perjury, that the information provided in the report is accurate and complete for the previous calendar year. The attestation must be signed by the appropriate personal representative who is responsible for the CSN agency’s operation in the state. (4) Noncompliance. CSN agency providers that fail to submit the annual staffing report may be subject to sanctions in accordance with 130 CMR 450.238: Sanctions: General, including, but not limited to, termination as a MassHealth CSN agency. (G) Member Complaint Resolution. (1) Member Complaint Resolution Protocol. The CSN agency must have a member complaint resolution protocol that is maintained in its Policy and Procedure Manual described at 130 CMR 438.415(A). CSN agencies without an implemented member complaint resolution protocol may be subject to administrative sanction under 130 CMR 450.000: Administrative and Billing Regulations. (a) The CSN agency must investigate complaints made by a member, the member’s representative (if any), and the member’s caregivers and family, including, but not limited to, complaints on the following topics: 1. treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; and 2. mistreatment; neglect; verbal, mental, sexual, or physical abuse, including injuries of unknown source; and/or misappropriation of member property by anyone furnishing services on the CSN agency’s behalf. (2) Content of Member Complaint Resolution Protocol. The member complaint resolution protocol must (a) detail how the CSN agency will generally manage received member complaints; (b) specify the agency employee(s) responsible for managing member complaint resolution; and (c) indicate how the CSN agency will ensure a written response to all member complaints within two business days of the received complaint. (3) Recordkeeping and Documentation. The CSN agency must document and maintain record of all received complaints (whether provided in person; by phone; or in writing in email, letter, or text), and the documentation must at least include (a) the name, address, and telephone number of the member; (b) the name, address, and telephone number of the person filing the complaint (if not the member); (c) a summary of the complaint; (d) the date the provider received the complaint; (e) the name of the person receiving the complaint; (f) a summary of any investigation or actions taken by the CSN agency to resolve the complaint; and (g) if the CSN agency determined that an investigation of the complaint or further action was not necessary, the name of the person making this decision and the reason for the decision.