Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-97 - Private Non-Medical Institution Services › Subsection 144-101-II-97.08 - GENERAL DESCRIPTION OF THE FACILITY'S CLINICAL SERVICES

Current through 2024-29, July 17, 2024
Requirements identified in this Section shall be the
						responsibility of direct care staff. Direct care services include supervisory
						and training activities necessary to accomplish the provisions described in
						this Section. It also includes personal supervision or being aware of members'
						general whereabouts, observing or monitoring members to ensure their health and
						safety, assisting with or reminding members to carry out activities of daily
						living, and assisting members in adjusting to the facility and
						community.
97.08-1
Substance Use
					 Treatment PNMIs - Medical and Clinical Requirements
A.
Medical and Clinical
					 Responsibility
Clinical responsibility for implementation of each
						member's overall specific treatment plan shall rest with a treatment team,
						which shall be chosen from the qualified professional staff as defined in
						Section 2400 of the pertinent Chapter III, Principles of Reimbursement.
All services must be provided pursuant to a written
						service plan based upon an individual assessment made in accordance with the
						Regulations for Licensing/Certifying Substance Use Treatment Programs in the
						State of Maine.
Service plans must be reviewed and signed by a physician,
						psychiatrist, psychologist, social worker, licensed clinical professional
						counselor, registered nurse or licensed alcohol and drug counselor as defined
						in Chapter II, Section 97.07-2. Such qualified professional staff shall be
						responsible for the provision of direct services to members, and for direct
						supervision of all other staff in the implementation of the service plan
						through the various elements of the comprehensive treatment described in this
						Section. The qualified professional staff shall ensure that a full range of
						formal treatment services is provided to each member in conjunction with the
						structured set of activities routinely provided by the PNMI and in accordance
						with the individual member's needs. The range of formal treatment services
						provided tomembers by the PNMI shall aid the member, through non hospital based
						detoxification, type I residential rehabilitation, type II residential
						rehabilitation, halfway house services, extended care, adolescent residential
						rehabilitation, or personal care substance use services (shelter based), toward
						the primary goal of recovery for the chemically dependent person.
PNMI staff shall assess members for unmet mental health
						needs and complement the substance use plan of care with appropriate referrals
						for mental health care.
B.
Personal Care Services
PNMIs approved and funded by Office of Behavioral Health
						in licensed facilities must also provide necessary personal care services for
						the promotion of ongoing treatment and recovery. MaineCare does not cover
						personal care services provided by a family member.
Personal care services shall be prescribed by a
						physician, provided by qualified staff, and will occur in the substance use
						treatment PNMI where the member receiving services resides.
Personal care services shall consist of, but are not
						limited to, the following
- Assistance or supervision of activities of daily
						living that include bathing, dressing, eating, toileting, ambulation, personal
						hygiene activities, grooming, and the performance of incidental household tasks
						essential to the activities of daily living and to the maintenance of the
						member's health and safety within the substance use treatment PNMI;
- Supervision of or assistance with administration of
						physician-ordered medication;
- Personal supervision or being aware of the member's
						general whereabouts, observing or monitoring the member while on the premises
						to ensure their health and safety, reminding the member to carry out activities
						of daily living, and assisting the member to carry out activities of daily
						living, and assisting the member in adjusting to the group living
						facility;
- Arranging transportation and making phone calls for
						medical or treatment appointments as recommended by medical providers, or as
						indicated in the member's plan of care;
- Observing and monitoring member's behavior and
						reporting changes in the member's normal appearance, behavior, or state of
						health to medical providers or supervisory personnel as appropriate;
- Arranging or providing motivational, diversionary, and
						behavioral activities that focus on social interaction to reduce isolation or
						withdrawal and to enhance communication and social skills necessary for ongoing
						treatment and recovery, as described in the member's plan of care;
- Monitoring and supervising member's participation in
						the treatment; and
- Psychosocial treatment including assisting members to
						adjust to the substance use treatment PNMI, to live as independently as
						possible, to cope with personal problems during periods of stress, to accept
						and adjust to their personal life situations, to accept and cope with their
						chemical addictions and to decrease unhealthy behaviors leading to possible
						relapse into active addiction, in addition to providing services and a
						supportive environment which promotes feelings of safety and freedom from
						danger, fear or anxiety.
C.
Non Hospital-based Detoxification
MaineCare limits non hospital-based detoxification
						services to seven (7) days for each admission episode, with no limit on the
						number of admissions or covered days on an annual basis. The facility may
						provide detoxification services for a longer period if medical necessity is
						substantiated and ordered by the medical director, and documented in the
						member's clinical file by the facility's designated medical staff.
Detoxification services provide immediate diagnosis and
						care to members having acute physical problems related to substance use.
						Providers of detoxification services shall make and maintain arrangements with
						external clinicians and facilities for referral of the member for specialized
						services beyond the capability of the PNMI.
Each member shall receive a complete physical
						examination by a physician within forty-eight (48) hours of admission and the
						results shall be entered in the member's record. Admissions resulting from a
						direct physician referral by telephone may be sufficient to meet this
						requirement so long as the orders are taken by an RN or an LPN who has been
						trained to take telephone orders. The referring physician shall sign these
						orders within forty-eight (48) hours.
