130 CMR 458.00 — Homeless Medical Respite Services

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv Homeless Medical Respite Services Manual Transmittal Letter HMR-1 Date 01/03/25

1. Program Regulations

130 CMR 458.000: Homeless Medical Respite Services

130 CMR 458.00 Homeless Medical Respite Services

458.401 Introduction ....................................................................................................................... 1

458.401: Introduction ....................................................................................................................... 1

458.402 Definitions ........................................................................................................................ 1

458.402: Definitions ........................................................................................................................ 1

458.403 Eligible Members .............................................................................................................. 4

458.403: Eligible Members .............................................................................................................. 4

458.404 Provider Eligibility ........................................................................................................... 5

458.404: Provider Eligibility ........................................................................................................... 5

458.405 Provider Enrollment Process............................................................................................. 7

458.405: Provider Enrollment Process............................................................................................. 7

458.406 Provider Reporting Requirements..................................................................................... 8

458.406: Provider Reporting Requirements..................................................................................... 8

458.407 Revocation of Enrollment and Sanctions .......................................................................... 8

458.407: Revocation of Enrollment and Sanctions .......................................................................... 8

458.408 In-state Providers: Maximum Allowable Fees ................................................................. 9

458.408: In-state Providers: Maximum Allowable Fees ................................................................. 9

458.409 Site Inspections ................................................................................................................. 9

458.409: Site Inspections ................................................................................................................. 9

458.410 Scope of Services .............................................................................................................. 9

458.410: Scope of Services .............................................................................................................. 9

458.411 Staffing Requirements .................................................................................................... 17

458.411: Staffing Requirements .................................................................................................... 17

458.412 Supervision, Training, and Other Staff Requirements .................................................... 18

458.412: Supervision, Training, and Other Staff Requirements .................................................... 18 458.413 Transfers to Another Homeless Medical Respite............................................................. 19

458.414 Recordkeeping Requirements ......................................................................................... 19

458.414: Recordkeeping Requirements ......................................................................................... 19

458.415 Medical Leave of Absence Introduction ......................................................................... 21

458.415: Medical Leave of Absence Introduction ......................................................................... 21

458.416 Medical Leave of Absence: Conditions of Payment ....................................................... 21

458.416: Medical Leave of Absence: Conditions of Payment ....................................................... 21

458.417 Medical Leave of Absence: Payment ............................................................................. 22

458.417: Medical Leave of Absence: Payment ............................................................................. 22

458.418 Medical Leave of Absence: Failure to Readmit.............................................................. 22

458.418: Medical Leave of Absence: Failure to Readmit.............................................................. 22

458.419 Non-Medical Leave of Absence (NMLOA): Introduction ............................................. 22

458.419: Non-Medical Leave of Absence (NMLOA): Introduction ............................................. 22

458.420 Nonmedical Leave of Absence: Payment Conditions ..................................................... 23

458.420: Nonmedical Leave of Absence: Payment Conditions ..................................................... 23

458.421 Written Policies and Procedures ..................................................................................... 24

458.421: Written Policies and Procedures ..................................................................................... 24

458.422 Quality Management ....................................................................................................... 24

458.422: Quality Management ....................................................................................................... 24

458.423 Member Communications Requirements ....................................................................... 25

458.423: Member Communications Requirements ....................................................................... 25

458.424 Service Limitations ......................................................................................................... 25

458.424: Service Limitations ......................................................................................................... 25

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 458.000)

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458.401 Introduction

458.401: Introduction

130 CMR 458.000 establishes the requirements for participation of homeless medical respite providers in MassHealth. All homeless medical respite providers participating in MassHealth must comply with the MassHealth regulations, including, but not limited to, regulations set forth in 130 CMR 458.000 and in 130 CMR 450.000: Administrative and Billing Regulations.

458.402 Definitions

458.402: Definitions

The following terms used in 130 CMR 458.000 have the meanings given in 130 CMR 458.402 unless the context clearly requires a different meaning.

Acute Care Hospital. A facility that (i) is licensed as a hospital by the Massachusetts Department of Public Health (DPH) under M.G.L. c. 111, §51 (if in-state) or by the governing or licensing agency in its state (if out-of-state); (ii) is Medicare-certified and participates in the Medicare program; (iii) participates in the Medicaid program; (iv) has more than 50% of its beds licensed as medical/surgical, intensive care, coronary care, burn, pediatric (Level I or Level II), pediatric intensive care (Level III), maternal (obstetrics), or neonatal intensive care beds (Level III) as determined by DPH (or if out-of-state, the governing or licensing agency in its state, and as determined by MassHealth); and (v) utilizes more than 50% of its beds exclusively as either medical / surgical, intensive care, coronary care, burn, pediatric (Level I or Level II), pediatric intensive care (Level III), maternal (obstetrics), or neonatal intensive care beds (Level III), as determined by MassHealth. An acute hospital is not a chronic disease and rehabilitation hospital or a hospital licensed primarily to provide mental health services, or any unit of a facility that is licensed as a nursing facility, chronic disease unit, or rehabilitation unit.

Adverse Incident. An occurrence that represents actual or potential serious harm to the well- being of a member or to others under the care of the medical respite provider. Adverse incidents may result from the actions of a member served, actions of a staff member rendering services, or incidents that compromise the health and safety of the member, or operations of the provider.

Behavioral Health Disorder. Any disorder pertaining to mental health or substance use as defined by the Diagnostic and Statistical Manual of Mental Disorders.

Community Support Program for Homeless Individuals (CSP-HI). A specialized community support program service, operated in accordance with 130 CMR 461.000: Community Support Program Services, to address the health-related social needs of MassHealth members who (1) are experiencing homelessness and are frequent users of acute health MassHealth services, as defined by MassHealth; or (2) are experiencing chronic homelessness, as defined by the U.S. Department of Housing and Urban Development.

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Homelessness. A condition of any person who 1) lacks a fixed, regular, and adequate nighttime residence, and who has a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings including a car, park, abandoned building, bus or train station, airport, or camping group; 2) is living in a supervised publicly or privately operated emergency shelter designated to provide temporary living arrangements, including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations or by federal, state, or local government programs for low- income individuals; or 3) is exiting an institution where he or she resided for 90 days or less and who resided in an emergency shelter or place not meant for human habitation immediately before entering that institution.

Homeless Medical Respite or Medical Respite. Post-hospital or pre-procedure services delivered by a medical respite provider in accordance with 130 CMR 458.410(B) and (C) respectively to eligible MassHealth members as set forth in 130 CMR 458.403.

Homeless Medical Respite Provider or Medical Respite Provider. An entity that meets all conditions of participation of the MassHealth Medical Respite program described in 130 CMR 458.404 is enrolled as a provider in the MassHealth Medical Respite program.

Low-barrier Access. An approach that eliminates as many preconditions to medical respite program entry as possible and responds to the needs and concerns of individuals seeking assistance.

Low-demand Setting. A residential setting that relies on harm reduction practices to serve hard- to-reach and hard-to-engage individuals experiencing homelessness with severe mental illness and/or substance use disorder that does not require sobriety or compliance with treatment for admission or continued stay.

Medical Leave of Absence (MLOA). A short-term absence from a medical respite provider service location, during which a member does not receive medical respite services because the member is temporarily admitted to a hospital, nursing facility, or other medical setting. Absences may be planned or unplanned.

