Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma
MASSHEALTH
TRANSMITTAL LETTER ADH-15
October 2002
TO:      Adult Day Health Providers Participating in MassHealth
FROM:      Wendy E. Warring, Commissioner
RE:      Adult Day Health Manual (Revisions to Program Regulations)

The regulations governing adult day health programs have been completely revised. The National Adult Day Health Guidelines were used to develop the revised regulations.
The revisions create two levels of care for adult day health, basic and complex. These levels are based on the member’s care needs. To be eligible for the complex level of care a member must meet the clinical criteria for nursing-facility placement. The revised regulations explain the criteria for each of the levels of care and the scope of services that adult day health centers must provide. There has been a modification of a tiered payment structure, which takes into account the differing needs of the population served by the adult day health program.
Effective November 1, 2002, adult day health providers who meet requirements to receive a transitional payment rate, as described in 130 CMR 404.414(D)(2), for members who meet the requirements for complex level-of-care services must bill Service Code X9842 only to receive the transitional payment rate.
The revised regulations state that the program director must have two years’ managerial experience and two years of experience working with adults in a professional or volunteer position.
The revised regulations describe the required quality assurance and quality improvement plans.
These regulations are effective November 1, 2002.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Adult Day Health Manual
Pages iv, vi, vii, 4-1 through 4-22, 6-1, 6-2, D-1 and D-2

MASSHEALTH
TRANSMITTAL LETTER ADH-15 October 2002 Page 2
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Adult Day Health Manual
Pages iv, 4-1, and 4-2 — transmitted by Transmittal Letter ADH-14
Page vi — transmitted by Transmittal Letter ADH-9
Pages vii, viii, 4-7, 4-8, 4-9, and 4-12 through 4-21 — transmitted by Transmittal Letter ADH-1
Pages 4-3 and 4-4 — transmitted by Transmittal Letter ADH-13
Pages 4-5, 4-6, and 4-6a — transmitted by Transmittal Letter ADH-8
Pages 4-10 and 4-11 — transmitted by Transmittal Letter ADH-3
Page 6-1 — transmitted by Transmittal Letter ADH-12

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT DAY HEALTH MANUAL	SUBCHAPTER NUMBER AND TITLE
TABLE OF CONTENTS	PAGE
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	TRANSMITTAL LETTER
ADH-15	DATE
11/01/02	
4. PROGRAM REGULATIONS
404.401:	Statement of Purpose 		4-1
404.402:	Definitions 		4-1
404.403:	MassHealth Member Eligibility Requirements 		4-2
404.404:	MassHealth Provider Eligibility Requirements 		4-2
404.405:	MassHealth Clinical Authorization for Admission and Continued Services 		4-3
404.406:	Adult Day Health Program Requirements 		4-3
404.407:	Adult Day Health Program Service Requirement for Clinical Eligibility 		4-10
404.408:	Adult Day Health Personnel Requirements 		4-12
404.409:	Adult Day Health Staff Qualifications and Responsibilities 		4-13
404.410:	Adult Day Health Program Reporting Requirements 		4-15
404.411:	Withdrawal by an Adult Day Health Provider from MassHealth 		4-16
404.412:	Adult Day Health Program Physical Plant Requirements 		4-17
404.413:	Transportation Services 		4-19
404.414:	Payment for Services 		4-20
404.415:	Conditions of Payment 		4-21
404.416:	Noncovered Services 		4-21

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT DAY HEALTH MANUAL	SUBCHAPTER NUMBER AND TITLE
TABLE OF CONTENTS	PAGE
vi	

	TRANSMITTAL LETTER
ADH-15	DATE
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6. SERVICE CODES AND DESCRIPTIONS
Per Diem Services 	
Transportation Services 	

6-1 6-1

Appendix A. DIRECTORY 		A-1
Appendix B. ENROLLMENT CENTERS 		B-1
Appendix C. THIRD-PARTY LIABILITY CODES 		C-1
Appendix D. DEMENTIA DAY SERVICE 		D-1
Appendix W. EPSDT SERVICES: MEDICAL PROTOCOL AND
PERIODICITY SCHEDULE 		W-1
Appendix X. FAMILY ASSISTANCE COPAYMENTS AND DEDUCTIBLES 		X-1
Appendix Y. REVS/CODES MESSAGES 		Y-1
Appendix Z. EPSDT SERVICES LABORATORY CODES 		Z-1

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT DAY HEALTH MANUAL	SUBCHAPTER NUMBER AND TITLE
PREFACE	PAGE
vii	

	TRANSMITTAL LETTER
ADH-15	DATE
11/01/02	
The regulations and instructions of the Division of Medical Assistance governing provider participation in MassHealth are published in the Provider Manual Series. The Division publishes a separate manual for each provider type.
Each manual in the series contains administrative regulations, billing regulations, program regulations, service codes and descriptions, billing instructions, and general information. The Division's regulations are incorporated into the Code of Massachusetts Regulations (CMR), a collection of regulations promulgated by state agencies within the Commonwealth and by the Secretary of State. Regulations promulgated by the Division of Medical Assistance are assigned Title 130 of the Code. The regulations governing provider participation in MassHealth are assigned Chapters 400 through 499 within Title 130. Pages that contain regulatory material have a CMR chapter number in the banner beneath the subchapter number and title.
Administrative regulations and billing regulations apply to all providers and are contained in 130 CMR Chapter 450.000. These regulations are reproduced as Subchapters 1, 2, and 3 in this and all other manuals.
Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For adult day health services providers, those matters are covered in 130 CMR Chapter 404.000, reproduced as Subchapter 4 in the Adult Day Health Manual.
Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for making changes by hand ("pen-and-ink" revisions), and by substituting, adding, or removing pages. Some transmittal letters will be directed to all providers; others will be addressed to providers in specific provider types. In this way, a provider will receive all those transmittal letters that affect its manual, but no others.
The Provider Manual Series is intended for the convenience of providers. Neither this nor any other manual can or should contain every federal and state law and regulation that might affect a provider's participation in MassHealth. The provider manuals represent instead the Division's effort to give each provider a single convenient source for the essential information providers need in their routine interaction with the Division and with MassHealth members.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT DAY HEALTH MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 404.000)	PAGE
4-1	

