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-102 - Rehabilitative Services › Appendix 144-101-II-102-I

Current through 2024-29, July 17, 2024
PROVISIONAL ACCREDITATION PROCESS
The purpose of this Appendix is to describe the initial
						eighteen (18) month approval process for providers who are not ready to undergo
						the Rehabilitation Accreditation Commission (CARF) survey and certification and
						are requesting MaineCare reimbursement under this Section. The initial approval
						process is intended to assure the Maine Department of Health and Human Services
						that the applicant agency has a thorough understanding of the requirements of
						this Section, has sufficient clinical and administrative capability to carry
						out the intent of this Section, and has taken steps to assure the safety,
						quality, and accessibility of the service.
The Department will administer the initial approval
						process.
Step #1 - Identification of Provider and
						Verification of the Provider's Intent to Undergo the Provisional Accreditation
						Process
A. The director or administrator of the applicant agency
						must contact the Department to request the initiation of the process. The
						applicant agency's request must be accompanied by the following information:
1. Name of the agency (and the legal entity sponsoring
						the facility if different);
2. Address of the agency;
3. Name of agency contact person;
4. Telephone number of agency contact person; and
5. Estimated number of individuals to be served (service
						capacity).
B. The Department will start the review process. A
						representative of the Department will contact the agency within ten (10)
						working days of receipt of the identification information in order to:
1. Identify the Department's representative assigned to
						carry out the review process;
2. Provide clarification regarding the process;
						and
3. Request written information to use in the document
						review phase of the process.
Step #2 - Document Review
This part of the process must be initiated at least
						thirty (30) days prior to the date when the agency proposes to provide services
						for MaineCare reimbursement under this Section. If the agency satisfies the
						requirements of this review, the Department will provisionally certify the
						agency for ninety (90) days from the first date of service for which MaineCare
						reimbursement is requested. In order to continue certification beyond this
						period, the agency must (during the ninety (90) day period) have undergone the
						on-site survey described in Step #3 of this Appendix and been granted continued
						approved status as a result of that review.
The following requirements must be satisfied to gain
						ninety (90) day provisional certification. Additionally, the provider must show
						it will be in compliance with the MaineCare Benefits Manual
						requirements.
A. Compliance with applicable legal requirements and
						regulations of all governmental and legally authorized agencies under whose
						authority the agency operates. These include, but are not limited to, those
						regulations regarding equal employment opportunity, state and federal wage hour
						regulations, health and safety codes, and affirmative action. The applicant
						must submit documents demonstrating compliance with such regulations.
B. Provision of documents providing the legal basis for
						the organization and identifying the members of the governing body or, in the
						case of a proprietary organization, the designated authority. The documents
						must identify the chief executive of the organization.
C. Provision of by-laws, or other applicable
						documentation, describing and governing the purpose, scope and activities of
						the organization.
D. A narrative history of the organization, which
						provides a brief history of the agency's activities.
E. A description of the agency's services, with
						particular attention to those governed by Section 102 of the MBM. Service
						descriptions must include the purpose of each service and be written so as to
						govern the direction and character of each service.
F. The agency's criteria for admission/entrance to the
						service being reviewed.
G. Policies and procedures that address activities
						associated with member intake, assessment, individual planning, case
						coordination, and record keeping.
H. The agency's actual or projected staffing plan. This
						plan must identify staff providing covered services. There must be clear
						indication of which staff are actually employed by the agency at the time of
						Document Review.
I. Qualifications of all staff, consultants, independent
						contractors, trainees/interns, and volunteers.
J. Policies that address member rights and preserve
						confidentiality. These policies must meet the requirements of Chapter I of the
						MaineCare Benefits Manual.
K. Policies and procedures regarding quality
						assurance.
L. Proof of liability insurance covering the services
						reimbursed under this Section.
Within thirty (30) days of receipt of all information
						required by Step #2, the Department will issue a decision regarding the
						findings of the Document Review to the agency and to the Office of MaineCare
						Services. The finding will document all areas found to be non-compliant with
						the requirements of Step #2 and will stipulate corrective action, which must be
						accomplished to obtain 90-day provisional certification.
The agency must request an application for MaineCare
						enrollment from Provider File at the Office of MaineCare Services. Provider
						File will then process the agency application in order to begin MaineCare
						reimbursement after receiving the ninety (90) day provisional
						certification.
Step #3 - On-Site Review
Within ninety (90) days of the first date of service
						provided under this Section, the agency must have undergone an On-Site
						Review.