Medical Respite Service Period. Up to 183 days, whether consecutive or non-consecutive, that a member can receive medical respite, including post-hospital medical respite, pre-procedure medical respite, and medical and nonmedical leave of absence days, during a 12-month period starting with a member’s first day of admission at a homeless medical respite provider service location. A new medical respite service period can begin following the completion of the 12- month period if the member meets clinical eligibility requirements.

Memorandum of Understanding. An agreement that defines the intention of parties to work together and outlines the roles and responsibilities of each party.

Mental Health Disorder. Any disorder pertaining to mental health as defined by the Diagnostic and Statistical Manual of Mental Disorders.

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Non-congregate Room. A private room or semi-private room.

Nonmedical Leave of Absence (NMLOA). A short-term absence from a medical respite provider service location, during which a member does not receive medical respite services for nonmedical reasons. Absences may be planned or unplanned.

Post-hospital Medical Respite. Services delivered by a medical respite provider in accordance with 130 CMR 458.410(B) for a member who: is currently experiencing homelessness; has a primary acute medical issue that is not yet resolved but no longer requires or does not require a hospital level of care and does not meet a skilled nursing facility level of care; and is being discharged from a hospital after an inpatient stay or leaving from an emergency department visit.

Pre-procedure Medical Respite. Services delivered by a medical respite provider, in accordance with 130 CMR 458.410(C) for members currently experiencing homelessness, who do not have consistent access to a private bathroom and have a colonoscopy procedure scheduled that a medical professional has indicated as needing preparation. Each pre-procedure medical respite stay is limited to two full consecutive calendar days.

Private Room. A non-congregate room with a bed for a single person that is not shared with more than one person at a time.

Progressive Engagement. A services approach to addressing a member’s homelessness that is based on tailoring assistance to each member’s needs and assessing what works best for them, with their specific strengths, and in their specific situation. This services approach offers members support to address their immediate housing needs first, with ability to scale assistance up or down dependent on the member’s needs for services to address their homelessness.

Release of Information. A document through which a member establishes parameters for whether and how they authorize their personal health information to be shared (including specifying what information may be shared, with whom and for what timeframes) and which specifies under what statutes, guidelines, or other authorities such information may be released.

Safe Haven. Safe, low-demand settings for people with mental health or substance use disorders utilizing non-traditional, non-threatening methods of progressive engagement and are an alternative model to shelter for people experiencing homelessness. There are no treatment demands or requirements placed on safe haven residents. However, expectations for residents include eventual transition to stable housing and engagement or re-engagement with services.

Semi-private Room. A non-congregate room with up to four beds to allow up to four people at a time to share the room, with at least a physical barrier (e.g., a curtain) in place to designate each person’s space.

Substance Use Disorder. Any disorder pertaining to substance use as defined by the Diagnostic and Statistical Manual of Mental Disorders.

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458.403 Eligible Members

458.403: Eligible Members

(A) MassHealth members. The MassHealth agency covers medical respite services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in the MassHealth agency’s regulations, including, but not limited to, the restrictions and limitations of 130 CMR 458.000: Homeless Medical Respite Services and 130 CMR 450.000: Administrative and Billing Regulations.

(B) Member Eligibility Criteria. To receive Medical Respite services, a member must: (1) Be 18 years of age or older; (2) Be an individual currently experiencing homelessness as defined in 130 CMR 458.402; (3) Meet any medical necessity criteria for medical respite, which may be established by MassHealth via provider bulletin, administrative bulletin or other written issuance; and (4) Satisfy either all of the eligibility criteria in 130 CMR 458.403(B)(4)(a) or all of the eligibility criteria in 130 CMR 458.403(B)(4)(b): (a) Eligibility for post hospitalization medical respite services:

1. The member has been admitted to an acute care hospital medical or surgical service or has presented to an acute care hospital emergency department with a medical or surgical issue;
2. The member has a primary acute medical issue that is not yet resolved but is expected to resolve and can be safely managed in a medical respite setting with the medical respite provider’s support accessing primarily home- and community-based MassHealth services;
3. The member does not meet nursing facility level of care criteria in accordance with 130 CMR 456.409;
4. The member is anticipated to no longer require or does not currently require acute care hospital level of care in accordance with 130 CMR 415.000 and has been deemed stable and ready for discharge to a home-based setting in the community;
5. The member is experiencing homelessness and does not have a stable and safe housing option identified or the resources to obtain appropriate housing where they can be safely discharged; and
6. The member is independent with regards to Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL), except for needing short-term assistance with regaining the ability to perform ADLs and IADLs as part of the recuperative process. (b) Eligibility for pre-procedure medical respite:
7. The member has a referral for a colonoscopy procedure or a colonoscopy procedure scheduled within one day of admission to the medical respite; and
8. The member cannot prepare for the colonoscopy effectively due to not having consistent access to a private bathroom.

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458.404 Provider Eligibility

458.404: Provider Eligibility

An entity is eligible to enroll as a provider in the MassHealth medical respite program only if they meet all provider participation requirements as specified in 130 CMR 458.404: Provider Eligibility and 130 CMR 450.000: Administrative and Billing Regulations. To be eligible for participation in MassHealth as a Medical Respite Provider, an entity must meet all of the criteria below.

(A) Have at least two years of experience providing services to persons experiencing homelessness.

(B) Be able to ensure timely access to primary care services, as necessary, including the provision or coordination of orders, referrals and prescriptions for services to address physical, mental or functional needs, through a licensed medical provider whose scope of practice allows for delivery of medical services in a home setting, including the medical respite service location. If such licensed medical provider is not employed by or part of the same entity as the medical respite provider, the medical respite provider must execute a memorandum of understanding with such licensed medical provider, prior to initiating services, which must describe the proposed roles and responsibilities of the medical respite provider and the licensed medical provider for timely access to and provision of primary care services for the purposes of the medical respite program. The provider must make a copy of the memorandum of understanding available to MassHealth upon request.

(C) Demonstrate, through attestation or such other method as determined appropriate by MassHealth, comprehensive knowledge of: (1) available community resources, including but not limited to health care, behavioral health, and home health services; (2) how to access these resources in a timely manner; (3) how to arrange for services to be delivered onsite at the medical respite, if applicable; and (4) how to arrange for transportation to receive services in the community.

(D) Be able to ensure the provision of intensive housing navigation services through a CSP-HI provider in accordance with 130 CMR 461.000: Community Support Program Services. The medical respite provider and the CSP-HI provider may be part of a single entity or may be operated by different entities. If the medical respite provider is not operated by the same entity as the CSP-HI provider, the Medical Respite Provider must execute a memorandum of understanding with such CSP-HI provider, prior to initiating services, which must describe the proposed roles and responsibilities of the medical respite provider and the CSP-HI provider for the provision of intensive housing navigation services for the purposes of the medical respite program. The provider must make a copy of the memorandum of understanding available to MassHealth upon request.