PNMIs shall provide medical evaluation and diagnosis
						upon intake. Designated areas suitable (1) for the provision of general medical
						services, and (2) to control and administer drugs prescribed by the PNMI's
						legally qualified staff, shall be maintained by the PNMI so as to assure the
						appropriate treatment of physical illness and maintenance of good general
						health among members. The member shall receive continuing medical supervision
						under the direction of a physician while in the PNMI that shall be documented
						in the member's case record. The PNMI shall establish procedures for the prompt
						detection and treatment of physical health problems through surveillance,
						periodic appraisals and physical examinations.
The PNMI's qualified staff shall teach attitudes, skills,
						and habits conducive to good health and enabling the member to sustain a
						substance free lifestyle. The treatment mode may vary with the member's needs
						and may be in the form of individual, group or family counseling.
The PNMI shall maintain a medical staffing pattern, which
						enables it to meet the physical care requirements delineated above. The PNMI
						shall provide for twenty-four (24) hour, on-premises medical coverage by a
						registered nurse or licensed practical nurse who is experienced in the disease
						process of chemical dependency. Physician back up and on-call staff shall be
						provided to deal with medical emergencies.
D.
Residential Rehabilitation Type
					 I
MaineCare limits residential rehabilitation type I to
						thirty (30) days for any single admission, with a limit of two (2) admissions
						and thirty (30) covered days on an annual basis per member. These limits allow
						some clinical flexibility should additional treatment be required, or should a
						member drop out very early in treatment and are admitted at a later
						date.
Any continuous stay in excess of twenty-eight (28) days
						requires documented need in the member's treatment plan.
Residential rehabilitation shall provide scheduled
						therapeutic treatment consisting of diagnostic and counseling services designed
						to enable the member to develop a substance free lifestyle.
Each member shall receive a complete physical examination
						by a physician within seventy-two (72) hours of admission and the results shall
						be entered in the member's record. Admissions resulting from a direct physician
						referral by telephone may be sufficient to meet this requirement so long as the
						orders are taken by an RN or an LPN who has been trained to take telephone
						orders. The referring physician shall sign these orders within forty-eight (48)
						hours.
PNMIs shall provide medical evaluation upon intake and
						laboratory examinations as deemed appropriate by the physician as soon as
						practicable after admission. The PNMI shall establish procedures for the prompt
						detection and treatment of physical health problems through surveillance,
						periodic appraisals, and physical examinations. Arrangements with external
						clinicians and facilities for referral of the member for specialized services
						beyond the capability of the PNMI shall be made and maintained by the
						PNMI.
The PNMI's qualified staff shall teach attitudes, skills,
						and habits conducive to good health and the maintenance of a substance free
						lifestyle. The treatment mode may vary with the member's needs and may be in
						the form of individual, group or family counseling at a minimum of ten (10)
						hours per week.
The PNMI shall maintain a medical staffing pattern, which
						enables it to meet the physical care requirements delineated above. The PNMI
						shall provide for twenty-four (24)-hour staff coverage. Physician back-up and
						on-call staff shall be provided to deal with medical emergencies. The PNMI
						shall not subcontract any of its obligations and rights pertaining to medical
						services described in this Section. For the purposes of this Section, physician
						consultant services are not considered subcontracting.
E.
Adolescent Residential
					 Rehabilitation Services
Adolescent residential rehabilitation PNMIs provide the
						opportunity for recovery through modalities, which emphasize personal growth
						through family and group support and interaction. The PNMI's qualified staff
						shall teach attitudes, skills, and habits, conducive to facilitating the
						member's transition back to the family and community. Adolescent residential
						rehabilitation PNMIs are designed to last at least three (3) months and are
						limited to twelve (12) months per single admission.
MaineCare does not cover in-house, accredited,
						individualized schooling, weekly vocational exploration groups, and structured
						recreational activities.
Services must include but are not limited to:
- Medical evaluation;
- Physical examination within seventy-two (72) hours
						following admission or no more than thirty (30) days prior to admission, and
						laboratory examinations as appropriate and as soon as practicable after the
						member's admission;
- Individual and group counseling at a minimum of ten
						(10) hours per week for each member;
- Arrangements for needed health care services;
						and
- Planning for and referral to further treatment.
The PNMI shall document that all persons providing
						services are legally qualified through licensure, certification, and/or
						registration as required to provide the service. PNMIs shall have qualified (as
						described in Section 2400 of these principles) staff coverage twenty-four (24)
						hours a day, including weekend coverage and shall include weekly clinical
						supervision to the staff to ensure the well-being of the members and to provide
						for the growth and development of the staff.
The PNMI shall not subcontract any of its obligations and
						rights pertaining to medical services described in this Section. For the
						purposes of this Section, physician consultant services are not considered
						subcontracting.
F.
Halfway House Services
MaineCare limits halfway house services to a single
						admission of one hundred eighty (180) covered days on an annual basis per
						member. Any stay in excess of one hundred eighty (180) days requires documented
						need in the member's service plan.
