University of Massachusetts Medical School ACQUIRED BRAIN INJURY WAIVER PROVIDER CREDENTIALING SUPPLEMENT

Transcription

1 University f Massachusetts Medical Schl PROVIDER NAME: DATE: ADDRESS: PHONE : FAX: FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): SOCIAL SECURITY NUMBER : Page 1 f 17 UCHECKLIST All prviders (Organizatins r Self-Emplyed Prviders) will submit the fllwing dcumentatin and materials: MassHealth Acquired Brain Injury (ABI) Waivers Prvider Applicatin Massachusetts Medicaid Prgram Prvider Agreement MassHealth Trading Partner Agreement Federally Required Disclsures Frm Data Cllectin Frm Authrizatin fr Electrnic Funds Transfer (EFT) f MassHealth Payments Massachusetts Substitute W-9 Frm ABI Waiver Prvider Credentialing Supplement OrganizatinsU nly, will als submit: Prf f Liability Insurance Prf f Wrkers Cmpensatin Insurance Jb descriptins f key persnnel Jb descriptins fr each jb title prviding ABI Waiver services Business Certificatins by Organizatin Type, including dcumentatin f 501(c)(3) status fr nn-prfit rganizatins Unifrm Financial Reprt (UFR) r cpy f mst recent audit If any EOHHS agency has cancelled their cntract with yu r yur rganizatin in the past three (3) years, please submit a ne-page explanatin which identifies the cntract that was cancelled and describes: the state agency invlved, why the cntract was cancelled and hw the situatin was rectified, r if it was nt reslved.

2 University f Massachusetts Medical Schl Fr infrmatinal purpses nly:* Please indicate gegraphic regin(s) where are yu are willing t prvide services (Check all that apply See Appendix 1 fr list f municipalities by regin): Bstn/Metr Central Sutheast/Cape/Islands Nrtheast Western If applicable, please list the twn/s that yu d nt prvide service t within a particular gegraphic area: In additin t English, please indicate any languages yu r yur rganizatin service prvider staff speak: Language One: Language Tw: * This infrmatin is nt fr the purpse f credentialing and will nt restrict the gegraphic area yu may serve. SERVICE-SPECIFIC REQUIREMENTS INSTRUCTIONS: Service-specific requirements begin n page 3 f this supplement. Please check and submit all the related dcumentatin fr each service type which yu r yur rganizatin are willing t be qualified t prvide. Organizatins r self-emplyed prviders submitting an applicatin fr multiple service types will be credentialed fr each type. Page 2 f 17

3 University f Massachusetts Medical Schl SERVICE SPECIFIC REQUIREMENTS Adult Cmpanin UAdult Cmpanin- Organizatin r Self-Emplyed Prvider U Nn-medical care, supervisin and scializatin services prvided t a Participant. Cmpanins may assist r supervise the Participant with such light husehld tasks as meal preparatin, laundry, and shpping. Each participating prvider is required t sign a Health r Human Service rganizatin r individual MassHealth Prvider Agreement by which it agrees t with experience prviding nnmedical care, cmply with the Federal and State laws, regulatins, and supervisin, and scializatin fr persns with ABI r plicies gverning the ABI Waiver, including the similar disabilities standards fr the specific Medicaid waiver service the All rganizatin staff r self-emplyed prviders prvider will deliver. shuld meet the fllwing qualificatins: Have a high schl diplma, UAND/OR Have life experience wrking with individuals with disabilities Be able t handle emergency situatins CPR certificatin fr all direct care staff Staff members shall have the ability t cmmunicate effectively in the language and cmmunicatin style f the participant t whm they prvide services and his r her family UDcuments t be submitted by Organizatins: Descriptin f experience prviding Adult Cmpanin Services r similar services (nt t exceed 1 Page) Staff Rster which includes: staff name, psitin, and # f hurs per week that they perfrm the abve listed service Resume f Prgram Directr UDcuments t be submitted by Self-emplyed Prvider applicants: Resume Descriptin f experience prviding Adult Cmpanin r similar services (nt t exceed 1 page) CPR Certificate Tw (2) Letters f prfessinal reference CORI Request Frm Fr rganizatinal prviders, the standards include, but are nt limited t: Fr each emplyee prviding Adult Cmpanin services, maintain the fllwing recrds: CORI Reference Checks Resume Training/in-service certificates Cpy f Prfessinal License (if applicable) Perfrmance evaluatins Tuberculsis Screening & Testing Prgram Plicies and Prcedures inclusive f: Cnfidentiality and Release f Infrmatin Incident Reprting Human Rights Mandatry Reprting Cmplaint Reslutin Jb Descriptins and Salary Scales Universal Precautins Plicy that prhibits wrkers frm handling participants mney Fr self-emplyed prviders, the standards include, but are nt limited t: Maintain dcumentatin f cmpleted trainings Maintain a recrd fr each participant receiving care r services as required in CMR Maintain a recrd f Tuberculsis Screening & Testing Wrk with UMMS Credentialing staff t establish plicies and prcedures Page 3 f 17