	TRANSMITTAL LETTER
ADH-15	DATE
11/01/02	
404.401: Statement of Purpose
The regulations at 130 CMR 404.000 establish the Division’s requirements for providers of adult day health services. All providers participating in MassHealth must comply with all the Division’s regulations including, but not limited to, 130 CMR 404.000 and 130 CMR 450.000.
404.402: Definitions
The following terms used in 130 CMR 404.000 have the meanings given in 130 CMR 404.402 unless the context clearly requires a different meaning.
Activities of Daily Living (ADL) — the following personal care activities: bathing, dressing, toileting, transfers, ambulation, and eating.
Adult Day Health (ADH) Program (Site) — a physical location that has been reviewed and approved by the Division and by other appropriate authorities for the provision of adult day health services for a specific number of daily members. If a provider offers adult day health services in more than one location, each location is a separate site and must meet the provisions of 130 CMR 404.000.
Adult Day Health Services — all services provided at a Division-approved adult day health program that meet the conditions of 130 CMR 404.000. The general goal of these services is to provide an organized program of nursing services and supervision, maintenance-therapy services, and socialization.
Attendance Day — any day that a member attends the adult day health program for a minimum of six hours.
Basic Level of Care Services — services required by all ADH program members as described in 130 CMR 404.407.
Case Management — an interdisciplinary, collaborative process to assess, plan, implement, coordinate, monitor, and evaluate the care and services required to meet the member’s health-care needs.
Certified Capacity — a capacity approved by the Division as outlined in 130 CMR 404.412(H). Once a provider is approved, the average daily census at the provider site must not exceed the certified capacity.
Complex Level of Care Services — services required in addition to basic level of care services by program members as described in 130 CMR 404.414(A)(2).
Health Promotion and Prevention Rate (HPPR) — a covered rate as outlined in 130 CMR 404.414(D).

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT DAY HEALTH MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 404.000)	PAGE
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Maintenance-Therapy Services — supplemental or follow-up physical, occupational, or speech therapy to maintain optimal functioning and to prevent regression. These services must be performed by adult day health program staff under the direction of the therapist, the program's registered nurse, or both.
Nursing Assessment — an assessment done by the program registered nurse that includes a review of the member’s health status and medical needs.
Member — an individual aged 18 or older receiving services at an adult day health program.
Program Day — any day during which the adult day health program is in operation.
Professional Staff — the program director, all licensed staff, the social worker, and the activities director.
Significant Change —a major change in the resident’s status that:
(1)	is not self-limiting;
(2)	impacts more than one area of the member’s health status; and
(3)	requires an interdisciplinary review or revision of the care plan.
404.403: MassHealth Member Eligibility Requirements
(A)(1) MassHealth Members. The Division covers adult day health services only when provided to eligible MassHealth members, subject to the restrictions and limitations set forth in the Division’s regulations. The Division’s regulations at 130 CMR 450.105 specifically state, for each MassHealth coverage type, which services are covered and which members are eligible to receive those services.
(2) Recipients of the Emergency Aid to the Elderly, Disabled, and Children Program. For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled, and Children Program, see 130 CMR 450.106.
(B) For information on verifying member eligibility and coverage type, see 130 CMR 450.107.
404.404:  MassHealth Provider Eligibility Requirements
To participate in MassHealth as an adult day health program provider, a provider must:
(A)	enter into a provider contract with the Division;
(B)	operate in Massachusetts and meet the Massachusetts Bureau of Buildings and Standards requirements for adult day health programs, local fire department requirements, local board of health requirements, and the requirements of 130 CMR 404.412;
(C)	agree to periodic inspections that assess the quality of member care and ensure compliance with 130 CMR 404.000. Programs found to be out of compliance will be subject to the provisions of 130 CMR 450.000;
(A)	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT DAY HEALTH MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 404.000)	PAGE
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(D) offer both basic and complex level-of-care services. Providers who were approved before November 1, 2002, need not offer both. Those who were approved providers before November 1, 2002, must offer at least the level-of-care service at which they were approved; and
(E) agree to comply with all the provisions of 130 CMR 404.400, 450.000, and all other applicable Division rules and regulations.
404.405:  MassHealth Clinical Authorization for Admission and Continued Services
(A)	Clinical Eligibility Requirement. Each MassHealth member requesting coverage for adult day health services must be screened by the Division or its agent and determined clinically eligible for ADH services. The screening must be completed before the first date of service that coverage is requested. In determining clinical eligibility, the Division or its agent will apply the criteria and service requirements of 130 CMR 404.407.
(B)	Notification of Clinical Approval for Adult Day Health Services. If the Division or its agent determines that a member is eligible for coverage of adult day health services, the Division or its agent will issue an authorization that contains the name of the adult day health program and the effective date of coverage. The notification will include the name of the screening agent and effective date of clinical eligibility.
(C)	Notification of Clinical Denial for Adult Day Health Services and Right of Appeal.

(1)	If the request for coverage of adult day health services is denied, the Division or its agent will notify both the member and the referral source. The notice of denial will state the reason for the denial and will contain information about the member’s right to appeal, and of the appeal procedure.
(2)	If the request for coverage of adult day health services is denied, a member may appeal this decision by requesting a fair hearing from the Division. The request for a fair hearing must be made in writing within 30 days of receiving the denial. The Division’s Board of Hearings will conduct the hearing in accordance with 130 CMR 610.000.
(D)	Review Requirement. The provider must annually review all MassHealth members for
continued eligibility. In addition, the provider must review the member if there has been a
significant change in the member’s status as defined in 130 CMR 404.402 and 404.414(C).
404.406:  Adult Day Health Program Requirements
All providers of adult day health services must meet the requirements of 130 CMR 404.000 and 450.000 to enroll in MassHealth. To provide adult day health services at the complex level of care, providers must meet the requirements and provide the additional services in accordance with 130 CMR 404.408(A)(2) and 404.414(A)(2). In addition, those programs serving members with cognitive impairments such as dementia or Alzheimer’s disease who require complex level-of-care services must meet the requirements and provide the additional services listed in Appendix D of the Adult Day Health Manual.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT DAY HEALTH MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 404.000)	PAGE
4-4	

	TRANSMITTAL LETTER
ADH-15	DATE
11/01/02	
(A)	Administrative Requirements. All adult day health programs must have a mission statement
that includes:
(1)	the goals and objectives of the program;
(2)	the service components of each level of need;
(3)	an organizational chart describing the lines of authority and communication needed to manage the adult day health program; and
(4)	a description of the governing body.
(B)	Administrative and Medical Policies and Procedures. Each program must have written
policies and procedures, including, but not limited to, the following issues:
(1)	admissions criteria;
(2)	discharge criteria;
(3)	medication administration;
(4)	universal precautions;
(5)	communicable disease;
(6)	recognizing elder abuse;
(7)	grievance procedures for members;
(8)	staff evaluation;
(9)	staff training;
(10)	nondiscrimination;
(11)	annual quality improvement;
(12)	confidentiality;
(13)	member rights;
(14)	cultural competency;
(15)	counseling members and families; and
(16)	personnel policy and procedures.

