Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.415 - Scope of Adult Foster Care Services

Current through Register 1525, July 5, 2024
(A)
Direct Care
. The AFC provider must ensure the delivery
			 of direct care to members in a qualified setting, as described in
			 130
			 CMR 408.435, by a qualified AFC caregiver, as
			 described in
			 130
			 CMR 408.434, who lives in the residence and
			 paid by the AFC provider. AFC must be ordered by a PCP and delivered by a
			 qualified AFC caregiver under the oversight of the registered nurse and the MDT
			 in accordance with each member's written plan of care. Direct care includes
			 24-hour supervision, and daily assistance with ADLs and IADLs as defined in
			 130
			 CMR 408.402.
(B)
Nursing
			 Oversight
. The AFC 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 in130 CMR
			 408.433(C)(2)(a) and
			 130
			 CMR 408.433(E)(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 AFC plan of care and must include all of the
			 following activities:
(1) completing or
			 coordinating all applicable clinical assessments and clinical evaluations,
			 provided that only a registered nurse can complete such assessments and
			 evaluations;
(2) developing the
			 member's interim and final AFC 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 AFC plan
			 of care;
(5) coordinating the
			 delivery of AFC 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) services, Department of Mental
			 Health (DMH) services, and Massachusetts Rehabilitation Commission (MRC)
			 services;
(6) conducting on-site
			 visits with each member at the qualified setting:
(a) for members authorized for AFC level I
			 service payment, the nurse must conduct on-site visits every other month, or
			 more often as the member's condition warrant 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, as determined by the MDT in
			 accordance with
			 130
			 CMR 408.433(B), a community
			 support specialist may conduct up to three non-consecutive on-site visits per
			 12-month period in place of the nurse; and
(b) for AFC level II service payment, the
			 nurse must conduct on-site visits every month, or more often as the member's
			 condition warrants, to ensure the member receives one visit by the nurse and
			 one visit by the care manager every month, if determined appropriate by the MDT
			 in accordance with
			 130
			 CMR 408.433(B), a community
			 support specialist may conduct up to six non-consecutive on-site visits per
			 12-month period in place of the nurse;
(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 AFC with the member, AFC caregiver, and AFC provider
			 personnel;
(12) developing, in
			 conjunction with the MDT the AFC caregiver, and the member or responsible
			 party, an emergency backup and personal care contingency plan for each member
			 receiving AFC that includes an alternative plan for the member if the AFC
			 caregiver is temporarily unable to provide care; and
(13) overseeing, monitoring, supporting,
			 training, and evaluating AFC caregivers.