4 University f Massachusetts Medical Schl SERVICE SPECIFIC REQUIREMENTS Chre Services UChre Services Organizatin An unusual r infrequent husehld maintenance task that is needed t maintain the Participant's hme in a clean, sanitary, and safe envirnment. This service includes heavy husehld chres such as washing flrs, windws, and walls; tacking dwn lse rugs and tiles; and mving heavy items f furniture in rder t prvide safe access and egress. Health r Human Service rganizatin with experience prviding services needed t maintain the hme in a clean, sanitary, and safe cnditin Staff members shall have the ability t cmmunicate effectively in the language and cmmunicatin style f the participant t whm they prvide services and his r her family The prvider must accept r reject an ABI Waiver service request by the end f the next business day fllwing receipt f the request UDcuments t be submitted: Descriptin f experience prviding Chre Services r similar services (nt t exceed 1 Page) Staff Rster which includes: staff name, and psitin Resume f Prgram Directr Each participating prvider is required t sign a MassHealth Prvider Agreement by which it agrees t cmply with the Federal and State laws, regulatins, and plicies gverning the ABI Waiver, including the standards fr the specific Medicaid waiver service the prvider will deliver. Fr rganizatinal prviders, the standards include, but are nt limited t: Fr each emplyee prviding Chre Services, maintain the fllwing recrds CORI Reference Checks Resume Training/in-service certificates Cpy f Prfessinal License (if applicable) Perfrmance evaluatins Tuberculsis Screening &Testing Prgram Plicies and Prcedures inclusive f: Cnfidentiality and Release f Infrmatin Incident Reprting Human Rights Mandatry Reprting Cmplaint Reslutin Jb Descriptins and Salary Scales Universal Precautins Plicy that prhibits wrkers frm handling participants mney Page 4 f 17

5 University f Massachusetts Medical Schl SERVICE SPECIFIC REQUIREMENTS Cmmunity-Based Substance Abuse Treatment UCmmunity-Based Substance Abuse Treatment - Organizatin Individually designed strategies and appraches prvided via 24-hur supprt and supervisin in a residential rehabilitatin substance abuse treatment and educatin prgram fr adults, that prmte independence and integratin t decrease the Participant's substance abuse and/r alchl abuse behavirs that interfere with his r her ability t remain in the cmmunity. Licensed as a residential rehabilitatin substance abuse treatment and educatin prgram fr adults; UAND Private rganizatin perating as a free standing residential rehabilitatin substance abuse treatment prgram fr adults, NOT prvided in a hspital, nursing facility r similar medical facility UDcuments t be submitted: Cpy f DPH License; Letter stating that the rganizatin meets free standing residential rehab requirements Descriptin f experience prviding Cmmunity- Based Substance Abuse services (nt t exceed 1 Page) Each participating prvider is required t sign a MassHealth Prvider Agreement by which it agrees t cmply with the Federal and State laws, regulatins, and plicies gverning the ABI Waiver, including the standards fr the specific Medicaid waiver service the prvider will deliver. Fr rganizatinal prviders, the standards include, but are nt limited t: Fr each emplyee prviding Cmmunity-Based Substance Abuse Treatment Services, maintain the fllwing recrds: CORI Reference Checks Resume Training/in-service certificates Cpy f Prfessinal License (if applicable) Perfrmance evaluatins Tuberculsis Screening &Testing Prgram Plicies and Prcedures inclusive f: Cnfidentiality and Release f Infrmatin Incident Reprting Human Rights Mandatry Reprting Cmplaint Reslutin Jb Descriptins and Salary Scales Universal Precautins Plicy that prhibits wrkers frm handling participants mney Page 5 f 17

