411-045-0080 - Provision of Services

411-045-0080. Provision of Services

(1) PACE Services:

(a) PACE covered services for all participants must be the same regardless of the source of payment. They must include all OHP covered services specified in OAR 410-141-0480 and Medicare covered services. In addition the covered services must include the following:

(A) Interdisciplinary assessment and treatment planning;

(B) Case management and social work services;

(C) Personal care and supportive services;

(D) Nutritional counseling;

(E) Recreational therapy;

(F) Meals and nutritional supplement as appropriate;

(G) Community based long term care including nursing facility care as appropriate; and

(H) Other services determined necessary by the Interdisciplinary Team to improve or maintain the PACE participants overall health and functioning or to provide pain management and comfort care.

(b) The following are non-covered services under PACE:

(A) Any service that is not authorized by the Interdisciplinary Team, even if it is a covered service, unless it is an emergency service;

(B) Any service listed in OAR 410-141-0500 Excluded Services and Limitations as described in 410-120-1200, or in the individual DMAP Provider Guides;

(C) Any service that is excluded under the Oregon Health Plan unless it is a covered service under 42 CFR 460.92 or Medicare;

(D) Excluded services listed in 42 CFR 460.96; and

(E) Services furnished outside of the United States except as permitted under 42 CFR 424.122 through 424.124 and under Oregon's approved Medicaid plan.

(c) The PACE program must operate at least one PACE center either in or contiguous to its defined service area, with sufficient capacity to allow routine attendance by PACE participants. The frequency of attendance at a PACE Center is determined by the Interdisciplinary Team and is to be based on the needs and preferences of each participant.

(d) A PACE program must ensure accessible and adequate services to meet the needs of its participants.

(e) The PACE program must establish an Interdisciplinary Team at each PACE Center to comprehensively assess and develop a written care plan to furnish care that meets the needs of each participant in all care settings 24 hours a day, every day of the year.

(f) Each PACE Center must employ at a minimum a half-time physician and a full-time Center Manager, Registered Nurse and Social Worker with a Master's degree before they may add a Nurse Practitioner, Physician Assistant, Licensed Practical Nurse or Social Worker with a Bachelor degree.

(g) The Interdisciplinary Team members must have appropriate licensure for their respective disciplines within the state. One year's experience in working with the elderly or in caregiving is required with exceptions approved by the Department.

(h) Personal care attendants, who are not Certified Nursing Assistants, must be enrolled in a Department approved training program within the service area within 6 months of hire and complete the program within 12 months of hire.

(i) The Interdisciplinary Team is responsible for the initial assessment, periodic reassessments, care plan, and coordination of 24 hour care delivery.

(A) The initial assessment must be completed within 10 working days following enrollment.

(B) The Interdisciplinary Team must consolidate their individual assessments into a care plan within 10 working days following enrollment.

(C) The appropriate Interdisciplinary Team members must update the care plan within 5 working days following a significant change in the participant's health status or at the request of the participant or the participant's representative.

(D) The Interdisciplinary Team members actively involved in the participant's care plan must conduct an in-person reassessment and revise the care plan with the participant and the participant's representative or caregiver at least semiannually, and meet with the members of the Interdisciplinary Team and update the care plan as needed. To the extent it is appropriate, the participant and the participant's representative or caregiver shall be involved in establishing the participant's goals.

(E) The Interdisciplinary Team must implement, coordinate and monitor the effectiveness of the care plan and, as appropriate, involve the participant and the participant's representative in care conferences or family meetings when there are issues or changes in the care plan.

(F) The care plan must specify the care needed to meet the participant's medical, physical, emotional and social needs as identified in the individual assessments. The team must document the care plan and any changes made to it in the participant's clinical record.

(2) Health Care:

(a) PACE programs will have written policies and procedures that ensure the provision of all medically and dentally appropriate care and covered services, including urgent and emergency services, preventive services and ancillary services included in the PACE contract with the Department. PACE programs must communicate these policies and procedures to PACE staff and contracted providers, regularly monitor compliance with these policies and procedures, and take any corrective action necessary to ensure compliance. PACE programs must document all monitoring and corrective action activities.

(b) The PACE program must maintain a provider panel sufficient to ensure adequate capacity and expertise to provide timely and appropriate access to covered services.

(c) PACE programs must ensure that all providers providing services to PACE participants are credentialed upon initial contract with the PACE program and re-credentialed no less frequently than biennially thereafter. This process must include a review and determination based on the results of the PACE program's quality improvement activities.

(d) The credentialing and re-credentialing process must include review of any information in the National Practitioner Databank; and

(A) A determination, based on the requirements of the discipline or profession, that providers have current licensure in the state in which they practice or appropriate certification; and

(B) Applicable hospital privileges; and

(C) Appropriate malpractice insurance.