(C)	Hours of Operation. An adult day health program must operate at least Monday through Friday for eight hours a day.
(D)	Scope of Basic Level-of-Care Services. All adult day health programs participating in MassHealth must provide the following services.
(1) Nursing Services and Health Oversight. The adult day health center must provide nursing coverage on site for a minimum of eight hours a day, four hours of which must be provided by a registered nurse. The balance of the coverage may be provided by a licensed practical nurse. When the average daily census reaches 35 members or more, the adult day health center must provide nursing coverage on site for a minimum of 12 hours, four hours of which must be provided by a registered nurse. When the average daily census reaches 50 members or more, the adult day health center must provide nursing coverage on site for a minimum of 16 hours a day, eight hours of which must be provided by a registered nurse. Nursing services must be provided to meet the needs of each member and must include:

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT DAY HEALTH MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 404.000)	PAGE
4-5	

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(a)	administration of medications and treatments prescribed by the member’s physician during the time the member is at the program;
(b)	education in hygiene and health concerns;
(c)	development and coordination of each member's care plan;
(d)	monitoring each member's health status and documenting those findings in the member's medical record at least monthly and more often if the member's condition requires more frequent monitoring;
(e)	reporting changes in the member’s condition to the member’s physician;
(f)	oversight of maintenance-therapy treatment as recommended by a therapist; and
(g)	coordinated implementation of physician's orders with the member, family, and program staff.
(2)	Therapy Services.
(a)	The program must provide occupational, physical, and speech/language services at a maintenance level based on a physician’s order and a therapy assessment. Maintenance services must be supervised by the program’s registered nurse.
(b)	The program must arrange for restorative therapy based on a physician’s order and a therapy assessment.
(c)	The appropriate licensed personnel must review therapy assessments and services every six months. Providers must document this review.

(3)	Assistance with Activities of Daily Living. The program must have sufficient staff to provide assistance with ADLs as defined in 130 CMR 404.407(C).
(4)	Nutritional and Dietary Services.
(a)	The program must provide to members each day of attendance:
(i) a hot meal equivalent to at least one-third of the recommended daily dietary
allowance established by the American Dietary Association;
(ii) special diets, if required by a member and prescribed by a physician;
(iii) an alternate food choice; and
(iv) two snacks, one in the morning and one in the afternoon.
(b)	The program must also offer nutrition counseling, consumer-shopping advice, and menu planning provided under the supervision of a registered nurse or dietitian to the member and, if necessary, the member’s family.
(c)	The program must provide dietary services based on a dietary assessment, a physician’s order, or both. Dietary services must be supervised by the program’s registered nurse.
(d)	The appropriate licensed personnel must review dietary assessments and services every six months. Providers must document this review.
(5)	Counseling Services. A social worker must provide individual and group counseling
services to members and their families.
(a)	Licensed professional staff may provide this service if the program's daily census is under 24 members and a social worker is not employed by the program. (See 130 CMR 404.408 for personnel requirements.)
(b)	A staff person who is not a social worker must demonstrate that they have had training, experience, or both, in counseling adults.
(c)	Counselors must offer assistance with personal, social, family, and adjustment problems the member may experience at the program.
(a)	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT DAY HEALTH MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 404.000)	PAGE
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(d) If the member or the member’s family requires specialized counseling, the program must refer the member or family to the appropriate community resource.
(6)	Activities.
(a)	The program must provide, on an individual and group basis, social, recreational, and educational activities designed to improve or maintain the member’s self-awareness and level of functioning.
(b)	Before the start of each month, the program must make available to members and staff a monthly calendar of activities and events.
(c)	The dignity, interests, and therapeutic needs of individual members must be considered in the development of activities.
(7)	Case Management. If a member needs services from other community agencies, and if no
agency is acting as coordinator of services for that member, the adult day health program
must assume the role of coordinator.
(E) Recordkeeping Requirements.
(1)	Administrative Records.
(a)	The program must make all records available to the Division as needed for evaluation
and review. The program must submit incident reports of patient harm or injury to the
Division within three business days.
(b)	The program must maintain documentation of the following:
(i)   the number of members being served;
(ii) the number of individuals waiting for admission to the program; (iii) the number of staff; (iv) incident reports; (v) complaint and grievance reports;
(vi) a personnel file on each staff person and their qualifications; (vii) contracts for therapy, nutritional, and other services; and (viii) other records as that may be required by the Division.
(2)	MassHealth Participation Agreement. Upon the Division’s determination of coverage,
the program must complete a written agreement with the applicant and, if appropriate, with the
applicant's legal guardian. This agreement must specify:
(a)	the services offered to the applicant by the program;
(b)	the obligations of the applicant and his or her family to the program;
(c)	the days and hours of program operation, including:
(i)  a schedule of holidays when the program is closed;
(ii) the days per week the member will attend;
(iii) the procedures for notifying members of unexpected closing of the program
due to disaster or inclement weather; and
(iv) arrangements for transporting the member to and from the program;
(d)	emergency procedures; and
(e)	reasons for discharge from the program. (See 130 CMR 404.406(G).)
(d)	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT DAY HEALTH MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 404.000)	PAGE
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(3) Emergency Services. The program must establish emergency policies and procedures in writing. These procedures must include the following:
(a)	an emergency file (such as a Kardex or emergency fact sheet) on each member that
must contain:
(i)     the name and telephone number of the member’s physician;
(ii)    the member’s diagnosis;
(iii) any special treatments or medications the member may need;
(iv)    insurance information; and (v) the name and telephone number of a family member, sponsor, or friend to be notified in case of emergency;
(b)	a policy for emergency evacuation that is in compliance with local fire department requirements;
(c)	a procedure for emergency evacuation that is conspicuously posted throughout the program site;
(d)	monthly evacuation drills, records of which must be kept on file at the site;
(e)	training and certification of all drivers of vehicles owned by the program or contracted vehicles, in emergency procedures, cardiopulmonary resuscitation (CPR) by an approved CPR instructor, and basic first aid. The provider must keep records of drivers’ CPR and first-aid training and certification on file;
(f)	training of all direct care staff in CPR and first aid. The provider must keep records of all direct care staff CPR and first-aid training on file;
(g)	a procedure to be followed in the event a member is missing or lost; (h) a procedure for relocation of members in an emergency; and (i) procedures for handling medical emergencies at the program.
(F) Documentation Requirements.
(1) Member Records. The program must have available, and maintain on site for at least 12 months, a medical record for each member as requested by the Division. The program must maintain the member record for seven years from the date of the member’s death or discharge. The record retention rules apply to all members regardless of the member’s length of stay. The member record must contain:
(a)	admission information:
(i) the member information sheet;
(ii) the clinical authorization by the Division or its agent; and (iii) the MassHealth Participation Agreement;
(b)	medical information:
(i) a copy of the most recent physical examination;
(ii) the physician orders;
(iii) medical history;
(iv) tuberculosis screening documentation; (v) a list of any known allergies;
(vi) information concerning member’s dietary requirements; (vii) the medication administration record (MAR); (viii) the initial nurse’s assessment;
(ix) the results of the functional assessment annually and at significant change; (x) advanced directives; and (xi) the name of the health-care proxy;