6 University f Massachusetts Medical Schl SERVICE SPECIFIC REQUIREMENTS Day Services (2 pages) UDay Services - OrganizatinU A structured, site-based, grup prgram fr participants that ffers assistance with the acquisitin, retentin, r imprvement in self-help, scializatin, and adaptive skills, and that takes place in a nnresidential setting separate frm the Participant's private residence r ther residential living arrangement. Services ften include assistance t learn activities f daily living and functinal skills; language and cmmunicatin training; cmpensatry, cgnitive and ther strategies; interpersnal skills, prevcatinal skills; and recreatinal and scializatin skills. Health r Human Service Organizatin engaged in the business f prviding Day Services t persns with acquired brain injuries r similar disabilities Prgrams must emply a designated Prgram Directr wh must have a Master s degree in health and human services related field r a Bachelrs degree with five years experiencing wrking with individuals with ABI r similar disability Senir Staff must have a Bachelr s in rehabilitatin r related field; and tw years experience wrking with the ABI ppulatin Staff members shall have the ability t cmmunicate effectively in the language and cmmunicatin style f the individual t whm they prvide services and his r her family Fire Drills must be cnducted at least quarterly At a minimum, maintain 1:6 staff t Participant rati Must meet site requirements established by the Mass Rehabilitatin Cmmissin fr the prvisin f day services t persns with a acquired brain injuries UDcuments t be submitted by existing Day Service prviders wh are either MassHealth enrlled r State Agency certified/ licensed: Dcumentatin indicating current Day Service Prvider apprval: Adult Day Health Certificate; UOR Dcumentatin that indicates the rganizatin has met the requirements f 130 CMR as a Day Habilitatin Prgram; UOR State Agency Day Prgram License/Certificate, i.e. DDS/DMH/MRC Staff Rster which includes: staff name, psitin, and # f hurs per week that they perfrm the abve listed service Resume f Prgram Directr and applicable prfessinal licensure Occupancy permit which includes capacity and current census Page 6 f 17 (cntinued n next page) Each participating prvider is required t sign a MassHealth Prvider Agreement by which it agrees t cmply with the Federal and State laws, regulatins, and plicies gverning the ABI Waiver, including the standards fr the specific Medicaid waiver service the prvider will deliver. Fr rganizatinal prviders, the standards include, but are nt limited t: Fr each emplyee prviding Day Services, maintain the fllwing recrds: CORI Reference Checks Resume Training/in-service certificates Cpy f Prfessinal License (if applicable) Perfrmance evaluatins Tuberculsis Screening &Testing Fr each cnsultant (i.e. f therapies such as Speech Therapy, Occupatinal Therapy, etc.) maintain the fllwing recrds: Cntracts Resumes Prfessinal licenses Prgram Plicies and Prcedures inclusive f: Cnfidentiality and Release f Infrmatin Incident Reprting Human Rights Mandatry Reprting Cmplaint Reslutin Jb Descriptins and Salary Scales Universal Precautins Plicy that prhibits wrkers frm handling participants mney Plicy fr Fire Safety and Fire Drills Plicy which illustrates Evacuatin Plan inclusive f Emergency prtcl

7 University f Massachusetts Medical Schl DAY SERVICES REQUIREMENTS (cnt d) Dcuments t be submitted by new Day Service Prviders: Descriptin f experience prviding day services r similar service (nt t exceed 1 Page) Day Prgram rganizatin chart Prpsed Staff Rster which includes: staff name, psitin and # f hurs per week that they perfrm the abve listed service Cpy f CARF Accreditatin (if applicable) Resume f Prgram Directr and applicable prfessinal licensure Occupancy permit which includes capacity and current census Lcal fire department inspectin reprt Current lcal Bard f Health inspectin r certificate (e.g. Fd Establishment permit). If the twn r city where the prgram will be sited des nt require a Bard f Health inspectin, the prvider must submit supprting dcumentatin. A flr plan (r drawing) f the prpsed prgram site which identifies: Label all rms fr use, be specific as t length and width f each space Prvide square ftage fr each rm r space Clset, strage areas, hallways, lbbies and similar spaces shuld be clearly labeled with the dimensins indicated Cpy f the evacuatin plan fr meeting the special needs f members, under circumstances requiring emergency evacuatin Page 7 f 17