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(E) Have dedicated confirmed access to a building structure to provide medical respite services that: (1) is a community-based setting that: (a) complies with all state and local fire, safety, and health codes; and (b) has a written disability access plan that ensures the setting can be accessed and used by people who have disabilities, including, but not limited to, mobility impairments and other physical disabilities; (2) provides access to the following rooms/spaces and services: (a) Non-congregate rooms for each member to have a personal bed for 24 hours a day, including at least one private room to allow for distance and disease control as medically necessary (e.g. for members with highly infectious conditions, who are immunocompromised, etc.); (b) Sufficient bathrooms with bath and shower facilities, including at least one private bathroom that is accessible for members with disabilities; (c) Sufficient space for members to receive safe and private, as appropriate, access at the medical respite service location to clinical services that the member would have otherwise been able to receive at home had they not been experiencing homelessness, such as home health, physical therapy, speech therapy, etc. (3) Free laundry facilities for member’s personal belongings; (4) Secure storage for member’s personal belongings; (5) Access to and secure storage for medications; (6) Access to a phone/tablet for telehealth and/or communications related to medical needs for members; (7) Linens (i.e., bedding and towels) for sleeping and bathing, with linen laundering services arranged for by the medical respite provider; (8) At least two working refrigerators of appropriate size to: (a) store medications; and (b) store food and meals for members. (9) Access to safety devices and emergency medications, including onsite availability of over-the-counter opiate antagonists such as Narcan to reverse the life-threatening effects of a known or suspected opiate overdose, an automated external defibrillator (AED), and Epinephrine, as appropriate. (10) For locations where the medical respite service location is co-located in a building that already receives state funding from the Executive Office of Housing and Livable Communities (EOHLC) for emergency shelter, the Department of Public Health (DPH) Bureau of Substance Addiction Services for Low-demand housing or Substance Use treatment, or the Department of Mental Health (DMH), the provider must: (a) Ensure that the medical respite is physically and functionally separated from other state-funded services provided in the building; and (b) Receive written permission to co-locate from the other state agency providing funding prior to beginning operations in accordance with 130 CMR 458.405(A)(2).

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458.405 Provider Enrollment Process

458.405: Provider Enrollment Process

(A) A complete application for enrollment in the medical respite program must be submitted for each medical respite provider. The application submission must: (1) Identify all of the applicant’s proposed medical respite service locations; (2) Specify whether the applicant is also a CSP-HI provider or if it is partnering with a CSP- HI provider to meet the requirements of 130 CMR 458.404(D), and, if partnering, include the name(s) of the partnering CSP-HI provider and an attestation that the applicant will have an executed Memorandum of Understanding prior to initiating provision of medical respite services as required under 130 CMR 458.404(D); (3) Specify whether the applicant also employs a licensed medical provider for the provision of primary care services or if it is partnering with a licensed medical provider for the provision of primary care services to meet the requirements of 130 CMR 458.404(B), and, if partnering, include the name(s) of the partnering licensed medical provider and an attestation that the applicant will have an executed Memorandum of Understanding prior to initiating provision of medical respite services, as required under 130 CMR 458.404(B); (4) Include written permission to co-locate with a program funded by another state agency, as required under 130 CMR 458.404(E)(10), if any service location listed in the application meets the co-location conditions of 130 CMR 458.404(E)(10); and (5) Be accurate and complete, and submitted as directed by MassHealth.

(B) The MassHealth agency may request additional information or perform a site inspection to evaluate the applicant’s compliance with all applicable MassHealth rules and regulations prior to enrollment.

(C) Based on the information in the enrollment application, information known to the MassHealth agency about the applicant, and the findings from any site inspection deemed necessary, the MassHealth agency will determine whether the applicant is eligible for enrollment. In the event of an application listing multiple service locations, MassHealth will evaluate each identified service location for eligibility prior to enrollment.

(D) The MassHealth agency will notify the applicant of its determination in writing. An application will not be considered complete until the applicant has responded to all MassHealth requests for additional information, and MassHealth has completed any site inspection it deems necessary.

(E) If the MassHealth agency determines that the applicant or any of its service locations is not eligible for enrollment, the notice of determination will contain a statement of the reasons for that determination, such as incomplete application materials.

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(F) The enrollment is valid only for the entity and service location(s) specifically identified for enrollment in the notice of determination and is not transferable to other entities or other service locations or programs operated by the applicant. Any medical respite provider seeking to establish an additional service location that was not approved in the initial notice of determination must apply for the enrollment of the additional service location as directed by MassHealth, and MassHealth shall issue a new notice of determination with respect to the additional service location. In order to receive payment for services rendered at a particular service location, the service location must be specifically approved to render medical respite services in a written notice of determination.

458.406 Provider Reporting Requirements

458.406: Provider Reporting Requirements

(A) Each medical respite provider must comply with all applicable reporting requirements that pertain to the practice, facility, policies or staffing of the program as directed by the MassHealth agency through provider bulletin, administrative bulletin, or other written issuance, and in compliance with 130 CMR 450.000: Administrative and Billing Regulations and 130 CMR 458.000: Homeless medical respite Services.

(B) Adverse Incident Reports. Each medical respite provider must report adverse incidents to the MassHealth agency within 24 hours of discovery of the incident, or, if the incident occurs on a holiday or weekend, on the next business day, in a format specified by the MassHealth agency.

(C) Discharge Reports. As required by MassHealth via provider bulletin, administrative bulletin or other written issuance, each medical respite provider must submit reports to MassHealth documenting discharge locations for all members served in the medical respite. For any members discharged to a shelter or the street, the reports must document the efforts made to identify alternative options for discharge, pursuant to 130 CMR 458.410(B)(10).

(D) Additional Information. medical respite providers must submit or report to MassHealth such additional information as MassHealth may from time to time reasonably require.

458.407 Revocation of Enrollment and Sanctions

458.407: Revocation of Enrollment and Sanctions

The MassHealth agency has the right to audit or review a medical respite provider’s continued compliance with the rules and regulations of the MassHealth program, including but not limited to the conditions for participation under 130 CMR 458.404 and the reporting requirements in 130 CMR 458.406 at any time. The MassHealth agency may apply administrative sanctions, which may include but are not limited to termination from the MassHealth medical respite program, pursuant to 130 CMR 450.000: Administrative and Billing Regulations, if it determines the medical respite provider has violated applicable MassHealth rules and regulations.

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458.408 In-state Providers: Maximum Allowable Fees

458.408: In-state Providers: Maximum Allowable Fees

(A) The MassHealth agency pays for Medical Respite services with rates set by EOHHS, subject to the conditions, exclusions, and limitations set forth in 130 CMR 458.000. EOHHS fees for medical respite services are contained in 101 CMR 321.00: Rates for Homeless Medical Respite Services.

(B) Administrative Operations. Payment by the MassHealth agency for medical respite services includes payment for administrative operations and for all aspects of service delivery not explicitly included in 130 CMR 458.000, such as, but not limited to: (1) staff supervision or consultation with another staff member; (2) providing information for the coordination of referrals; and (3) recordkeeping and reporting.

458.409 Site Inspections

458.409: Site Inspections

(A) The MassHealth agency, and its agents and designated contractors may, at any time, conduct announced or unannounced site inspections of any and all provider locations to determine compliance with applicable regulations, which can include auditing activities in accordance with 130 CMR 450.000: Administrative and Billing Regulations. Such site inspections need not pertain to any actual or suspected deficiency in compliance with the regulations.