(e) The PACE program may elect to contract for or to delegate responsibility for this process but the PACE program will retain responsibility for delegated activities, including oversight of the following processes:

(A) PACE programs must ensure that services are provided within the scope of license or certification of the provider or facility, and that providers are appropriately supervised according to their scope of practice;

(B) PACE programs, or their delegated agent, must maintain records documenting academic credentials, training received, licenses or certifications of staff and facilities used, and reports from the National Practitioner Data Bank;

(C) PACE programs must not refer PACE participants to or use providers who have been suspended or terminated from the Division of Medical Assistance Programs or excluded as Medicare/Medicaid providers by CMS or convicted of criminal offenses against Medicare, Medicaid, or Title XX of the Social Security Act or related state law by any lawful court in this state. PACE programs must not accept billings for services to PACE participants provided after the date of such providers suspension or termination or conviction.

(f) PACE programs must have written procedures that allow for choice of a Primary Care Provider (PCP) for physical health within the PACE program's PCPs or contracted providers. Information about which PCPs are not accepting new patients will be provided by the PACE program to potential PACE participants.

(g)

(A) PACE programs must ensure a newly enrolled PACE participant receives timely, adequate and appropriate health care services necessary to establish and maintain the health of the PACE participant. PACE programs must coordinate services for PACE participants who require services from agencies providing non-covered services. The PCP will arrange, coordinate, and monitor all medical, mental health, and dental care for that PACE participant on an ongoing basis.

(B) A PACE program's liability covers the period between the participant's enrollment and disenrollment with the PACE program, unless the participant is hospitalized at the time of disenrollment. In such an event, the PACE program is responsible for the participant in accordance with its contract with the Department. The PACE program must have written procedures that describe how it will comply with this obligation.

(h) The PACE program must identify the training needs of its provider panel and PACE staff and address such needs to improve the ability of the providers and staff to deliver covered services within the PACE program.

(3) Emergency and Urgent Care Services:

(a) PACE programs must have written policies and procedures and monitoring systems that ensure the provision of appropriate urgent care, emergency, and triage services 24-hours a day, 7-days-a-week for all PACE participants. PACE programs must communicate these policies and procedures to their staff and contracted providers; regularly monitor compliance with these policies and procedures and take any corrective action necessary to ensure provider compliance. PACE programs must document all monitoring and corrective action activities.

(b) PACE programs must have written policies and procedures and monitoring processes to ensure that urgent or emergency calls are responded to appropriately. These policies should address the following elements:

(A) The maintenance of 24-hour telephone coverage (not a recording) either onsite or through call sharing or an answering service, adequate to triage urgent care and emergency calls from PACE participants;

(B) The standards for call-back for emergency or urgent care, routine problems, and the provision of interpretive services after office hours. Urgent calls will be returned appropriate to the participant's condition but in no event more than 30 minutes after receipt. If information is not adequate to determine if the call is urgent, the call will be returned within 60 minutes to fully assess the nature of the call. If information is adequate to determine the call may be emergent in nature, the call must be returned immediately;

(C) Provisions for notifying other providers requesting approval to treat a PACE participant, including emergency departments;

(D) Provisions to ensure that relevant information is entered into the appropriate clinical record of the PACE participant regardless of who responds to the call or the time of day the call is received. PACE programs must monitor for compliance with this requirement;

(E) Written procedures and trained staff to communicate with hearing impaired PACE participants via TDD/TTY or Relay Service, and with limited English proficient PACE participants;

(F) Telephone coverage at PACE program centers and administrative offices that will permit access to administrative staff during normal office hours, including lunch hours, and have assigned administrative staff available for emergencies after hours and on weekends; and

(G) Provisions to monitor compliance with the policies and procedures governing 24-hour telephone coverage and on-call PCP and administrative coverage, take corrective action as needed, and report findings to the PACE program's Quality Improvement Committee.

(c) If a screening examination in an emergency room leads to a clinical determination by the examining physician that an actual emergency medical condition exists under the prudent layperson standard as defined in emergency services, the PACE program must pay for all services required to stabilize the patient. The PACE program may not require prior authorization for emergency services. The PACE program may not retroactively deny a claim for an emergency screening examination because the condition, that appeared to be an emergency medical condition under the prudent layperson standard, turned out to be non-emergency in nature.

(d) When a PACE participant's PCP, or other PACE program representative instructs the PACE participant or his or her representative to seek emergency services, in or out of the network, the PACE program is responsible for payment of the screening examination and for other medically appropriate services. The PACE program is responsible for payment of post-stabilization care that was:

(A) Pre-authorized by the PACE program; or

(B) Not pre-authorized by the PACE program if the program (or the on-call provider) failed to respond to a request for pre-authorization within one hour of the request being made, or the PACE program or provider on call could not be contacted.

(4) Continuity of Care:

(a) PACE programs must develop and maintain a formal referral system consisting of a network of consultation and referral providers, including alternative care settings, for all services covered in their contract with the Department. PACE programs must ensure that access to and quality of care provided in all referral settings is monitored. Referral services and services received in alternative care settings must be reflected in the PACE participant's clinical record. PACE programs must establish and follow written procedures for participating and non-participating providers in the PACE programs referral system. Procedures will include the maintenance of records within the referral system sufficient to document the flow of referral requests, approvals and denials in the system.