8 University f Massachusetts Medical Schl SERVICE SPECIFIC REQUIREMENTS Hmemaker Hmemaker (HM) - Organizatin A persn wh perfrms light husekeeping duties (fr example, cking, cleaning, laundry, and shpping) fr the purpse f maintaining a husehld. Health r Human Service Organizatin engaged in the business f prviding Hmemaker services whse emplyees have at least ne f the fllwing qualificatins: Certificate f 40-hur hmemaker training; OR Certificate f 60-hur persnal care training; OR Certificate f hme health aide training; OR Certificate f nurse s aide training Staff members shall have the ability t cmmunicate effectively in the language and cmmunicatin style f the Participant t whm they prvide services and his r her family CPR certificatin fr all direct care staff Prviders must ensure that supervisin is prvided by Scial Wrkers, Registered Nurses, and/r prfessinals with relevant expertise with availability ffered during regular business hurs, and n weekends, hlidays, and evenings Supervisin must be carried ut at least nce every three mnths by a qualified supervisr. In-hme supervisin must be dne with a representative sample f participants A sufficient number f HM staff must be available t meet the needs f participants accepted fr service The prvider must accept r reject an ABI Waiver service request by the end f the next business day fllwing receipt f the request Dcuments t be submitted: Descriptin f experience prviding HM services r similar services (nt t exceed 1 page) Resumes f staff prviding supervisin t HM Staff Rster which includes: staff name, psitin, and # f hurs per week that they prvide the abve listed service Each participating prvider is required t sign a MassHealth Prvider Agreement by which it agrees t cmply with the Federal and State laws, regulatins, and plicies gverning the ABI Waiver, including the standards fr the specific Medicaid waiver service the prvider will deliver. Fr rganizatinal prviders, the standards include, but are nt limited t: Fr each emplyee prviding HM services, maintain the fllwing recrds: CORI Reference Checks Resume Training/in-service certificates Cpy f Prfessinal License (if applicable) Perfrmance evaluatins Tuberculsis Screening &Testing Prgram Plicies and Prcedures inclusive f: Cnfidentiality and Release f Infrmatin Incident Reprting Human Rights Mandatry Reprting Cmplaint Reslutin Jb Descriptins and Salary Scales Universal Precautins Plicy that prhibits wrkers frm handling participants mney Page 8 f 17

9 University f Massachusetts Medical Schl SERVICE SPECIFIC REQUIREMENTS Individual Supprt and Cmmunity Habilitatin Individual Supprt and Cmmunity Habilitatin Organizatin r Self-Emplyed Prviders Regular r intermittent services designed t develp, maintain, and/r maximize the participant s independent functining in self-care, physical and emtinal grwth, scializatin, cmmunicatin, and vcatinal skills, t achieve bjectives f imprved health and welfare and t the supprt the ability f the participant t establish and maintain a residence and live in the cmmunity. All rganizatin staff r self-emplyed prviders shuld meet the fllwing qualificatins: Have a Cllege degree (preferably in a human service field) plus experience in prviding cmmunity-based services t individuals with disabilities r at least 2 years cmparable, cmmunity-based, life r wrk experience prviding services t individuals with disabilities Have the ability t cmmunicate effectively in the language and cmmunicatin style f the Participant t whm they prvide services and his r her family CPR certificatin fr all direct care staff Dcuments t be submitted by rganizatins: Descriptin f experience prviding Individual Supprt and Habilitatin services r similar services (nt t exceed 1 Page) Resume f Prgram Directr and applicable licenses Staff Rster which includes: staff name, psitin, and # f hurs per that they prvide the abve listed service Dcuments t be submitted by self-emplyed prviders : Resume Descriptin f experience prviding Individual Supprt and Cmmunity Habilitatin r similar services (nt t exceed 1 page) CPR Certificate Tw (2) Letters f prfessinal reference CORI Request Frm Each participating prvider is required t sign a MassHealth Prvider Agreement by which it agrees t cmply with the Federal and State laws, regulatins, and plicies gverning the ABI Waiver, including the standards fr the specific Medicaid waiver service the prvider will deliver. Fr rganizatinal prviders, the standards include, but are nt limited t: Fr each emplyee prviding Individual Supprt and Cmmunity Habilitatin services, maintain the fllwing recrds: CORI Reference Checks Resume Training/in-service certificates Cpy f Prfessinal License (if applicable) Perfrmance evaluatins Tuberculsis Screening &Testing Prgram Plicies and Prcedures inclusive f: Cnfidentiality and Release f Infrmatin Incident Reprting Human Rights Mandatry Reprting Cmplaint Reslutin Jb Descriptins and Salary Scales Universal Precautins Plicy that prhibits wrkers frm handling participants mney Fr self-emplyed prviders, the standards include, but are nt limited t: Maintain dcumentatin f cmpleted trainings Maintain a recrd fr each participant receiving care r services as required in CMR Maintain a recrd f Tuberculsis Screening & Testing Wrk with UMMS Credentialing staff t establish plicies and prcedures Page 9 f 17