Commonwealth of Massachusetts
Division of Medical Assistance
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ADULT DAY HEALTH MANUAL	SUBCHAPTER NUMBER AND TITLE
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(c)	progress notes, including:
(i) nursing notes;
(ii) therapy notes;
(iii) activity notes;
(iv) social service notes;
(v) dietary notes; and
(vi) ADL daily records (staff log of care received by member);
(d)	correspondence from family, therapists, physicians, or others pertaining to the care of the member in the program;
(e)	the discharge plan;
(f)	the attendance record;
(g)	legal documentation, for example, signed authorizations for release of information; and (h) the individual plan of care.
(2)	Physician's Documentation.
(a)	Before the member’s first attendance day, the program must obtain the necessary
documentation from the member’s physician.
(b)	The physician’s documentation must include:
(i) physician orders for adult day health services;
(ii) the member's medical history;
(iii) results of a physician's visit within the past three months; (iv) results of a physical examination given within the past twelve months. If the individual has been hospitalized in the preceding three months, a complete discharge summary may be used to fulfill the physical examination requirement; (v) a list of current medications and treatments; (vi) a statement of special dietary requirements;
(vii) a statement indicating any contraindications or limitations to the individual's participation in program activities; and (viii) recommendations for therapy, when applicable.
(c)	In the case of an emergency admission, the program must request from the Division an
extension of the physician’s documentation requirements. The program must obtain the
physician’s signature as evidence of review of the quarterly care plan within three business
days.
(3)	Member Care Plan.
(a) Within six program days after a member's date of admission, the adult day health
program's staff must complete a care plan for the member. The care plan must be written in a
problem-oriented format. The program's registered nurse must coordinate the development of
the member care plan. The plan must include:

Commonwealth of Massachusetts
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(i) a treatment plan based on the member's physician's orders;
(ii) a nursing assessment;
(iii) if applicable, therapy services;
(iv) a social service and activity plan designed to meet the member’s psychosocial
and therapeutic needs; and
(v) documentation of any other health or supportive services the member is receiving
off-site (for example, homemaker, home health, visiting nurse, personal care, or therapy
services).
(b)	At least quarterly, professional staff must review and update each member’s care plan,
including:
(i) the ADL flow sheet;
(ii) the monthly nursing progress notes;
(iii) the monthly therapist notes;
(iv) the quarterly activity notes;
(v) the quarterly social service notes;
(vi) the physician orders;
(vii) the member’s physical examination; and
(viii) the member’s discharge plan.
(c)	The program must forward a copy of the member’s care plan to the member’s physician
every three months. The program must inform the physician of any subsequent change in the
member’s care plan. The program must ensure that the physician reviews, signs, and returns
the care plan.
(G) Member Discharge and Referral.
(1)	Discharge from an ADH may be initiated by either the program or the member.
(a)	A provider may initiate discharge of a member when the individual:
(i) no longer meets the clinical criteria for ADH;
(ii) develops behavioral problems that may endanger or seriously disrupt other members or staff;
(iii) requires increased services that the program is unable to provide. In this circumstance, the program must arrange for the member to be discharged to a more appropriate setting. The program may not discharge the member until appropriate services are available; or
(b)	A member may choose to discontinue services at any time. In this circumstance,
the provider is not responsible for discharge service planning, as outlined in
130 CMR 404.406(G)(2) through (5).
(2)	The program must develop a written discharge plan that includes:
(a)	a discharge summary;
(b)	recommendations for sources of continuing care (for example, Aging Service Access Points, home health agencies, and institutional care); and
(c)	referrals to community service agencies for appropriate services, for individuals who do not meet minimum ADH coverage criteria.
(a)	
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Division of Medical Assistance
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(3)	The adult day health program must notify a member, the member’s family, or authorized representative and the member’s physician at least two weeks before discharging the member from the program. This notification must be mailed to the member and the member’s family or authorized representative. The provider must also notify the local Aging Service Access Point two weeks prior to discharge, in cases where a member will be referred for alternative community services. The program may discharge a member in less than two weeks if a sudden change in the member’s condition makes continued participation harmful to the member or other members. The program must document the need for immediate discharge.
(4)	The program must discuss the discharge with the member’s family and coordinate transition to appropriate and available services.
(5)	The program must make at least one follow-up telephone call between 20 and 25 business days following discharge, and document its findings of the member’s post-discharge status and condition in the member’s medical record.
(H) Marketing Plan. The program must establish a marketing plan that describes strategies for informing communities in its service area of the program's services.
(I) Quality Assurance/Quality Improvement Plan. Each program must develop an annual quality improvement plan that:
(1)	identifies specific measurable objectives to assess the clinical outcomes of the care and services;
(2)	identifies a method or methods of evaluation;
(3)	identifies a staff member who is responsible for developing the plan;
(4)	explains how the quality improvement information will be used;
(5)	identifies interventions;
(6)	describes the implementation of interventions;
(7)	evaluates the interventions; and
(8)	addresses additional quality improvement projects as determined by the Division.
404.407: Adult Day Health Program Service Requirement for Clinical Eligibility
(A) To be clinically eligible for MassHealth payment of adult day health services, a MassHealth member must:
(1)	have a medical or mental dysfunction that involves one or more physiological systems and requires nursing care (The dysfunction does not have to be one that can be stabilized.);
(2)	require services in a structured adult day health setting;
(3)	have a personal physician;
(4)	agree to attend the program a minimum of two full six-hour days per week, unless the member’s physician completes a written justification for other time periods, which are submitted to the Division for approval;
(5)	require a health assessment, oversight, monitoring, or services provided by a licensed nurse; and
(6)	require one or both of the following:

