Plan of Care Requirements

All CSN agency services must be provided under an individualized plan of care developed for the member. The physician or ordering non-physician practitioner must sign the plan of care before services are provided to the member. (A) Providers Qualified to Establish a Plan of Care. (1) The member’s physician or ordering non-physician practitioner in consultation with the CSN agency must establish a written plan of care and the physician or ordering non-physician practitioner must recertify, sign, and date the plan of care every 60 calendar days. (2) The CSN agency may establish an additional nursing plan of care, when appropriate, that may be incorporated into the physician or ordering non-physician practitioner’s plan of care, or be prepared separately. The additional plan of care does not substitute for the physician or ordering non-physician practitioner’s plan of care. (3) If a CSN agency is co-vending a case with other CSN providers or home health agency providers, each provider is responsible for establishing a separate plan of care signed by the member’s physician or ordering non-physician practitioner. (B) Content of the Plan of Care. The orders on the plan of care must specify the total number of CSN hours and complex care assistant hours, as applicable, that the MassHealth agency or its designee has authorized to be provided to the member. The physician or ordering non-physician practitioner must sign and date the plan of care before the CSN agency submits its claim for those services to the MassHealth agency for payment. Alternatively, the physician or ordering non- physician practitioner must comply with the verbal order provisions at 130 CMR 438.416(D). Any increase in the total number of CSN hours and complex care assistant hours, as applicable, must be requested in advance by the physician or ordering non-physician practitioner with verbal or written orders and authorized by the MassHealth agency or its designee. If the member is enrolled in the Primary Care Clinician (PCC) Plan, the CSN agency must communicate with the member’s PCC both when the goals of the care plan are achieved and when there is a significant change in a member’s health status. The plan of care must also include (1) the member’s name and date of birth; (2) all pertinent diagnoses, including the member’s mental, psychosocial, and cognitive status; (3) types of medical supplies and DME required; (4) the member’s prognosis, rehabilitation potential, functional limitations, permitted activities, nutritional requirements, medications, and treatments; (5) the total number of nursing hours requested by the CSN agency, if different from the total number of CSN hours authorized by the MassHealth agency or its designee; (6) the total number of complex care assistant hours requested by the CSN agency, if different from the total number of complex care assistant hours authorized by the MassHealth agency or its designee, as applicable; (7) any teaching activities to be conducted by the nurse to teach the member, family member, or caregiver how to manage the member’s treatment regimen (ongoing teaching may be necessary where there is a change in member’s condition or treatment); (8) a description of the patient’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors; (9) a plan for medical emergencies; (10) goals toward discharge planning from CSN agency services when appropriate; and (11) any additional items the CSN agency or physician or ordering non-physician practitioner chooses to include. (C) Certification Period. The plan of care required under 130 CMR 438.416(A)(1) must be reviewed, signed, and dated by a physician or ordering non-physician practitioner at least every 60 days, unless the provider follows the verbal order provisions at 130 CMR 438.416(D). (D) Verbal Orders. (1) Notwithstanding the requirements of 130 CMR 438.416(A), services that are provided from the beginning of the certification period (see 130 CMR 438.416(C)) and before the ordering physician or ordering non-physician practitioner signs the plan of care are considered to be provided under a plan of care established and approved by the physician or ordering non-physician practitioner if (a) the clinical record contains a documented verbal order from the ordering physician or ordering non-physician practitioner for the care before the services are provided; or (b) the physician or ordering non-physician practitioner signature is on the 60-day plan of care either before the claim is submitted or within 90 days after submitting a claim for that period. (2) If the member has other health insurance (whether commercial or Medicare), the provider must comply with the other insurer’s regulations for physician or ordering non-physician practitioner signature before billing the MassHealth agency. (E) Corrections to the Plan of Care. When correcting errors on a paper plan of care before it is signed by the physician or ordering non-physician practitioner, the CSN agency staff must cross out the error with a single line and place their initials and the date next to the correction. The use of correction fluid or correction tape on a plan of care is not permitted. (F) Face-to-face Encounter Requirements. (1) A face-to-face encounter between the member and an authorized practitioner is required for initial orders for CSN agency services. A face-to-face encounter is not required when the plan of care is reviewed and revised as required at 130 CMR 438.416(C) or at resumption of CSN agency services. (2) Authorized practitioners include (a) the ordering physician. In order to be an ordering physician, the physician must be enrolled in MassHealth; (b) the physician who cared for the member in an acute or post-acute care facility (acute/post-acute care attending physician) from which the member was directly admitted to the CSN agency; or (c) certain authorized non-physician practitioners, which include one of the following in a CSN agency context: 1. an ordering non-physician practitioner; or 2. a certified nurse midwife. (3) Documenting the Face-to-face Encounter in the Member’s Record. (a) The face-to-face encounter must be documented in the member’s record either on the plan of care or in other medical notes sufficient to make the link between the individual’s health conditions, the services ordered, an appropriate face-to-face encounter, and actual service provision. (b) The ordering or acute/post-acute care attending physician or ordering non-physician practitioner may serve as the physician writing the plan of care. When the acute/post- acute care attending physician or ordering non-physician practitioner writes the plan of care, such attending practitioners must document that the face-to-face encounter is related to the primary reason the patient requires CSN agency services and that the encounter with an authorized practitioner occurred within the required timeframes. The plan of care or the medical notes must include which authorized practitioner conducted the encounter and the date of the encounter. (c) If the face-to-face encounter was not provided by the ordering physician or ordering non-physician practitioner, the authorized practitioner who did conduct the face-to-face encounter is required to communicate the clinical findings of the face-to-face encounter to the ordering physician or ordering non-physician practitioner. This requirement is necessary to ensure that the ordering physician or ordering non-physician practitioner has sufficient information to determine the need for CSN agency services in the absence of conducting the face-to-face encounter himself or herself. (d) The CSN agency must maintain a copy of the face-to-face documentation. (G) MassHealth Members Enrolled in the Primary Care Clinician (PCC) Plan. If a member is enrolled in the PCC Plan, the CSN agency must provide the PCC with a copy of the member’s plan of care for each certification period.