(B) After any site inspection where deficiencies are observed, the MassHealth agency will prepare a written site inspection report. The site inspection report will include the deficiencies found, and the period within which the deficiency must be corrected. The program must submit a corrective action plan, within the timeframe set forth by the MassHealth agency, for each of the deficiencies cited in the report, including the specific corrective steps to be taken, a timetable for these steps, and the date by which full compliance will be achieved. The MassHealth agency will review the corrective action plan and will accept the corrective action plan only if it conforms to these requirements.

(C) Nothing in this section shall be construed to prevent MassHealth from applying administrative sanctions, pursuant to 130 CMR 450.000: Administrative and Billing Regulations, for violations of rules or regulations of the MassHealth program identified in connection with a site visit.

458.410 Scope of Services

458.410: Scope of Services

(A) The homeless medical respite provider delivers Medical Respite services to members in a community-based setting that meets the building requirements in 130 CMR 458.404(E).

(B) Post-Hospitalization Medical Respite Services. A medical respite provider must have the capacity to provide at least the following service components, which reflect a safe haven service model in a low-demand setting, for members requiring post-hospitalization medical respite services:

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(1) Screening, Intake, and Admission Services. (a) The medical respite provider must screen potentially eligible members referred by Acute Care Hospitals to confirm eligibility for post-hospitalization medical respite services set forth in 130 CMR 458.403: Eligible Members within two calendar days of the member leaving the acute care hospital using policies and procedures that ensure equitable access for underrepresented, historically marginalized groups and reflect the various identities of populations of people experiencing homelessness. The medical respite provider, through the screening process, must document their determination using their professional judgement that admission into the medical respite is likely to reduce or prevent the need for further acute care. (b) The screening and intake procedures shall reflect low-barrier access to services. (c) The medical respite provider will participate, as appropriate, in member discharge planning with the referring acute care hospital provider, which may include sending a staff person to the acute care hospital to meet the referred member or discussing the member’s health needs with the acute care hospital staff. (d) As part of the admission process, introduce and orient the member to medical respite services and staff, provide a tour of the building, and provide a packet of written materials that includes instructions on how to use amenities available on-site. (e) As part of the admissions process, review with the member the types of services that the member will have access to on-site and off-site in accordance with 130 CMR 458.410, including a review of the medical respite provider’s policy regarding whether members who choose to enroll in hospice while at the medical respite will be allowed to stay at the service location to receive hospice services. (f) Medical respite providers shall utilize a code of resident conduct or behavioral agreement document that describes program policies, including description of prohibited behaviors considered threatening to other residents or staff, and the policies and procedures for early discharge for engaging in such prohibited behavior. (g) Behavioral agreement documents reflecting a low-demand setting service model shall be provided to, reviewed by, and signed by the member within 24 hours of admission, and shall be available to all members throughout their medical respite stay upon request. If a member is unable or unwilling to sign behavioral agreement documents, the medical respite provider shall note in the member’s health record that the behavioral agreement documents were provided and verbally reviewed and the member refused to sign. (2) Assessment Services. The medical respite provider shall conduct needs assessments, periodic reassessments, and daily wellness checks for each member receiving medical respite services, and must document such assessments in the member’s health record. Specifically, the medical respite provider shall: (a) Within 24-hours of admission, conduct an assessment to ensure immediate medical needs are met for the member, including ensuring the availability of needed prescriptions. (b) Within four calendar days of admission, conduct a comprehensive baseline needs assessment to determine factors that will influence care, treatment, safety in the milieu and needed services from the medical respite provider and other community-based providers using standardized and non-standardized measures, as appropriate. The assessment must include, at a minimum:

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1. the member’s understanding and knowledge of their health status;
2. current diagnoses, pertinent history, medication history (including allergies and sensitivities), current medications, and current treatments;
3. gender identity and sexual orientation;
4. physical and mental health status;
5. behavioral health needs, including substance use and screening for suicidal and homicidal ideation;
6. active symptoms;
7. fall and overdose risks;
8. screening for health-related social needs; and
9. cultural and language needs and considerations. (c) Conduct a comprehensive housing assessment within the first week of the medical respite stay, including at a minimum:
10. housing history;
11. housing needs and preferences;
12. barriers to obtaining housing such as criminal records, past evictions, and any rental arrears owed; and
13. status of any current housing applications. (d) Conduct a comprehensive needs reassessment with the member as frequently as necessary and in no event less than every 60 days. (e) Conduct at least one wellness check every 24 hours. (3) Care Planning. The provider must complete an individualized care plan for every member receiving medical respite services upon completion of the comprehensive baseline needs assessment and must update the individualized care plan, as necessary, after each comprehensive needs reassessment. Specifically, the individualized care plan must: (a) With input from the member, identify the member’s needs, goals and priorities, and include planned treatments and planned strategies and interventions to support the member’s goals. (b) As appropriate, be developed in consultation with the member and member’s chosen support network, which may include family, and other natural or community supports; (c) As appropriate, be developed by incorporating available records from referring and existing providers and agencies, including any bio-psychosocial assessment, reasons for referral, goals, and discharge recommendations. (d) Be in writing, and include at least the following information, as appropriate to the member’s needs:
14. The member’s identified needs that may be addressed through the provision of medical respite services;
15. The member’s strengths;
16. Clearly defined interventions and measurable goals;
17. Identified interventions, services, and public benefits that the member may be eligible for or entitled to (e.g. SNAP benefits, housing assistance, TANF, etc.) to be coordinated by the provider based on member’s goals and the reason for referral/admission to the medical respite;

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5. Supports for self-administration of medications and member progress toward self- management of medications, including plans for optimizing medication adherence, which may include education or identification and provision of supports and adaptations for taking medications;
6. Clearly defined staff responsibilities and assignments for implementing the plan;
7. The date the plan was last reviewed or revised;
8. The signatures of the member, medical respite staff and/or CSP-HI involved in the most recent review or revision; and
9. An initial timeline for the medical respite stay and planning for discharge post- medical respite. (e) Be reviewed and revised at least every 60 days and updated with any significant changes. (4) Case Management Services. The provider must have effective methods to proactively coordinate care and refer members promptly and efficiently to community resources based on the member’s care plan. (a) The medical respite provider must conduct case management services in accordance with written policies and procedures for addressing a member’s physical, behavioral health, social and functional needs. Policies and procedures should minimally address:
10. Coordinating with pre-existing case management and facilitating ongoing case management supports as needed;
11. Identifying barriers to accessing health care and related services;
12. Helping members navigate health systems and establish ongoing relationships with primary care providers and other health care providers;
13. Helping members establish relationships with community behavioral health providers as needed;
14. Supporting members when behavioral concerns arise to maximize retention in the medical respite;
15. Helping members, as appropriate, understand MassHealth hospice service options and any potential changes to medical respite services or ability to remain in the medical respite setting if the member decides to enroll in the hospice program;
16. Coordinating transportation to and from medical appointments and support services;
17. Facilitating member follow up for medical appointments and accompanying the member to medical appointments, when necessary, to aid the member in addressing their conditions and symptoms and advocating for preferences for care;
18. Ensuring communication occurs between medical respite staff and other health care providers to follow up on any changes in the member’s individualized care plan;
19. Providing access to available social support groups, including on-site member groups, health education, and outside support groups (e.g., cancer support, addiction support, religious and spiritual groups, etc.);
20. Facilitating family/caregiver or support system interaction at the direction and preference of the member;
21. Connecting to and engaging with community health workers and peer support services, in accordance with needs and preferences of the member;
22. Actively communicating and coordinating care with MassHealth managed care plans and Community Partners, if applicable;