(a)	assistance with one or more activities of daily living (see 130 CMR 404.407(C)); or
(b)	at least one skilled service (see 130 CMR 404.407(B)).
(a)	
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(B) Skilled services are those services ordered by a physician that fall within the professional disciplines of nursing, physical, occupational, and speech therapy. Skilled services include:
(1)	intravenous, intramuscular, or subcutaneous injection, or intravenous feeding;
(2)	nasogastric-tube, gastrostomy, or jejunostomy feeding;
(3)	nasopharyngeal aspiration and tracheostomy care. However, long-term care of a tracheotomy tube does not, in itself, indicate the need for skilled services;
(4)	treatment and/or application of dressings when the physician has prescribed irrigation, the application of medication, or sterile dressings of deep decubitus ulcers, other widespread skin disorders, or care of wounds, when the skills of a registered nurse are needed to provide safe and effective services (including, but not limited to, ulcers, burns, open surgical sites, fistulas, tube sites, and tumor erosions);
(5)	administration of oxygen on a regular and continuing basis when the member's medical condition warrants skilled observation (for example, when the member has chronic obstructive pulmonary disease or pulmonary edema);
(6)	skilled-nursing observation and evaluation of an unstable medical condition (observation must, however, be needed at frequent intervals throughout the day);
(7)	skilled nursing for management and evaluation of the member's care plan when underlying conditions or complications require that only a registered nurse can ensure that essential unskilled care is achieving its purpose. The complexity of the unskilled services that are a necessary part of the medical treatment must require the involvement of skilled nursing personnel to promote the member's recovery and safety;
(8)	insertion, sterile irrigation, and replacement of catheters, care of a suprapubic catheter, or, in selected residents, a urethral catheter. A urethral catheter, particularly one placed for convenience or for control of incontinence, does not justify a need for skilled-nursing care. However, the insertion and maintenance of a urethral catheter as an adjunct to the active treatment of disease of the urinary tract may justify a need for skilled-nursing care. In such instances, the need for a urethral catheter must be documented and justified in the member's medical record (for example, cancer of the bladder or a resistant bladder infection);
(9)	gait evaluation and training administered or supervised by a registered physical therapist while at the center for members whose ability to walk has recently been impaired by a neurological, muscular, or skeletal abnormality following an acute condition (for example, fracture or stroke). The plan must be designed to achieve specific goals within a specific time frame;

(10)	certain range-of-motion exercises may constitute skilled physical therapy only if they are part of an active treatment plan for a specific state of a disease that has resulted in restriction of mobility (physical-therapy notes showing the degree of motion lost and the degree to be restored must be documented in the member's medical record);
(11)	hot pack, hydrocollator, paraffin bath, or whirlpool treatment will be considered skilled services only when the member's condition is complicated by a circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications; and
(10)	
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Division of Medical Assistance
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(12) physical, speech/language, occupational, or other therapy that is provided as part of a planned program that is designed, established, and directed by a qualified therapist. The findings of an initial evaluation and periodic reassessments must be documented in the member's medical record. Skilled therapeutic services must be ordered by a physician and be designed to achieve specific goals within a given time frame.
(C) Assistance in activities of daily living include:
(1)	bathing when the member requires either direct care or constant supervision and cueing during the entire activity;
(2)	dressing when the member requires either direct care or constant supervision and cueing during the entire activity;
(3)	toileting, bladder or bowel, when the member is incontinent of bladder or bowel or requires scheduled assistance or routine catheter or colostomy care;
(4)	transfers when the member must be assisted or lifted to another position;
(5)	ambulation when the member must be physically steadied, assisted, or guided in ambulation, or is unable to self-propel a wheelchair appropriately without the assistance of another person; and
(6)	eating when the member requires constant supervision and cueing during the entire meal, physical assistance with a portion of the meal, or being fed the entire meal by staff.
404.408: Adult Day Health Personnel Requirements
(A)	Adult day health programs must have available sufficient direct-care staff to meet the needs
of their members.
(1)	For basic level of care services, the program must maintain a minimum-staffing ratio of one direct care staff person to six members.
(2)	For complex level of care services, the program must maintain a minimum-staffing ratio of one staff person to four members.
(3)	Programs offering both basic and complex level-of-care services must maintain proportionate direct-care staff ratios to meet the needs of members based on the ratio of members requiring basic and complex level-of-care services.
(B)	Pre-employment Requirements.
(1)	Before hiring staff and approving volunteers, the program must check the candidate's references and job history and ensure that the candidate has had a Criminal Offender Records Information (CORI) check.
(2)	Each staff person must have a satisfactory pre-employment physical examination within 12 months before employment and a tuberculosis screening. The provider must obtain a copy of these reports within 30 days of employment and keep this report in the employee’s personnel record. The personnel policies must specify the intervals at which future physical examinations are required. All staff must have an annual tuberculosis screening.
(1)	
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(C) Administrative and Training Requirements.
(1)	Programs must provide staff training appropriate to the mix of services provided. Staff must have adequate skills, education, and experience to serve the population in a manner consistent with the philosophy of the adult day health center. All paid and volunteer staff must participate. Programs must keep training attendance records on file.
(2)	Programs must provide a minimum of eight hours of in-service training sessions per year.
(3)	For each staff position, the program must have a separate job description that includes title, reporting authority, qualifications, and responsibilities.
(4)    The program must evaluate staff annually, using a standardized evaluation tool and a face-to-face meeting. A record of each staff person's performance evaluation must be maintained in his or her personnel file.
404.409: Adult Day Health Staff Qualifications and Responsibilities
(A)	Program Director. The provider must employ a full-time program director.
(1)	Qualifications. The program director must have two years of managerial experience and two years experience working with adults in a health-care setting in a professional or volunteer position.
(2)	Responsibilities. The program director’s responsibilities include:

(a)	directing and supervising all aspects of the program;
(b)	personnel management;
(c)	supervision and evaluation of all staff;
(d)	coordination of all admissions;
(e)	overseeing program safety and emergency evacuation plans;
(f)	development and implementation of the program's marketing plan;
(g)	fiscal administration of the program;
(h) coordination of transportation services; and
(i) establishing collaborative relationships to ensure that necessary support services are available to members and their families.
(B)	Assistant Program Director. One professional staff person must be designated as an assistant program director. The assistant program director must have the same qualifications as the program director and will assume the responsibilities of program director as needed.
(C)	Registered Nurse. There must be a registered nurse on site each program day. For minimum nursing staffing requirements, see 130 CMR 404.406(D)(1). A registered nurse must be available while members are on site.
(1) Qualifications. The registered nurse must be licensed by the Massachusetts Board of Registration in Nursing to practice in the Commonwealth of Massachusetts. The nurse must have at least two years’ recent experience in the direct care of adults or chronically disabled persons.

