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-2 - Adult Family Care Services › Subsection 144-101-II-2.07 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
2.07-1
Assessments for Service Planning
A.
Assessment
: Providers shall
					 conduct an assessment, with the Department's assessment tool to determine each
					 member's level of functioning and general health status, regardless of
					 eligibility or source of payment. The results of the assessment shall be the
					 basis for the development of the individual service plan described in Section
					 2.07-2. Providers must submit a copy of the completed assessment to the
					 Department's authorized representative within 14 days of the assessment. A copy
					 must be maintained in the member's record.
1.
					 A person trained in the use of the MDS-ALS must conduct the initial assessment
					 within 30 days of admission. Providers must use the Department-approved tool
					 (MDS-ALS) according to the instructions in the training manual for the MDS-ALS
					 tool.
2. The member, or his or her
					 legally responsible representative, will provide input into and be an integral
					 part of the assessment process. The member's family or significant other also
					 may be involved, unless such involvement is not feasible or contrary to the
					 wishes of the member or legally responsible representative.
3.
Re-assessments
. After the
					 initial assessment, the member shall receive an assessment using MDS-ALS at
					 least once every six months, or sooner in the event of a significant change,
					 either an improvement or decline, in his or her functional status. The provider
					 must revise the service plan based upon the needs identified at the
					 re-assessment. Providers shall submit a copy of the completed assessment to the
					 Department's agent within 14 days of the assessment. The assessments will be
					 sequenced from the date in Section S.2.B. of the MDS-ALS, assessment completion
					 date. Providers must complete subsequent assessments within 180 days from the
					 date in S.2.B. Providers must complete significant change assessments within 14
					 days after determination is made of a significant change in resident status as
					 defined in the training manual for the MDS-ALS tool. Providers must complete a
					 resident tracking form within 7 days of the discharge, transfer or death. The
					 provider must maintain all completed assessments within the previous 12 months
					 in the member's active record.
4.
Accuracy of Assessments
The accuracy of the MDS-ALS will affect coverage of
						services outlined in individual service plans as well as payment to the
						provider. The Department will aggregate results of the assessment to give the
						provider feedback on critical quality indicators. Therefore, the following
						requirements must be met:
a. Only
					 staff trained in completion of the MDS-ALS by the Department may conduct or
					 coordinate assessments.
b. Each
					 individual who completes a portion of the assessment must sign and date the
					 form to certify the accuracy of that portion of the assessment.
c. The Department requires documentation to
					 support the time periods and information coded on the MDS-ALS.
d. The Department may sanction a provider
					 whenever the provider willfully and/or knowingly certifies (or causes another
					 individual to certify) a material and false statement in an assessment. This
					 may be in addition to any other penalties provided by statute, including but
					 not limited to, 22 M.R.S.A. §15.
e. The Department has the right to review all
					 forms, documentation and evidence used for completion of the MDS-ALS at any
					 time. The Department will undertake quality review periodically to ensure that
					 assessments are completed accurately, correctly, and on a timely
					 basis.
f. Facilities shall submit
					 completed assessments to include admissions, semi-annuals, annuals, significant
					 change, and other required assessments and MDS-ALS tracking forms within 30
					 days of completion to the Department of its designated agent.
5.
Quality Review of the
					 MDS-ALS process: Definitions
The Department conducts MDS-ALS assessment reviews. The
						process includes a review of assessments, documentation and evidence used in
						completion of the assessments, in accordance with this Section to ensure that
						assessments accurately reflect the member's characteristics and
						condition.
Assessment review error rate
is the
						percentage of unverified resource-adjusted price group records in the drawn
						sample. The Department will draw samples from resource-adjusted group records
						completed for MaineCare members.
A
verified resource-adjusted group record
is an MDS-ALS assessment form completed by the provider that has been
						determined to accurately represent the member's characteristics during the
						MDS-ALS assessment review process. Verification activities include reviewing
						assessment forms and supporting documentation, conducting interviews and
						observing members.
An
unverified resource-adjusted group
						record
is one that cannot be verified for payment purposes, since the
						Department has determined it may not accurately represent the member's
						characteristics and condition and, therefore, may result in an inaccurate
						classification of the member into a resource-adjusted grouping that increases
						the MaineCare weight assigned to the member.
An
unverified MDS-ALS record
is one that
						does not accurately reflect the member's condition.
6.
Criteria for Quality Review
The Department will select providers for an MDS-ALS
						quality review based upon but not limited to any of the following:
a. The findings of a licensing survey
					 conducted by the Department indicating that the provider is not accurately
					 assessing persons receiving assisted living services;
b. An analysis of a provider's resident
					 resource group profile indicating changes in the frequency distribution of
					 members in the major categories or a change in the average resource adjusted
					 groupings; or
c. Performance of the
					 provider, including but not limited to, on-going problems with assessment
					 completion and timeliness, untimely submissions and high assessment error
					 rates.
7.
Quality
					 Review Process
a. Department staff or
					 designated agent(s) shall conduct reviews.
b. Providers selected for review must
					 coordinate access to members, and provide access to professional and direct
					 care staff, the provider assessors, member records, and completed assessment
					 tools, as well as documentation regarding the member's service needs and
					 services delivered.
c. The
					 Department shall draw samples from MDS-ALS assessments completed for MaineCare
					 members.
d. At the conclusion of
					 the on-site portion of the review process, the reviewers shall hold an exit
					 conference with provider representatives. Reviewers will share written findings
					 for reviewed records. The reviewer may also request reassessment of members
					 where assessments are in error.
8.
Sanctions
The Department will sanction providers who fail to
						accurately complete assessments in a timely manner. Effective July 1, 2004,
						when a sanctionable event occurs, the Department shall base the sanctions on
						the total MaineCare payment to the provider from the
						4th through the 6th
						months preceding the month in which the sanctionable event occurred. (For
						example, if the sanctionable event occurred in July, the sanction would be
						calculated by multiplying the sanction rate times the total MaineCare payments
						to the provider during the preceding January, February and March.) The amount
						of the sanction will be based on an application of the percentages below
						multiplied by the MaineCare payments to the provider during the
						4th through 6th months
						preceding the event. In no event will the payment to the provider be less than
						the price that would have been paid with an average resource-adjusted price
						equal to 0.551. The Department will calculate sanctions as follows:
a. 2% of MaineCare payments when the
					 assessment review results in an error rate of 34% or greater, but is less than
					 37%;
b. 5% of MaineCare payments
					 when the assessment review results in an error rate of 37% or greater, but is
					 less than 41%;
c. 7% of MaineCare
					 payments when the assessment review results in an error rate of 41% or greater,
					 but is less than 45%;
d. 10% of
					 MaineCare payments when the assessment review results in an error rate of 45%
					 or greater; or
e. 10% of MaineCare
					 payments if the provider fails to complete reassessments within 7 days of a
					 written notice/request by the Department.