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14. Providing support with MassHealth eligibility and enrollment processes, including, as applicable, supporting the completion of redetermination paperwork or supporting enrollment processes for MassHealth managed care plans or community partners; and
15. Submitting applications for Supplemental Security Income, Social Security Disability Insurance, Supplemental Nutrition Assistance Program, Department of Transitional Assistance, Department of Mental Health, Department of Developmental Services, Massachusetts Rehabilitation Commission, Medicare or other state and federal benefit programs for which the member may be eligible. (b) When referring a member to a non-medical respite provider for services, the medical respite provider must ensure continuity of care, exchange of relevant health information, and avoidance of service duplication. (c) Referrals should result in the member being directly connected to community resources for assistance with housing, employment, recreation, transportation, education, social services, health care, outpatient behavioral health services, and legal services, as applicable. The medical respite provider must document in the member’s health record a written or verbal acknowledgement by the referred entity that includes which of the member’s needs may be met by the referred entity and provides next steps for the member to receive the referred services, if applicable. (5) Health and Referral Navigation. The medical respite provider must conduct health and referral navigation to support the member in receiving the services identified in their individualized care plan. Specifically, the medical respite provider must: (a) Assist with member self-administration of medications, including, as necessary:
16. Assisting with prescription management to fill/refill medications;
17. Safely and securely storing member’s medications;
18. Measuring correct doses, preparing medications, and observing member use;
19. Preparing regular (e.g., weekly or monthly) medication box organizers;
20. Providing medication reminders to members;
21. Coordinating self-administration of medications, such as for injections and eye, ear and topical medications. (b) Connect the member to primary care and community health care providers based on individual needs either off-site or on-site at the medical respite service location. Services delivered on-site at the medical respite service location are limited to those that a member would typically be able to safely receive in a home setting after discharge from a hospital; (c) Assist member with setting up and scheduling appointments with established and new providers, including specialty providers, and transferring health information to providers; (d) Address external barriers to receiving and engaging in services, including requesting needed referrals, navigating intake processes, or supporting the member in responding to delays, needed paperwork, or other barriers to attending appointments or receiving health services; (e) Facilitate member access to obtain durable medical equipment (DME), wound care, oxygen, and incontinence supplies, as needed;

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(f) Ensure there is space at the medical respite for the member to engage with home- based clinical services (e.g., home health, home nursing care, physical therapy, speech, occupational therapy); (g) Coordinate with home-based clinical services providers scheduled to deliver services to ensure such providers arrive as scheduled and members are at the medical respite service location when such providers arrive; (h) Screen and support the navigation process of accessing services for substance use or mental health programs, as needed; and (i) Coordinating referrals for long-term services and supports, when appropriate. (6) Meal Provision Services. The medical respite provider must provide or arrange for meals for each member seven days per week, as follows: (a) Provide at least three meals per day and snacks. (b) Meal services must meet applicable public health department food handling guidelines. (c) Meal services may include provision of unprepared food for members who are able and prefer to prepare their own meals, if a fully equipped kitchen is available. (d) Kitchens must be kept safe and hygienic, including providing proper refrigeration and trash disposal. (e) Meal services must be culturally appropriate. (7) Intensive Housing Navigation Services. The medical respite provider must coordinate provision of CSP-HI services to each member in accordance with 130 CMR 461.000 Community Support Program Services pursuant to 130 CMR 458.404(D). (a) Referral to the CSP-HI services should occur as soon as possible upon admission, in accordance with the care planning process in 130 CMR 458.410(B)(3) and documented in the medical record. (b) Requirements of Section 2(C)(1)(b) of Guidelines for Medical Necessity Determination for the Community Support Program are waived for members receiving CSP-HI services while residing at a Homeless medical respite service location. Specifically, members do not need to have identified a permanent supportive housing opportunity where they will be moving into housing within 120 days in order to receive CSP-HI services while at the medical respite. (8) Discharge Planning Services. The provider must perform discharge planning services based on the member’s specific circumstances. (a) The medical respite provider’s discharge policy should be consistent with:

1. the low-demand setting approach of a safe haven model that does not require sobriety or compliance with treatment for admission or continued stay; and
2. the behavioral agreement acknowledged by the member at admission in 130 CMR 458.410(B)(1)(e). (b) The medical respite provider must have a discharge planning process that:
3. Engages the member in the discharge planning process to the extent feasible, including informing the member of the discharge policy and procedures;
4. Engages the member’s MassHealth managed care plan and/or community partner, if applicable, in assisting in the transition of care;
5. Arranges for necessary post-discharge support and clinical services, which shall be documented in the member’s health record;

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4. Provides members with options for placement after discharge and, within the confines of available resources or options at the time of discharge, makes every effort to discharge the member to a location other than a shelter or unsheltered location and appropriate level of care and environment, and in the event of discharge to a shelter unsheltered location, arranges for post-discharge services and clinical services as required by 130 CMR 458.410(B)(10)(b)(iii);
5. Documents in the member’s medical record all measures taken to avoid discharge to a shelter or unsheltered location, including but not limited to the documentation of all options for discharge offered, and as applicable, any competent refusal of such options;
6. Keeps a record of all discharges in a form approved by MassHealth and submits such information to MassHealth on a quarterly basis in accordance with 130 CMR 458.406(C);
7. Has a discharge policy that addresses non-routine discharge, including but not limited to death, incarceration, leaving against medical advice, or unplanned leaves of absence; and
8. Has a policy on storage of member belongings after discharge, including length of time belongings will be stored and how belongings may be accessed, including for both planned and unplanned discharges. (c) For planned and unplanned discharges, the medical respite provider, in collaboration with its partner CSP-HI provider, must provide a discharge summary to the member and provide the member with opportunity to discuss the discharge information. Discharge instructions must be provided to the member, in writing, so as to be easily understood by the member and include:
9. Written medication list and medication refill information;
10. Health summary list, allergies, and plans for how to respond to indications of a worsening condition;
11. Instructions for accessing relevant resources in the community (e.g., shelters, day centers, transportation, etc.);
12. List of scheduled or needed follow-up appointments and contact information for the member’s medical providers;
13. Special medical instructions (e.g., weight bearing limitations, dietary precautions, wound orders);
14. List of scheduled or needed follow-up appointments, contact information for community case management and related resources, and where to follow up regarding pending applications (e.g., housing navigators, social service agencies);
15. Health care proxy and advance directive information; and
16. If applicable, list of pending housing options, including status of applications and any scheduled or needed follow up appointments. (d) For planned discharges, provide the discharge summary to the member so the summary is available at the time the member is discharged. For unplanned discharges, provide the discharge summary to the member within three business days of the member’s request. (e) The medical respite provider must generate and send a discharge summary from the medical respite clinical team to the member’s primary care provider and MassHealth managed care plan, if applicable, within two business days of discharge.