A halfway house shall provide scheduled therapeutic and
						rehabilitative treatment consisting of transitional services designed to enable
						the member to sustain a substance free lifestyle in an unsupervised community
						living situation.
Counseling staff of the PNMI shall perform an assessment
						of the member's medical and social/psychological needs, as required by the
						Office of Behavioral Health, within five (5) days of admission unless the
						member can show evidence of such examination within the last thirty (30) days.
						Such assessment may be completed prior to admission by the substance use
						treatment facility referring the member. This assessment may additionally
						include, but not be limited to an examination for contagious or infectious
						disease, determination of the status of chronic physical disease and
						examination of nutritional deficiencies. Arrangements with external clinicians
						and facilities for referral of the member for specialized services beyond the
						capability of the PNMI shall be made and maintained by the PNMI.
The PNMI's qualified staff shall teach attitudes,
						skills, and habits conducive to facilitating the member's transition back to
						the community. The treatment mode may vary with the member's needs and may be
						in the form of individual, group or family counseling.
The PNMI shall have a written agreement with an
						ambulance service to assure twenty-four (24)-hour access to transportation to
						emergency medical care facilities for members requiring such transport.
						Physician back-up and on-call staff shall be provided to deal with medical
						emergencies.
The PNMI shall not subcontract any of its obligations and
						rights pertaining to medical services described in this Section, with the
						exception of physician consultant services.
G.
Extended Care Services
MaineCare limits extended care services to a single
						admission of two hundred seventy (270) covered days on an annual basis per
						member. Any stay in excess of two hundred seventy (270) days requires
						documented need in the member's treatment plan.
Extended care services shall provide scheduled
						therapeutic plan consisting of treatment services designed to enable the member
						to sustain a substance free lifestyle within a supportive environment.
Each member shall receive a complete physical
						examination by a physician within seventy-two (72) hours of admission and the
						results shall be entered in the member's record. Physical examinations
						performed more than thirty (30) days before admission are not acceptable. If
						the member's admission was based on the results of a physical examination
						performed thirty (30) or fewer days before admission, the PNMI's physician must
						approve the prior examination or re-examine the member within forty-eight (48)
						hours after admission.
PNMIs shall provide medical evaluation upon intake and
						laboratory examinations as deemed appropriate by the physician as soon as
						practicable after admission. The PNMI shall establish procedures for the prompt
						detection and treatment of physical health problems through surveillance,
						periodic appraisals, and physical examinations. The PNMI is responsible for
						referring the member to external clinicians and facilities for specialized
						services beyond the capability of the PNMI.
The PNMI's qualified staff shall teach attitudes,
						skills, and habits conducive to facilitating the member's transition back to
						the community. The treatment mode may vary with the member's needs and may be
						in the form of individual, group or family counseling.
The PNMI shall have a written agreement with an ambulance
						service to assure twenty-four (24)-hour access to transportation to emergency
						medical care facilities for members requiring such transport. Physician back-up
						and on-call staff shall be provided to deal with medical emergencies.
The PNMI shall not subcontract any of its obligations
						and rights pertaining to medical services described in this Section, with the
						exception of physician consultant services.
H.
Residential Rehabilitation Type
					 II
Residential Rehabilitation Type II will provide a
						structured therapeutic environment for members who are on a waiting list for
						treatment, or who have either completed detoxification treatment, or are
						otherwise not in need of detoxification services. The primary objectives of
						Residential Rehabilitation Type II are; to stabilize the substance user in
						order to provide continuity of treatment, to enable the member to develop an
						appropriate supportive environment, to remain substance free and to develop
						linkages with community services.
The term of residency shall not exceed forty-five (45)
						days. The PNMI shall provide a daily structured sequence of individual and/or
						group counseling for the treatment of substance use provided by qualified staff
						members (listed in Section 2400 of the pertinent Chapter III, Principles).
						MaineCare does not cover other educational and vocational counseling required
						by the Office of Behavioral Health Regulations for Extended Care
						Shelters.
Services provided will depend upon the therapeutic needs
						of individual members and must include but are not limited to:
- Evaluation of the member's medical and psychosocial
						needs;
- A medical examination by a physician within five (5)
						days of admission unless the member can show evidence of such examination
						within the last thirty (30) days;
- Opportunities for learning basic living skills, such
						as personal hygiene skills, knowledge of proper diet and meal preparation,
						constructive use of leisure time, money management and interpersonal
						relationship skills, all of which are considered non-covered services by
						MaineCare;
- Clinical services, including individual and group
						counseling; and
- Opportunity for family involvement.
The PNMI shall have twenty-four (24)-hour coverage by
						on-site trained staff (as required by Office of Behavioral Health) and include
						weekend coverage.
Each PNMI shall provide at least one (1) hour per week
						of professional consultation to the clinical staff to ensure the wellbeing of
						the members and to provide for the growth and development of the staff. This
						consultation may be either on a group or individual basis.
The PNMI shall assure the availability of a
						transportation support system twenty-four (24)-hours a day, and shall maintain
						a written agreement for the provision of transportation between the facility
						and emergency care facilities.