Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.505 - Scope of Group Adult Foster Care Services

Current through Register 1525, July 5, 2024
(A)
Direct Care
. Direct care includes daily assistance
			 with ADLs and IADLs as defined in
			 130
			 CMR 408.502. The GAFC provider must ensure
			 the delivery of direct care to members by a qualified GAFC direct care aide, as
			 described in
			 130
			 CMR 408.524(C), who is
			 supervised by the GAFC provider. GAFC must be ordered by a PCP and delivered by
			 a qualified GAFC direct care aide under the supervision of the registered nurse
			 and the MDT in accordance with each member's written plan of care. Direct care
			 includes daily assistance with ADLs and IADLs as defined in
			 130
			 CMR 408.502.
(B)
Nursing
			 Oversight
. The GAFC provider must provide nursing oversight by a
			 registered nurse or licensed practical nurse under the supervision of a
			 registered nurse who meets the qualifications as described in
			 130
			 CMR 408.524(B)(2)(a) and
			 130
			 CMR 408.524(D)(1), who is
			 not related to the member, and who is licensed in Massachusetts. Nursing
			 oversight services must be individualized to meet the needs of each member in
			 accordance with the member's GAFC plan of care and must include all of the
			 following activities:
(1) completing or
			 coordinating all applicable clinical assessments and clinical evaluations,
			 provided that a licensed practical nurse may complete clinical assessments and
			 evaluations only under the supervision of a registered nurse;
(2) developing the member's interim and final
			 GAFC plan of care with input from the member or responsible party, all members
			 of the MDT, and other individuals designated by the member;
(3) completing a semi-annual health status
			 report for each member;
(4)
			 ensuring implementation of the GAFC plan of care;
(5) coordinating the delivery of GAFC with
			 any other health services or supportive services the member is receiving from
			 MassHealth or other agencies or organizations including, but not limited to,
			 visiting nurse services, therapy services, Department of Developmental Services
			 (DDS), Department of Mental Health (DMH) services, Executive Office of Elder
			 Affairs, and Massachusetts Rehabilitation Commission (MRC) services;
(6) conducting on-site visits with each
			 member at the member's home every other month or more often as the member's
			 condition warrants, where such visits alternate with the required visits by the
			 care manager to ensure the member receives one visit by the nurse or care
			 manager every month;
(7) completing
			 a nursing progress note for each on-site visit or encounter and upon
			 significant change;
(8) monitoring
			 each member's health status and documenting those findings in the member's
			 medical record for each on-site visit or encounter, or more often as the
			 member's condition warrants;
(9)
			 educating the member about hygiene and health concerns;
(10) reporting changes in the member's
			 condition to the member's PCP;
(11)
			 coordinating and implementing the PCP form and approval for GAFC with the
			 member and GAFC provider personnel;
(12) developing, in conjunction with the MDT,
			 the GAFC direct care aide, and the member or responsible party, an emergency
			 backup and personal care contingency plan for each member receiving GAFC that
			 includes an alternative plan for the member if the GAFC provider is temporarily
			 unable to provide care; and
(13)
			 overseeing, monitoring, supporting, training, and evaluating GAFC direct care
			 aides.