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(C) Pre-procedure Colonoscopy Services. A medical respite provider must have the capacity to provide at least the following service components for members needing pre-procedure colonoscopy services. (1) Screening, Intake, and Admission Services: (a) The medical respite provider must screen potential eligible members to confirm eligibility for pre-procedure colonoscopy services set forth in 130 CMR 458.403 using policies and procedures that ensure equitable access for underrepresented, historically marginalized groups and reflect the various identities of populations of people experiencing homelessness. The medical respite provider through the screening process must document their determination that the prospective member meets the eligibility criteria. (b) The medical respite provider shall coordinate the scheduling of the pre-procedure colonoscopy services with the provider conducting the colonoscopy procedure, as needed, to ensure the medical respite provider has the capacity to provide pre-procedure colonoscopy services in accordance with member needs. (c) The medical respite provider must perform admission activities in accordance with 130 CMR 130 458.410(B)(1)(d) through (g). (d) The medical respite provider must ensure the member has a prescription for pre- procedure preparation items and coordinate timely pick-up of prescription items from a pharmacy, as needed. (2) Pre-procedure Support Services. The medical respite provider must provide services and supports to members including: (a) Access to a private, comfortable, and safe environment for pre-procedure preparation activities, including access to a private room or semi-private room for up to 48 hours of admission to the medical respite location and ensure the room is available post-procedure for recovery prior to discharge; (b) Access to a private bathroom with bathroom supplies as needed to maximize comfort during the procedure preparation process; (c) Appropriate fluids and foods (e.g., Jello or popsicles of certain colors) in accordance with instructions from the procedure provider and specified prescription preparation items; (d) Counseling support, cueing, and supervision to members, as desired by the member, to support adherence with fluid intake amounts at time intervals specified in instructions from the colonoscopy procedure provider and prescription preparation items; (e) Coordination of transportation to the colonoscopy procedure and, post-procedure, back to the medical respite; and (f) Provide meal provision post-procedure, as needed. (3) Discharge Planning Services. The provider must perform discharge planning services based on the member’s specific circumstances for discharge and consistent with a safe haven model. Specifically, as part of the discharge planning process, the medical respite provider must: (a) Engage the member to the extent feasible, including informing the member of the discharge policy and procedures; (b) Arrange for necessary post-discharge support and clinical services, which must be documented in the member’s medical record;

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(c) Provide members with options for placement after discharge from the medical respite setting, and within the confines of available resources or options at the time of discharge, make every effort to transition the member to an acceptable disposition location and appropriate level of care and environment; and (d) Coordinate transportation as part of discharge.

458.411 Staffing Requirements

458.411: Staffing Requirements

(A) Minimum Staffing Requirements. medical respite provider staff must meet the minimum staff composition requirements outlined in 130 CMR 458.411 for each service location to adequately provide the required scope of services set forth in 130 CMR 458.410.

(B) Minimum Staff Composition. (1) The medical respite provider shall arrange for at least two medical respite provider staff to be available on-site 24 hours per day, seven days per week to ensure the safety of staff and members, provide oversight, manage building issues, provide meal services, and address non- clinical program concerns. (2) The medical respite provider shall: (a) Make available an adequate level of Massachusetts-licensed and appropriately credentialed staff necessary to provide the services set forth in 130 CMR 458.410; (b) When clinical staff are not on-site at the medical respite service location, engage an on-call nurse line or medical support service to provide clinical coverage up to 24-hours a day for non-emergency medical issues; and (c) Designate a specific staff person to serve as the program director who is qualified by education, training, or experience to direct and evaluate the provision of medical respite services. The person in this role must supervise the other staff persons providing medical respite services and must ensure that treatment and care are both adequate and appropriate to the needs of members and in compliance with 130 CMR 458.000. (3) Case Management. The medical respite provider shall engage a case manager responsible for the case management services in 130 CMR 458.410(A)(5) whose on-site and off-site availability ensures that members have reasonable access to case management supports. A staff person in the case manager role can fulfill the requirements of 130 CMR 458.411(B)(1) in support of on-site staff coverage. (4) Admissions Staffing. The medical respite provider must provide staffing to support admissions into the medical respite service location at least 28 hours per week over at least five calendar days including Friday, including coordinating access to clinical staff to assess and address immediate clinical needs for members in accordance with 130 CMR 458.410(B)(2). Providers must flexibly schedule admission staff and other provider staff to minimize delays to members seeking admission and align with typical discharge timeframes from referring organizations. (5) Staff Experience. The medical respite provider should: (a) incorporate individuals with relevant lived experience as staff or volunteers, where possible; and

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(b) engage staff with experience working with:

1. residents in a shared living environment; and
2. individuals experiencing homelessness; or
3. a history of mental health and substance use disorders.

458.412 Supervision, Training, and Other Staff Requirements

458.412: Supervision, Training, and Other Staff Requirements

(A) Staff Supervision Requirements. Medical Respite staff must have access to a licensed, at least master’s-level practitioner, with training and experience in providing services to adults experiencing homelessness, to provide supervision. Each staff member must receive supervision appropriate to the staff member’s skills, training, and level of professional experience.

(B) Staff Training. Staff should have appropriate training on relevant topics set forth in 130 CMR 458.412(C) to fulfill their roles, with all staff minimally receiving training on administering opiate antagonists; first aid and basic life support services (e.g., CPR provision and use of AEDs); trauma-informed de-escalation and appropriate staff responses to threatening behavior or violence; motivational interviewing and Progressive Engagement; principles of harm reduction, recovery and wellness; and management of urgent and emergent issues and escalation strategies, including contacting emergency providers, as needed.

(C) Staff Training Topics. The program must ensure that medical respite staff receive training to enhance and broaden their skills. Recommended training topics include, but are not limited to: (1) common diagnoses across medical and behavioral health care; (2) engagement and outreach skills and strategies; (3) service coordination skills and strategies; (4) behavioral health and medical services, community resources, and natural supports;(5) cultural competence; (6) managing professional relationships with members including but not limited to boundaries, confidentiality, and peers as workers; (7) service termination; (8) assertive engagement; (9) accessibility and accommodations; (10) communicating to outside emergency assistance; (11) responding to life-threatening emergencies; (12) strategies to maximize member and staff safety; (13) trauma-informed care; (14) traumatic brain injuries; (15) conflict resolution and mediation (16) the handling of alcohol, illegal drugs, and unauthorized prescription drugs found on site; (17) the handling of weapons brought into the medical respite program; and (18) medication administration treatment (MAT).

(D) Staff Professional Standards. Any staff, of any discipline, operating in the medical respite service location must comport with the standards and scope of practice delineated in their professional licensure and be in good standing with their board of professional licensure, as applicable.

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(E) Staffing Plan. The medical respite provider must maintain a staffing plan that includes policies and procedures to ensure all staffing and supervision requirements pursuant to 130 CMR 458.000 are met.

(F) Conflict of Interest. The medical respite provider must ensure appropriate protections against conflicts of interest in its medical respite services.

(G) CSP-HI Staffing. CSP-HI providers providing intensive housing navigation services for members shall receive supervision while at the medical respite site in accordance with the terms of the memorandum of understanding between the medical respite provider and CSP-HI. For staffing and supervision requirements applicable to CSP-HI providers, see 130 CMR 461.000.