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(2) Responsibilities. The responsibilities of the registered nurse include:
(a)	providing or supervising nursing services for each member, including all skilled nursing services listed in 130 CMR 404.407(B) and (C);
(b)	supervising other health-care staff;
(c)	coordinating the development and ongoing review of each member’s care plan;
(d)	assuring that nurse’s notes are written monthly, or more often if necessary to address significant changes and health-care teaching in each member’s record;
(e)	assisting as necessary in the delivery of other program services;
(f)	training adult day health staff; and
(g)	reviewing and implementing physician orders.
(D)	Activity Director. The program must employ an activity director who will be on site daily for
a minimum of four scheduled hours each day.
(1)	Qualifications. The activity director must have one or more years’ experience working in an adult social or recreational program.
(2)	Responsibilities. The responsibilities of the activity director include:

(a)	developing, in conjunction with the occupational therapy consultant, activity programs that meet the individual needs of each member;
(b)	supervising the activity program assistants;
(c)	planning and scheduling activities and social events;
(d)	writing, at least quarterly, notes in each member’s record on the member’s participation in activities;
(e)	participating in the quarterly review of each member’s care plan;
(f)	helping as necessary with other adult day health services; and
(g)	developing a monthly calendar of activities and events.
(E)	Social Worker. If the program’s average daily census is 24 or more members, the program
must employ a social worker who will be on site for a minimum of 20 scheduled hours each week.
(1)	Qualifications. The social worker must have at a minimum a bachelor's degree in human services from an accredited college or university and at least one year's recent experience working with adults in a professional capacity.
(2)	Responsibilities. The responsibilities of the social worker include:

(a)	individual, group, and family counseling;
(b)	informing members of and referring them to available community services;
(c)	the writing of social worker notes in the member’s record upon admission, at least quarterly thereafter, and when significant changes occur;
(d)	assistance, as appropriate, with other adult day health services; and
(e)	participation in the quarterly review of each member's care plan.

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(F)	Licensed Practical Nurse.
(1)	Qualifications. The licensed practical nurse must be licensed by the Massachusetts Board of Registration in Nursing to practice in the Commonwealth of Massachusetts.
(2)	Responsibilities. The responsibilities of the licensed practical nurse include:

(a)	providing nursing services and treatments to each member under the supervision of the program's registered nurse; and
(b)	if so delegated by the registered nurse, assuring that nurses’ notes are written monthly or as often as necessary to address significant changes and health-care teaching in each member’s record.
(G)	Aide.
(1)	Qualifications. Each aide must:
(a)	have one or more years' experience working with adults in a health-care or social-service setting; and
(b)	be qualified in cardiopulmonary resuscitation (CPR) and basic first aid.
(2)	Responsibilities. The responsibilities of the aide are to assist professional program
staff as required and to meet the needs of individual members.
(H) Consulting Therapists.
(1)	Qualifications. Consulting therapists must meet the requirements set forth in the MassHealth Therapist Manual, 130 CMR 432.000.
(2)	Responsibilities. All consulting therapists must document time and services in the member’s records.
(I)   Volunteers. The program must maintain a record of volunteer hours. The duties and responsibilities of volunteers will be determined by the program director. If a volunteer is to provide direct care, the volunteer must meet the qualifications of that direct-care staff as specified in 130 CMR 404.409.
404.410: Adult Day Health Program Reporting Requirements
(A)	The program director or designee is responsible for notifying the Division immediately in
writing in the following situations:
(1) fire, accident, injury, incidence of elder abuse, or evidence of serious communicable disease contracted by program staff or MassHealth members;
(2)   death of a MassHealth member when the death occurs at or en route to the ADH program; and (3) change in telephone or fax number or e-mail address of the adult day health program.
(B)	The program must obtain written approval from the Division before relocating a program site,
expanding the certified capacity at an existing site, or opening a satellite at a different program
site.

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(C) Annually, the program must submit to the Division:
(1)	a current local occupancy permit;
(2)	a current local fire department inspection certification; and
(3)	a current local board of health inspection certification.
(D)	The program must document transportation utilization.
(1)	The program must keep accurate records of the transportation rate established for each member.
(2)	When a private carrier is used, the program must submit to the Division a copy of the contract or agreement with the carrier.
(3)	The program must submit, per the Division’s requirements, a transportation report.
(E)	At the request of the Division, the provider must submit clinical and statistical reports to
demonstrate the medical necessity of services, the amount, duration, and level of services, and the
member’s acuity level.
404.411: Withdrawal by an Adult Day Health Provider from MassHealth
(A)	Provider Obligations.
(1)	An ADH program must not admit any new MassHealth members after the date on which the withdrawal notice was sent to the Division. Members of the ADH program who become eligible for MassHealth after the notice of withdrawal and MassHealth members who are hospitalized or otherwise absent when the notice was sent are not considered new admissions.
(2)	An ADH program that withdraws from MassHealth must continue to provide services to members until such time as other services have been arranged.
(3)	The ADH program must work promptly and diligently to arrange for the relocation of members to MassHealth-participating providers, or, if appropriate, to the community. For relocation requirements, see 130 CMR 410.405.
(B)	Notification to Member and Family.
(1)	The program must notify all members, guardians, family, and other funding sources in writing of the intended closing date no less than 45 days from the intended closing date and specify the assistance to be provided each member in identifying alternative services.
(2)	On the same date on which the adult day health program sends a withdrawal notice to the Division, the program must give notice, in hand, to all its members and their authorized representatives, including those members who have been transferred to hospitals, or who are on non-medical leave of absence. The notice must advise that any member who is eligible for MassHealth on the effective date of the withdrawal must relocate to an ADH participating in MassHealth to ensure continuation of MassHealth payment of services and must be determined eligible to continue to receive the services.
(1)	
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Division of Medical Assistance
Provider Manual Series
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(3)	The notice must also state that the ADH program will work promptly and diligently to arrange for the relocation of members to MassHealth-participating providers or, if appropriate, to alternative community service providers.
(4)	When it has been determined where a member is to be transferred, the ADH program must give the member written notice including the name of the new program to which the member will be transferred.
(C) Notification to the Division.
(1)	An adult day health program electing to withdraw from MassHealth must give written notice of its intention to withdraw to the Division, unless such withdrawal results from a situation beyond the control of the provider such as fire or an act of God. In the instance of alleged emergency withdrawal, the burden of proof will be on the provider. The provider must send the withdrawal notice by certified or registered mail (return receipt requested) to the Division’s Adult Day Health Unit and must be received by the Division no less than 90 days before the effective date of withdrawal.
(2)	Upon notification from the Division, the program must forward a list of all members currently enrolled in the program. The program must notify the Division in writing as members are placed in other programs, including the name of the new program and the members’ start date in the new program.
404.412: Adult Day Health Program Physical Plant Requirements
(A)	Providers must meet physical plant requirements as outlined in 130 CMR 404.412. However, those providers who were providers prior to November 1, 2002, and who continue to meet the physical plant requirements at the time of approval are not required to meet the requirements in 130 CMR 404.412(B) and (C).
(B)	A program must be located in a site that is:

