419.402 - Definitions

419.402. Definitions

The following terms used in 130 CMR 419.000 have the meanings given in 130 CMR 419.402 unless the context clearly requires a different meaning.

Activities of Daily Living (ADLs) - fundamental personal care tasks performed daily as part of an individual's routine self-care. ADLs include, but are not limited to, eating, toileting, dressing, bathing, transferring, and mobility or ambulation.

Clinical Assessment - the screening process of cataloging a member's need for DH using a tool designated by the MassHealth agency and that forms the basis for prior authorization.

Day Habilitation (DH) - a service, for individuals with an intellectual disability (ID) or a developmental disability (DD), that is based on a day habilitation service plan that sets forth measurable goals and objectives, and prescribes an integrated program of activities and therapies necessary to reach the stated goals and objectives.

Day Habilitation Provider (DH Provider) - the entity with responsibility for the day-to-day operation of facilities and programs subject to 130 CMR 419.000.

Day Habilitation Service Plan (DHSP) - a written plan of care for each member that sets forth realistic and measurable behaviorally based goals that prescribe an integrated program of individually designed activities and/or therapies necessary to achieve these goals. The objective of the plan is to help the member reach his or her optimal level of physical, cognitive, psychosocial, occupational capabilities, and wellness.

Department of Developmental Services (DDS) - an agency of the Commonwealth of Massachusetts established under M.G.L. c. 19B.

Department of Public Health (DPH) - an agency of the Commonwealth of Massachusetts, established under M.G.L. c. 17, ยง 1.

Developmental Disability - a severe, chronic disability that

(1) is attributable to other conditions found to be closely related to ID, apart from mental illness, which results in the impairment of general intellectual functioning or adaptive behavior similar to that of persons with ID, and which requires treatment or services similar to those required for such persons;

(2) is manifested before a person reaches 22 years of age;

(3) is likely to continue indefinitely; and

(4) results in substantial functional limitations in three or more of the following major areas:

(a) self-care;

(b) understanding and use of language;

(c) learning;

(d) mobility;

(e) self-direction; or

(f) capacity for independent living.

Developmental Skills Training - a series of planned, coordinated, goal-oriented services that are designed to improve the functional abilities of a person with an intellectual or developmental disability. Such services include, but are not limited to, self-help skills, sensorimotor skills, communication skills, independent living skills, affective development skills, social development skills, and behavioral skills.

EOHHS - the Executive Office of Health and Human Services established under M.G.L. c. 6A.

Full-time Equivalent (FTE) - a standardized measure of a program's personnel resources used by the EOHHS. One FTE equals coverage by one staff member for 40 hours per week.

Functional Level - the degree to which individuals can perform daily living activities and manage their lives independently. Functional level is measured through professional clinical assessments.

Hospital - a facility that is licensed or operated as a hospital by the Massachusetts department of public health or the Massachusetts department of mental health that provides diagnosis and treatment on an inpatient or outpatient basis for patients who have any of a variety of medical conditions.

Instrumental Activities of Daily Living (IADLs) - activities related to independent living that are incidental to the care of the member and that include, but are not limited to, household-management tasks, laundry, shopping, housekeeping, meal preparation and cleanup, transportation, care and maintenance of medical equipment and adaptive devices, medication management or any other need determined by the DH provider as being instrumental to the health care and general well-being of the member.

Intellectual Disability (ID) - significantly sub-average intellectual functioning existing concurrently with and related to significant limitations in adaptive functioning. ID originates before 18 years of age. The meaning of ID is consistent with the standard contained in the 11th edition of the American Association on Intellectual and Developmental Disabilities's Intellectual Disability: Definition, Classification, and Systems of Supports (2010) or any subsequent publication.

Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/ID) - a facility, or distinct part of a facility, that provides intermediate care facility services as defined under 42 CFR 440.150, and that meets federal conditions of participation, and is licensed by the Commonwealth primarily for the diagnosis, treatment, or rehabilitation for individuals with intellectual disabilities; and provides, in a protected residential setting, ongoing evaluation, planning, 24-hour supervision, coordination, and integration for health or rehabilitative services to help individuals function at their greatest ability.

Level II Preadmission Screening and Resident Review (Level II PASRR) - a comprehensive evaluation and determination performed by DDS for any individual seeking admission or continued stay in a Medicaid nursing facility, in accordance with 42 CFR 483.100, to determine whether an individual suspected of having intellectual or other developmental disability has such a condition and if so, whether the individual requires the level of services provided by a nursing facility, and if so, whether specialized services are required.

MassHealth - the medical assistance and benefit programs administered by EOHHS pursuant to Title XIX of the Social Security Act (42 U.S.C. 1396), Title XXI of the Social Security Act (42 U.S.C. 1397), M.G.L. c. 118E, and other applicable laws and waivers to provide and pay for medical services to eligible members.

Member - a person determined by the MassHealth agency to be eligible for MassHealth.

Nursing Facility (NF) - an institution (or a distinct part of an institution) which is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care, rehabilitation services for the rehabilitation of injured people, people with disabilities, or sick persons, or on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services that the meets the requirements of Sections 1919(a), (b), (c), and (d) of the Social Security Act and is licensed under and certified by the Massachusetts Department of Public Health.

Primary Care Provider (PCP) - a physician, physician assistant, or nurse practitioner who operates under the supervision of a physician.

Rolland Integrated Service Plan (RISP) - a comprehensive service plan developed by an interdisciplinary team consisting of the DDS service coordinator where applicable, the member (or authorized representative), NF staff representatives, the specialized services provider, and other relevant professionals (such as physical therapists, speech pathologists, occupational therapists, dieticians, and medical staff). The purpose is to address care in all settings for persons with ID or DD who reside in NFs and receive specialized services.

Service Needs Assessment (SNA) - a compilation of evaluations by qualified professionals that determine a member's level of functioning, needs, and strengths, and makes specific recommendations for day habilitation to address identified needs.

Significant Change - a major change in the member's status that:

(1) impacts more than one area of the member's health status; and

(2) requires the professional interdisciplinary team's review or revision of the DHSP.

Specialized Services - services specified by EOHHS for an NF resident with ID or DD which, combined with services provided by the nursing facility or other service providers, result in treatment that meets the requirements of 42 CFR 483.440(a)(1).

(Amended by Mass Register Issue 1373, eff. 9/7/2018.)

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