458.413 Transfers to Another Homeless Medical Respite

(A) Transfer Reasons. Members may transfer from one homeless medical respite service location to a different homeless medical respite service location operated by the same or a different provider. Acceptable reasons for transfer shall be limited to the following circumstances: (1) the member’s medical needs require transfer to a different medical respite service location to facilitate access to needed medical services; or (2) transfer to a different medical respite service location will enhance the member’s social supports (e.g., the member’s family lives in the new community).

(B) Discharge Planning. In accordance with requirements for planned discharges in 130 CMR 458.410(B)(10), the medical respite provider shall provide a discharge summary with required elements and coordinate transportation of the member and their belongings to the new medical respite service location. As part of the discharge summary, the medical respite provider shall notify the receiving medical respite provider about the number of medical respite days left in the member’s medical respite service period.

458.414 Recordkeeping Requirements

458.414: Recordkeeping Requirements

(A) Protection of personal health information. The medical respite provider must abide by all applicable laws relating to privacy and data security, including but not limited to the federal Health Information Portability and Accountability Act, and must obtain a Release of Information document from each member or the member’s legal guardian to release information obtained by the provider when necessary, as required by such laws.

(B) Member Records. (1) The medical respite provider must maintain member records in accordance with 130 CMR 450.000: Administrative and Billing Regulations, and, where appropriate, share the member records with other health care providers, including other medical respite providers. (2) Member records must be complete, accurate, and properly organized.

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(3) At a minimum, member records must include: (a) member demographics including the member's name, date of birth, and MassHealth identification number or other insurance identification information. Additional member demographic elements shall be requested and documented, if provided, including member contact information, gender identity, race, ethnicity, disability status, sexual orientation, marital status, language spoken, emergency contact, and the events precipitating the member’s referral to the medical respite program; (b) Documentation that the member receiving services meets the member eligibility criteria; (c) Documentation of assessments conducted by staff to determine member needs, including relevant medical, psychosocial, educational, and vocational history; (d) The member’s individualized care plan, along with any updates, and documentation of related care planning meetings; (e) Written record of all medical respite services, including clinical, case management and intensive housing navigation services provided to each member, including face-to- face, virtual, and collateral contacts, identification of the staff person(s) responsible for providing these services to the members, applications for programs or services completed, including housing applications and other state agency applications, and progress notes; (f) Reports on all collateral consults and collaborations with family, friends, and outside professionals involved in the member’s treatment; (g) All information and correspondence to and from other involved agencies, including appropriately signed and dated Release of Information forms; (h) If discharged, a discharge summary, including a summary of the member’s services, a brief summary of the member’s condition and response to services on discharge, achievement of goals, and housing plans.

(C) Program Records. The medical respite provider must maintain documentation reflecting compliance with the requirements of 130 CMR 458.000: Homeless Medical Respite Services, including 130 CMR 458.403: Eligible Members.

(D) Other Records and Reports as Directed by EOHHS. The program must maintain other records and reports as directed by EOHHS.

(E) Availability of Records. Any and all records must be made available to the MassHealth agency upon request.

(F) The medical respite provider must ensure that for any services delivered through a subcontractor, the subcontractors meet the recordkeeping requirements in 130 CMR 458.414: Recordkeeping Requirements.

(G) The medical respite provider must ensure that they have processes in place to receive information securely and regularly from any entities it may partner with for the purposes of 130 CMR 458.404(B) or (D).

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458.415 Medical Leave of Absence Introduction

458.415: Medical Leave of Absence Introduction

(A) MassHealth pays a medical respite provider to reserve a bed for up to 15 calendar days for each member’s medical respite Service Period for a member who is on a medical leave of absence (MLOA) from the medical respite setting, if all the conditions of 130 CMR 458.415: Medical Leave of Absence Introduction through 130 CMR 458.418: Medical Leave of Absence: Failure to Readmit are met.

(B) Following a MLOA of up to 15 calendar days, the medical respite provider must allow the member to return to the same medical respite service location unless the member: (1) no longer requires the services provided by the medical respite provider; or (2) no longer meets the criteria in 130 CMR 458.403(A); or (3) has reached the end of their medical respite Service Period.

(C) When a member’s MLOA exceeds 15 days or does not meet the requirements of 130 CMR

458.415 Medical Leave of Absence Introduction or 130 CMR 458.416: Medical Leave of

458.415: Medical Leave of Absence Introduction or 130 CMR 458.416: Medical Leave of Absence: Conditions of Payment, MassHealth will not pay the medical respite provider for additional MLOA days. In such situations, (1) The medical respite provider may implement its discharge process for the member when they reach their 16 th day. (2) If the member seeks to return to the medical respite setting following the member’s discharge and the member has additional days left in their medical respite service period, the medical respite provider may readmit the member to the same or a different service location, if there is capacity, and would not need to offer the member the same bed and room to which they were previously assigned.

458.416 Medical Leave of Absence: Conditions of Payment

458.416: Medical Leave of Absence: Conditions of Payment

(A) When a member is transferred from a medical respite service location for a MLOA , the medical respite provider must: (1) provide the member and the member’s authorized or legal representative with notice of the medical respite provider’s bed-hold policy, including the member’s right to return; (2) provide the member and the member’s authorized or legal representative with notice of the MLOA; (3) provide the member’s MassHealth managed care plan or Community Partner, if applicable, with notice of the MLOA; (4) document the date and time of the beginning of the MLOA in the member’s record; (5) automatically reserve the same bed and room occupied by the member at the time the leave of absence began for the member for the period of the MLOA, for up to 15 days, unless the health needs of the member following return require a change to a different bed and/or room, in which case the medical respite provider shall reserve a more appropriate bed and room for the member; and (6) ensure that for each day that a bed is reserved the reserved bed is not occupied.

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(B) Notwithstanding 130 CMR 458.416(A), MassHealth does not pay a medical respite for reserving a bed for a member: (1) if the member has notified the medical respite provider in writing that the member does not wish to return to the medical respite setting; (2) for any MLOA day in excess of the 15 days from the date of transfer from the medical respite; (3) for the day on which a member is transferred back to a medical respite or is discharged to a non-institutional setting, as such day should be billed as a medical respite service day; and (4) for any MLOA in cases where the member is transferred from a medical respite to a hospital and transferred back to the medical respite on the same calendar day, as such day should be billed as a medical respite service day.

(C) When a member is transferred from one medical facility to another medical facility during the MLOA, the medical respite provider must continue to reserve for the member the same bed and room occupied by the member at the time the MLOA began as long as the member continues to require a MLOA and the conditions in 130 CMR 458.415: Medical Leave of Absence Introduction through 130 CMR 458.418: Medical Leave of Absence: Failure to Readmit are met. A transfer from one medical facility to another continues the MLOA period initiated on the first day the member originally was transferred from the medical respite for the original MLOA and does not initiate another 15-day period.

458.417 Medical Leave of Absence: Payment

458.417: Medical Leave of Absence: Payment

(A) For billing and payment purposes, the day on which a member is transferred from a medical respite to a hospital or other medical facility is the first day of the MLOA from the medical respite. The day on which a member is transferred back to a medical respite service location is not a MLOA day.

(B) MassHealth will pay a medical respite provider for MLOA days at the rate specified by 101 CMR 321.00: Rates for Homeless Medical Respite Services.