It will be the responsibility of the applicant agency to
						contact the Department's representative who conducted the Document Review to
						arrange for the On-Site Review. The agency must request the On-Site Review at
						least thirty (30) days prior to the requested date of the Review.
The On-Site Review Team will consist of at least two (2)
						representatives of the Department of Health and Human Services. The team may
						also include a licensed practitioner of the medical profession with expertise
						in the area of brain injury rehabilitation. In the event the Department
						requires such a clinician as a member of the review team the costs of the
						clinician's services must be reimbursed by the agency being reviewed.
The On-Site Review will be scheduled for up to four (4)
						days. The reviewers will, through the inspection of the agency documents,
						interviews and observation, determine the extent to which the agency is in
						compliance with the policies and procedures previously submitted by the agency
						as well as the agency's compliance with all requirements of this Section of the
						MaineCare Benefits Manual. Particular attention will be given to items
						identified as requiring correction in the Document Review report.
The following represents the On-Site Review Team
						activities:
1. Orientation Session. The On-Site Review Team meets
						with agency staff and representatives of the governing body to clarify the
						purpose of the survey and explain each team member's role in the review. This
						is an opportunity for agency staff and representatives to ask questions about
						the process and provide files and records necessary to carry out the review. At
						this time the review team must be assigned a secure work space (where
						confidential material can be safely stored) and a separate area where
						interviews can be held. Staff interviews shall be arranged at this time.
2. A tour of the physical plant.
3. Record reviews, interviews with staff, board members,
						members, family members, representatives, or others, and program observation.
						The agency must post signs on a readily viewed area that the review is being
						performed and reviewers are available to meet with members in private, if
						requested.
4. On-Site Review Team meeting to coordinate findings and
						clarify questions requiring more attention.
5. Information gathering.
6. Exit interview with representatives of administration,
						the governing body, and staff. This is the agency's opportunity to question
						interpretations or findings of the Review Team. Any member or legal guardian
						who requests to attend the exit interview shall be allowed to do so.
The On-Site Review Team will write a report of its
						findings, including strengths and areas requiring improvement. The report will
						make recommendations regarding the continuation of provisional certification as
						well as listing corrective action the Team deems necessary. The report will be
						submitted to the Director of the Office of MaineCare Services and to Provider
						File at the Office of MaineCare Services within twenty (20) days of the
						completion of the On-Site Review. A copy of the report will be sent to the
						contact person at the applicant agency.
The Department will notify the agency of the decision
						regarding continuation or revocation of the agency's provisional certification
						status within ten (10) days of the receipt of the On-Site Review Team report.
						Agencies that fail to substantially meet the requirements outlined in Step #3
						will have their provisional certification revoked. In the event of revocation,
						the Office of MaineCare Services will stop MaineCare reimbursement as of the
						date of revocation. Any agency that is denied the continuation of provisional
						certification may appeal this decision. The appeal process is defined in
						Chapter I of the MaineCare Benefits Manual.
All three (3) steps defined in this Appendix must be
						completed in order for the agency to receive the eighteen (18) month
						provisional certification.
The provisional certification will be awarded one time
						only, for a total of eighteen (18) months from the first date of service,
						including the ninety (90) day certification defined in Step #2 of this
						Appendix.
Complaints made to the Department regarding an agency
						that has a provisional certification or is in the process of receiving a
						provisional certification will be investigated. The Department must determine
						the validity of the complaint and must withdraw the provisional certification
						or discontinue the process of reviewing the agency for provisional
						certification; whichever is appropriate, if the Department determines that the
						health or safety of a member receiving services is in jeopardy.
In the event that the Department determines the
						applicant is out of compliance with the requirements of any applicable policy,
						or when non-compliant items represent a threat to the health, safety, or rights
						of members to be served under this policy, the Department must refuse or
						withdraw provisional certification to the applicant. In the event the
						provisional certification is refused or withdrawn, the Department's decision
						may be appealed. Requests for hearings must be made, in writing, within ten
						(10) days of agency notification of an adverse decision. The appeal process is
						defined in Chapter I of the MaineCare Benefits Manual.
Each eligible program is allowed one eighteen (18) month
						provisional certification only. CARF accreditation must be obtained by the end
						of the eighteen (18) month provisional certification, or MaineCare will stop
						reimbursement until CARF accreditation is obtained.
If the application for CARF accreditation has been
						submitted and a review is scheduled, one three (3) month extension of the
						provisional certification will be granted by the Department.