§ 1247.42. Ongoing responsibilities of providers.
(a) Ongoing responsibilities of providers are established in § 1101.51 (relating to ongoing responsibilities of providers).
(b) In addition to the requirements set forth under subsection (a), a case manager shall comply with the following recordkeeping requirements:
(1) A case manager shall maintain an activity log on each recipient that includes, at a minimum:
(i) The case manager’s name.
(ii) The recipient’s name and MA identification number.
(iii) The time, date, place and a description of each targeted case management service.
(iv) Information relating to the services provided.
(2) The case manager’s recipient’s file shall include a copy of the medical treatment plan or other documentation obtained from the recipient’s physician no later than 30 days from the initial contact with the recipient. The case manager shall obtain an updated medical treatment plan from the recipient’s physician at least every 6 months.
(3) Case managers shall develop a service coordination plan (SCP) for each recipient that:
(i) Is based on the medical treatment plan developed by the recipient’s physician.
(ii) Incorporates social and other interventions needed to promote the well-being of the recipient.
(iii) Is developed within 30 days of notification by the Department that the recipient is eligible for the targeted case management program.
(iv) Includes active participation by the recipient or the recipient’s representative during the development and updating of the SCP.
(v) Is updated monthly to document and certify the effectiveness of services included in the plan and the recipient’s need for continuation of services.
(vi) Is submitted to the Department or its representative upon request or as designated by the Department.
(c) Services provided by a case manager are limited to the following:
(1) Screening. The case manager evaluates the recipient’s medical, social, psychological and financial condition as well as environmental factors by reviewing related documentation and interviewing the recipient to determine if the recipient is an appropriate candidate for targeted case management services under the MA Program.
(2) Assessing service needs. Based on the medical treatment plan, the case manager, in conjunction with the recipient or the recipient’s representative, will:
(i) Identify the recipient’s needs.
(ii) Identify targeted case management services that are appropriate based on the recipient’s health condition.
(iii) Establish realistic goals.
(3) Developing and implementing the SCP. The SCP will specify activities which serve as a means for the case manager and recipient to achieve the established goals. The plan will include appropriate referrals, service providers and community resources to be used. The plan will follow a format developed by the Department.
(4) Identifying, linking and coordinating services. Based on the SCP, the case manager shall locate resources and make referrals or arrangements for treatments and support services.
(5) Facilitating access to services. When necessary, the case manager shall intervene on behalf of the recipient to obtain needed services from appropriate agencies, private individuals or other service providers. The case manager shall provide support to the recipient and encourage the recipient to use services in accordance with the service coordination plan.
(6) Monitoring the effectiveness of services. To ensure appropriate quantity, quality and effectiveness of services in accordance with the SCP, the case manager shall monitor services on an ongoing basis.
(7) Reassessing the service needs. The case manager shall confer with the recipient and review the SCP periodically for changes in the recipient’s needs as determined by the Department. These changes shall be reflected by appropriate revisions to the SCP followed by changes in targeted case management services as indicated in the plan.
(d) The case manager shall meet with the recipient and, when appropriate, the recipient’s representative in the recipient’s place of residence within 30 days of the determination that the recipient is eligible for targeted case management services. Follow-up meetings with the recipient and, when appropriate, the recipient’s representative shall occur at least every 6 months. Exceptions to the requirements relating to meetings in the recipient’s place of residence will be made at the discretion of the Department taking into consideration unusual circumstances encountered.
(e) The case manager shall act promptly in situations that may jeopardize the goal of a recipient’s SCP.
(f) The case manager shall complete training programs developed or required, or both, by the Department within specified time frames.
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