(1)	on ground level (exceptions will be made on a case-by-case basis, as determined by the Division in collaboration with local authorities) with at least two means of egress;
(2)	free of architectural barriers;
(3)	designed to meet the needs of disabled persons; and
(4)	in compliance with local health, fire, and safety codes.
(C)	Adult day health space must be utilized only for the provision of adult day health services.
The Division may waive this requirement at its discretion. The program site must be designed
with adequate space for the provision of all adult day health services. Each site must include:
(1)	a dining area;
(2)	a clean and sanitary food-preparation area equipped with a refrigerator, a sink, and adequate counter and storage space;
(3)	a project area equipped with adequate table and seating space;
(4)	a group-activity area;
(5)	a private, enclosed space with four walls connected to the ceiling and the floor, free from disruption, for individual nursing services or counseling;
(6)	a rest area with four walls connected to the ceiling and floor with at least one bed, cot, or recliner for every 20 members based on capacity;
(7)	at least one comfortable resting chair for every six members per day based on capacity;
(1)	
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Division of Medical Assistance
Provider Manual Series
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(8)	storage space for program and operating supplies and equipment;
(9)	adequate outdoor space for members to safely arrive at and depart from the program site;

(10)	a locked storage area not accessible to members for the storage of toxic substances used either in activities or cleaning;
(11)	a secure environment for members who wander;
(12)	a conspicuously posted evacuation plan in each room;
(13)	equipment and furniture that is safe, clean, and appropriate;
(14)	when space for outdoor activities is available, it must be safe, accessible to the ADH program indoors, and accessible to individuals with disabilities;
(15)	if smoking is permitted, a designated smoking area away from the main activity area that is adequately ventilated and properly supervised;
(16)	its own separate space for all services and programming when located in a facility housing other services;
(17)	a private area for ADL needs including bathing, grooming, dressing, and incontinent care;
(18)	adequate toilet facilities that:

(a)	are located as near to the activity area as possible; and
(b)	are equipped with grab bars or side rails;

(19)	if the daily certified capacity of the program is 25 members or fewer, there must be at least two toilets, including at least one toilet facility designed or adapted to provide access and maneuverability for disabled individuals or individuals in wheelchairs; and
(20)	for sites whose certified capacity exceeds 25, additional toilet facilities in proportion to the requirements of 130 CMR 404.412(B)(19).
(D)	Before opening a site, relocating to a new site, or renovating a current site, the program must
submit to the Division:
(1)	a current local occupancy permit;
(2)	a current local fire department inspection certification; and
(3)	a current local board of health inspection certification. If the town or city where the adult day health center is requesting to provide services does not require a board of health inspection, the provider must submit supporting documentation.
(E)	The program must submit to the Division, within seven days of receipt, any waiver, variance,
or other changes received by the program from local, state, federal, or other sources.
(F)	The program must have on site a minimum of the following health-care equipment:
(1)	an emergency first-aid kit that is visible and accessible to staff;
(2)	a stethoscope;
(3)	a scale;
(4)	a blood-pressure apparatus;
(5)	foot basins;
(6)	thermometers;
(7)	a locked storage space for drugs separate from member activity areas;
(8)	refrigeration for drugs that is separate from food; and
(9)	at least three blankets designated for first aid and medical crisis use only.
(1)	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT DAY HEALTH MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 404.000)	PAGE
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(G) The program must have easily accessible fire extinguishers. One must be located in the kitchen and one located in each program area.
(H) The Division must approve the certified capacity for each participating provider site.
(1)	The maximum capacity limit may be increased only with the written approval of the
Division.
(2)	A minimum of 50 square feet of space must be available for each adult day health
member. This minimum does not include offices (except for the nurse’s office), toilets,
hallways, storage areas, reception areas, and other areas not used for the provision of adult day
health services.
(3) The capacity of an adult day health center is determined by the number of individuals receiving services in the space designated for adult day health regardless of the type of service or funding source.
404.413:  Transportation Services
(A)	Transportation service is defined as:
(1)	transporting members to and from the provider site;
(2)	assisting members while entering and exiting the vehicle; and
(3)	picking members up outside their home and dropping them off outside the program.

(B)	Providers must provide transportation directly or through a subcontractor.
(C)	Rates of Payment. The Division will pay the program for transportation service at a weighted-average, one-way rate established by the program and approved by the Division. Each program must submit their proposed one-way rates to the Division for approval. The Division will assess the proposed weighted-average rate and set the provider’s transportation service rate. The Division will pay the provider’s approved transportation service rate for each member transported by the program. When approving a transportation rate, the Division will consider:

(1)	the approved rates of other providers in that geographic area;
(2)	whether the provider is using the least expensive form of transportation; and
(3)	additional cost report information as requested by the Division.
(D)	Other Requirements. The program must ensure that:
(1)	all vehicles used for transporting members are licensed by the Massachusetts Registry of Motor Vehicles;
(2)	the operation of these vehicles is in accordance with all local, state, and federal statutes and ordinances; and
(3)	the drivers of these vehicles are fully instructed in the Massachusetts motor-vehicle laws, possess valid Massachusetts driver's licenses, have undergone a Criminal Offender Records Information (CORI) check and drug and alcohol testing, are certified in CPR and first aid, have experience transporting passengers, and have received training in meeting the needs of aged and disabled persons.
(E)	The ADH program and the transportation provider should attempt to minimize travel distance
and travel time. If a member needs to be transported outside the towns bordering the town where
the ADH center is located, they must receive prior authorization from the Division.