(b) PACE programs must have written procedures for referrals that ensure adequate prior notice of the referral to the referral providers and adequate documentation of the referral in the PACE participant's clinical record. These procedures must include:

(A) Review of information by the referring provider;

(B) Entry of information into the PACE participant's clinical record; and

(C) Monitoring of referrals to ensure that information, including information pertaining to ongoing referral appointments, is obtained from the referral providers, reviewed by the referring practitioner, and entered into the clinical record.

(c) PACE programs must have written procedures to orient and train their staff and the staff in contracted alternative care settings in the appropriate use of the urgent and emergency care systems, and the need to send any documents from emergency care to the PACE program.

(d) If a PACE participant is hospitalized in an inpatient or outpatient setting, PACE programs must ensure that:

(A) A notation is made in the PACE participant's clinical record of the reason, date, and expected duration of the hospitalization; and

(B) Upon discharge, a notation is made in the PACE participant's clinical record of the actual duration of the hospitalization and follow-up plans, including appointments for provider visits; and

(C) Pertinent reports from the hospitalization are entered in the PACE participant's clinical record. Such reports must include, as applicable, the reports of consulting practitioner's physical history, psycho-social history, list of medications and dosages, progress notes, and discharge summary.

(e) For PACE participants living in residential facilities or homes providing ongoing care, the IDT will work with the appropriate staff person identified by the facility to ensure that the PACE participant has timely and appropriate access to services according to the PACE participant's care plan, and to ensure coordination of care provided by the PACE program and care provided by the facility or home.

(f) For PACE participants living in residential facilities or homes providing ongoing care, PACE programs will provide medications in a manner that is compatible with the appropriate medication dispensing system of the facility, that meets state dispensing laws. PACE programs must provide emergency prescriptions on a 24-hour basis.

(g) When a PACE participant's care is being transferred from the PACE program to the PACE participant's new health care provider, the PACE program will make every reasonable effort within the laws governing confidentiality to coordinate transfer of the PACE participant into the care of the new provider.

(h) If a Primary Care Provider (PCP) terminates the patient/provider relationship, the PACE program will arrange for the participant to transfer his or her care to another PCP on the PACE program's panel who will accept the participant as his or her patient. All terminations of provider/patient relationships must be according to the PACE program's policies.

(i) PACE programs must have written procedures and criteria for health education of PACE participants and their caregivers. Health education will include: information on specific health care procedures, instruction in self-management of health care, promotion and maintenance of optimal health care status, patient self-care, and disease and accident prevention. Health education may be provided by PACE staff or other individual(s) or program(s) approved by the PACE program. PACE programs will endeavor to provide health education in a culturally sensitive manner to communicate most effectively with individuals from non-dominant cultures.

(5) Long term Care Services:

(a) PACE programs will have written policies and procedures that ensure the provision of all long term care services included in the PACE contract with the Department. PACE programs must communicate these policies and procedures to PACE staff and contracted providers, regularly monitor compliance with these policies and procedures, and take any corrective action necessary to ensure compliance. PACE programs must document all monitoring and corrective action activities.

(b) The PACE program must maintain a provider panel (either staff or contracted providers) sufficient to ensure adequate capacity and expertise to provide timely and appropriate access to covered long term care services.

(c) The PACE program must identify the training needs of its provider panel and PACE staff and address such needs to improve the ability of the providers and staff to deliver covered long term care services under the PACE program.

(d) In addition to Medicare covered services and the DMAP covered services listed in OAR 411-045-0080(1)(a), the PACE program is responsible for providing services either directly or through contracted providers that are licensed pursuant to state law including but not limited to the following:

(A) Comprehensive case management;

(B) In-Home Services as defined in OAR 411-030-0002 -- 411-030-0090;

(C) Home delivered meals;

(D) Personal Care Services as defined in OAR 411-034-0000 -- 411-034-0090;

(E) Non-medical transportation;

(F) Adult Day Services as defined in OAR 411-066-0000 -- 411-066-0020;

(G) Residential Care Facility Services;

(H) Assisted Living Facility Services;

(I) Adult Foster Home Services; and

(J) Nursing Facility Services.

(e) If the PACE program's facility is not in compliance with the provisions defined in OAR 411-066-0000 - 411-066-0020, they must submit a request to the Administrator of the Department for a variance. This request will be reviewed by the Administrator of the Department or his or her designee, and the representatives from the Department assigned to the PACE program.

(f) When a PACE program provides community based or long term care for residents outside of a participant's own residence it must assure that such facilities are licensed by the state. If the PACE program's facilities are not in compliance with the licensure requirements for those facilities, the PACE program must submit a request to the Department for a variance.

(SDSD 5-2000, f. 12-29-00 cert. ef. 1-1-01; SPD 2-2005, f. & cert. ef. 1-4-05)

Stat. Auth.: ORS 410.090

Stats. Implemented: ORS 410.070

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