458.418 Medical Leave of Absence: Failure to Readmit

458.418: Medical Leave of Absence: Failure to Readmit

(A) When a medical respite provider is notified that the member is ready to return to the medical respite following a MLOA of up to 15 days, the medical respite provider must readmit the member following a MLOA if the member meets criteria in 130 CMR 458.403.

(B) A medical respite that fails to readmit a member who requires medical respite services or otherwise violates these provisions may be subject to overpayment or sanction action under 130 CMR 450.000: Administrative and Billing Regulations.

458.419 Non-Medical Leave of Absence (NMLOA): Introduction

458.419: Non-Medical Leave of Absence (NMLOA): Introduction

(A) MassHealth will pay the medical respite provider to reserve a bed for a member when the member is temporarily absent from the facility for nonmedical reasons subject to the requirements set forth in 130 CMR 458.419: Non-Medical Leave of Absence (NMLOA): Introduction through 130 CMR 458.420: Non-Medical Leave of Absence: Conditions of Payment.

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(B) For the purpose of NMLOA, a day is defined as a continuous 24-hour period. Absences from the medical respite of less than 24 hours do not constitute a day of absence.

458.420 Nonmedical Leave of Absence: Conditions of Payment

458.420: Nonmedical Leave of Absence: Conditions of Payment

(A) Planned Nonmedical Leave of Absence Duration. MassHealth pays for temporary absences for a planned NMLOA for members in medical respite for up to a total of eight (8) days per medical respite service period.

(B ) Payment for Planned NMLOA. For the provider to obtain payment for a NMLOA, the following conditions must be met. (1) The member must request the nonmedical leave prior to taking the leave. (2) In preparation for the NMLOA, the provider's staff must discuss how medical needs will be met during the NMLOA, if applicable, and make arrangements, including packaging and providing medications. (3) During the period of NMLOA, the medical respite provider must hold the same bed and room occupied by the participant at the time the absence began and must not admit any other resident in the participant’s place. (4) The member's medical record maintained by the facility must document: (a) the home address, telephone number, and relationship of the person responsible for the member while the member is absent from the facility, if applicable; and (b) the duration of absence.

(C) Unplanned Nonmedical Leave of Absence. MassHealth pays for temporary absences for an unplanned NMLOA for members in medical respite for up to two days. On the day following two consecutive overnight absences, the medical respite provider may discharge the member. (1) When a member’s unplanned NMLOA exceeds two days, MassHealth will not pay the medical respite provider for additional unplanned NMLOA days. (a) The medical respite provider may implement its discharge process for the member on the day following two consecutive overnight absences. (b) If the member seeks to return to the medical respite following the unplanned NMLOA and the member has additional days left in their medical respite service period, the medical respite may readmit the member at the same or a different service location, if there is capacity and the member meets criteria in 130 CMR 458.403(B), and would not need to offer the member the same bed and room to which they were previously assigned. (D) For billing and payment purposes for planned NMLOA days, the day on which a member leaves from a medical respite to their planned destination is the first day of the NMLOA from the medical respite. The day on which a member returns to a medical respite is not a NMLOA day.

(E) For billing and payment purposes for unplanned NMLOA days, the day of absence following the first overnight absence from the medical respite service location would be considered the first day of the NMLOA from the medical respite. The day on which a member returns to a medical respite is not a NMLOA day.

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(F) MassHealth will pay a medical respite for NMLOA days at the rate specified by 101 CMR 321.00: Rates for Homeless Medical Respite Services.

458.421 Written Policies and Procedures

458.421: Written Policies and Procedures

(A) Written Policies and Procedures. The medical respite provider must have and adhere to written policies and procedures that include: (1) a statement of its philosophy and objectives and of the geographic area served; (2) an intake policy, including eligible referring acute care hospitals and screening individuals for eligibility; (3) admission procedures; (4) service delivery procedures, including, but not limited to, development of members’ individualized care plans, case assignment, case review, and discharge planning; (5) a referral policy, including procedures for ensuring coordinated member care; (6) recordkeeping policies, including what information must be included in each record, and procedures to ensure confidentiality; (7) personnel and management policies, including policies for hiring, training, evaluation, supervision, and termination protocol for all staff; (8) conflict of interest policies; (9) managing safety in the medical respite setting, including policies on weapon use and substance use; (10) managing planned and unplanned medical and non-medical leaves of absence; (11) managing urgent and emergent clinical issues; (12) discharge procedures, including when there are leaves of absence and when the member’s medical respite service period is ending; and (13) a written procedure for managing, reporting, responding to incidents, including member falls and proactive approaches to prevent future related incidents.

458.422 Quality Management

458.422: Quality Management

(A) Participation in MassHealth Quality Management. medical respite providers must participate in any quality management and program integrity processes established by the MassHealth agency, including making any necessary data available and access to visit the provider’s place of business upon request by the MassHealth agency or its designee.

(B) Quality Improvement Practices. The medical respite provider must establish and annually update a quality improvement (QI) plan that includes information on how the medical respite provider will implement and monitor high quality clinical and enabling services. The QI plan must include: (1) A systematic process with identified leadership, accountability, and dedicated resources, and includes stakeholders such as direct staff and consumers. (2) Use of data and objective measures to determine progress toward relevant, evidence- based benchmarks and quantitative and qualitative outcomes, including patient satisfaction and feedback surveys. (3) Metrics and outcomes used should identify potential disparities in populations referred, care, and outcomes.

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(4) The manner in which collected data is reported and analyzed to determine if goals are met and outcomes are improved. (5) An action plan to improve outcomes. (6) The provision of staff training to adjust services to address needs and changes identified through the systematic QI process.

458.423 Member Communications Requirements

458.423: Member Communications Requirements

A medical respite provider must: (1) Offer written materials in alternative formats and languages to accommodate individuals with disabilities or individuals with preferred languages other than English; and (2) Provide information verbally to members who are unable to read written materials offered to members by the medical respite provider, in the member’s preferred spoken language, where possible.

458.424 Service Limitations

458.424: Service Limitations

(A) Transportation. Medical respite providers may provide referrals to community-based transportation resources. Medical respite providers may pay for a member’s transportation costs related to the provision of medical respite services. The MassHealth agency does not reimburse medical respite providers for transportation costs.

(B) Funding Availability. Reimbursement for MassHealth services is subject to limitation based on the availability of full federal financial participation, and requirements for federal funding, pursuant to EOHHS’ Section 1115 Demonstration waiver and any other applicable federal statute, regulation, or payment limit.

(C) Admission Conditions. The MassHealth agency will not reimburse a medical respite provider for post-hospitalization medical respite services for a member who is in the community more than two calendar days after leaving an acute care hospital following an inpatient stay or from an emergency department visit.

(D) Duplicative Billing. A medical respite provider that also operates a different provider program in the same service location per 130 CMR 438.404(D)(10) is prohibited from billing the MassHealth agency for the same bed on the same day from both programs.

(E) Medical Respite Service Period. The MassHealth agency will not reimburse a medical respite provider for any days in the medical respite stay beyond the last day of the member’s 12-month medical respite service period.

REGULATORY AUTHORITY

130 CMR 458.000: M.G.L. c. 118E, §§ 7 and 12.

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