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404.414:  Payment for Services
The Division pays for medically necessary ADH services provided to MassHealth members who have been approved for adult day health services as outlined in 130 CMR 404.405(A) and meet the requirements of 130 CMR 404.414(B). There are three different payment rates, one for basic level of care, as defined in 130 CMR 404.407(A), one for complex level of care, as outlined in 130 CMR 404.414(A)(2), and one for health promotion and prevention, as outlined in 130 CMR 404.414(D).
(A)	Levels of Care.
(1)	Basic Level of Care. The Division covers adult day health services at the basic level of care to eligible adult members who meet the clinical eligibility requirements identified in 130 CMR 404.407(A).
(2)	Complex Level of Care. In addition to basic level-of-care services, the Division will pay for ADH at a complex level of care if a member has met basic level-of-care criteria, has met nursing facility eligibility criteria as outlined in 130 CMR 456.409, and is receiving those services at the center.
(B)	Acuity Level. Once a member has been determined to meet the minimum standard for
coverage of adult day health services, the provider may submit claims for either basic level of care
services, health promotion and prevention services, or complex level of care services.
(1)	The determination of what service level is paid for must be done on admission, annually, and with significant change in the member’s clinical status. The ADH program must use the assessment form designated by the Division to document the need for basic or complex level-of-care services.
(2)	The provider must assess the member’s clinical status annually and with significant change. The provider must bill the Division at the basic level-of-care rate until such time as the determination of acuity level indicates that the member's condition requires complex level-of-care services.
(3)	The provider need not complete a new acuity tool, if one has been completed within 15 days of the annual assessment.
(4)	The provider must maintain documentation in the member’s medical record that reflects the member's acuity level.
(C)	Significant Change.
(1)	If the member changes significantly due to progressive disease, functional decline, resolution of a problem, or other issues, a new assessment may be needed.
(2)	A significant change assessment must be completed if there is a consistent pattern of changes, with either one more areas of decline, or one or more areas of improvement.
(3)	Significant change assessments are not required for minor or temporary variations in resident status. Generally, if the condition has not resolved within approximately two weeks, an assessment should be done.
(4)	Complete the designated assessment tool no later that 14 days after determining a significant change has occurred.
(1)	
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(D) Rates of Payment.
(1)	Rates for Basic Level of Care and Complex Level of Care. The Division pays for basic level of care and complex level of care adult day health services at rates established by the Division of Health Care Finance and Policy.
(2)	Transitional Payment Rate. ADH providers who were, as of August 1, 2002, Dementia Day Service Providers under contract with Aging Service Access Points under the Executive Office of Elder Affairs Home and Community Based Waiver Program, will be paid, in lieu of the ADH rates of payment established by the Division of Health Care Finance and Policy, a per diem rate of $55.00 for providing complex level of care to a member. This rate will only apply to dates of service from August 1, 2002 through July 31, 2003. The transitional payment rate is limited to the number of members served in each provider’s Dementia Day Waiver Program as of August 1, 2002, as verified by payment information on file for dates of service August 1, 2002 through July 31, 2003. For dates of service on or after August 1, 2003, providers will be paid at the same level of care as other providers, as established by the Division of Health Care Finance and Policy.
(3)	Health Promotion and Prevention Rate (HPPR). The Division pays providers at the HPPR for adult day health services to a member who meets the clinical eligibility requirements at the time the member is admitted to the program but who, due to improved health, no longer meets these clinical requirements.
404.415:  Conditions of Payment
(A)	The Division pays for adult day health services beginning with the effective date of the authorization.
(B)	The Division pays an adult day health provider for only those attendance days attended by an eligible MassHealth member.
(C)	The Division pays for adult day health services only when the member attends for at least two six-hour days. Members must attend the program at least six hours each day, excluding transportation time to and from the program. Any alteration from this requirement is at the discretion of the Division and must be approved.
404.416:  Noncovered Services
The Division will not pay for adult day health services for:
(A)	individuals who reside in an institutional setting;
(B)	any canceled program days or any attendance days missed by a member for any reason; and
(C)	any portion of a day during which the member is absent from the site, unless the program documents that the member was receiving services from the program staff outside of the adult day health site in a community setting.
REGULATORY AUTHORITY
130 CMR 404.000: M.G.L. c. 118E, § 7 and 12.

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This page is reserved.

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601	Service Codes and Descriptions: Per Diem Services
(See 130 CMR 404.422.)
Service
Code       Service Description
Per diem services furnished on a single date or consecutive dates (times number of days)
X9841	Adult day health-basic level of care
X9842	Transitional payment rate
X9844	Adult day health-Health Promotion and Prevention Rate (HPPR)
X9845	Adult day health-complex level of care
602	Service Codes and Descriptions: Transportation Services
(See 130 CMR 404.413.)
Service
Code       Service Description
X0091     Transportation furnished on a single date or consecutive dates (one-way rate times trips per day times number of days)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT DAY HEALTH MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-2	

	TRANSMITTAL LETTER
ADH-15	DATE
11/01/02	
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Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT DAY HEALTH MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX D: DEMENTIA DAY SERVICE	PAGE
D-1	

	TRANSMITTAL LETTER
ADH-15	DATE
11/01/02	
Dementia Day Service Guidelines
The Dementia Day Program provides specialized day care services to address the needs of eligible individuals, for those who service the dementia, Alzheimer’s, and cognitively disturbed populations.
In addition to meeting the expectations of the adult day health regulations at 130 CMR 404.000, programs that offer services to dementia populations should follow these guidelines.
(A)	Philosophy. To provide therapeutic activities for debilitated older adults that maximize functional performance in areas such as cognition, health, mood, and behavior.
(B)	Admission. Admission and reimbursement of dementia-specific programming is based on the complex level of care for adult day health. To receive complex level-of-care rates, the members must meet nursing facility eligibility as outlined in 130 CMR 456.409. Adult day health programs must maintain documentation that demonstrates the complex level of care.
(C)	Member Care Plan. The member’s care plan should be developed to address the physical, psychosocial, behavioral, and activities of daily living needs of the member. The plan should include:

(1)	individual service needs;
(2)	measurable objectives of care for the member; and
(3)	a supportive service and activity plan designed to meet the psychosocial and therapeutic needs of the member.
(D)	Program Specifications.
(1)	When a program serves both a demented and non-demented population, a separate space must be available for programming for the dementia population.
(2)	Services and activities should include helping members and families adjust physically and psychologically to the illness.
(3)	Activities should be appropriate and provided for high- and low-functioning groups.
(4)	Activities should be habilitative and provide:

•	opportunities to maximize functional independence;
•	enjoyable, pleasurable experiences;
•	a positive outlet for energy and emotions;
•	opportunities for self-expression;
•	structured time;
•	relaxation and stress release;
•	accommodations for wandering in a safe climate;
•	physical fitness activities;
•	continued contact with the community;
•	opportunities for peer relationships;
•	coordination with those involved in the provision of care; and
•	coordination with community service providers for needed therapies and resocialization.
•	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ADULT DAY HEALTH MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX D: DEMENTIA DAY SERVICE	PAGE
D-2	

	TRANSMITTAL LETTER
ADH-15	DATE
11/01/02	
(E)	Staffing and Education.
(1)	Programs who serve demented clients, with either Alzheimer’s or dementia, should ensure that they can safely serve that population. Staff should have adequate skills, education, and experience to serve the population in a manner consistent with the philosophy of the adult day health center.
(2)	When a provider serves members at both basic and complex levels of care, direct care staff ratios should be blended to meet the needs of their members, as an aggregate to meet the ratio.
(3)	The program must maintain a staff-to-member ratio of at least 1:4 on site.
(4)	The program must provide the following education and training supports:

•	dealing with dementia;
•	verbal and non-verbal communication skills;
•	behavior management skills;
•	group process skills;
•	family functioning;
•	dealing with difficulty in group participation;
•	dealing with high anxiety;
•	dealing with aggressive behavior; and
•	dealing with wandering.
(F)	Physical Plant. The physical environment should create an atmosphere that helps individuals
compensate for cognitive losses, by providing:
(1)	a lower stimulation area or a room with reduced auditory and visual stimulation;
(2)	wall coverings that are simple in design on non-shiny paper or flat painted walls;
(3)	plant design, maintenance, and upkeep that incorporate current research findings that improve care for this population;
(4)	exit doors that are alarmed or secured;
(5)	security features to prevent unsupervised wandering; and
(6)	dividers, partitions, and barriers that are secured.