10 University f Massachusetts Medical Schl SERVICE SPECIFIC REQUIREMENTS Persnal Care Persnal Care Organizatin A range f assistance that is apprpriate and necessary fr the participant s health and well-being t enable the participant t accmplish fundamental activities f daily living, including, but nt limited t, eating, tileting, dressing, bathing, transferring, and ambulatin. Health r Human Service Organizatin engaged in the business f prviding persnal care services that emplys persnal care staff with at least ne f the fllwing qualificatins: Certificate f 60-hur persnal care training; OR Certificate f hme health aide training; OR Certificate f nurse s aide training CPR certificatin fr all direct care staff Have the ability t cmmunicate effectively in the language and cmmunicatin style f the Participant t whm they prvide services and his r her family Prviders must ensure that supervisin is prvided by Scial Wrkers, Registered Nurses; and/r prfessinals with relevant expertise with availability ffered during regular business hurs, and n weekends, hlidays, and evenings PC Supervisin: An RN must prvide in-hme supervisin f PC staff at least nce every 3 mnths with a representative sample f participants. A written perfrmance f PC skills must be cmpleted after each hme visit. LPNs may prvide in-hme supervisin if the LPN has a valid license in Massachusetts, and wrks under the directin f an RN wh is engaged in field supervisin a minimum f 20-hurs per week and is respnsible fr the field supervisin carried ut by LPN A sufficient number f PC staff must be available t meet the needs f participants accepted fr service. The prvider must accept r reject an ABI Waiver service request by the end f the next business day fllwing receipt f the request Dcuments t be submitted: Descriptin f experience prviding Persnal Care Services (nt t exceed 1 Page) Resume f Prgram Directr and applicable prfessinal licensure Staff Rster which includes: staff name, psitin, and # f hurs per week that they prvide the abve listed service Each participating prvider is required t sign a MassHealth Prvider Agreement by which it agrees t cmply with the Federal and State laws, regulatins, and plicies gverning the ABI Waiver, including the standards fr the specific Medicaid waiver service the prvider will deliver. Fr rganizatinal prviders, the standards include, but are nt limited t: Fr each emplyee prviding Persnal Care services, maintain the fllwing recrds: CORI Reference Checks Resume Training/in-service certificates Cpy f Prfessinal License (if applicable) Perfrmance evaluatins Tuberculsis Screening &Testing Prgram Plicies and Prcedures inclusive f: Cnfidentiality and Release f Infrmatin Incident Reprting Human Rights Mandatry Reprting Cmplaint Reslutin Jb Descriptins and Salary Scales Universal Precautins Plicy that prhibits wrkers frm handling participants mney Page 10 f 17

11 University f Massachusetts Medical Schl SERVICE SPECIFIC REQUIREMENTS Respite Respite - Organizatin Services prvided t individuals unable t care fr themselves; furnished n a shrt-term basis because f the absence r need fr relief f thse persns nrmally prviding the care. Agencies applying t be Respite prviders must: Be licensed as a hspital by MA Department f Public Health under 105 CMR ; OR Be certified as an assisted living residence by the Executive Office f Elder Affairs under 651 CMR 12.00; OR Be licensed as a nursing facility by the MA Department f Public Health under 105 CMR ; OR Meet site based requirements established by the MA Department f Develpmental Services under 115 CMR 7.00; OR Be enrlled as a participating adult fster care prvider in the MassHealth Prgram under 130 CMR Dcuments t be submitted: Descriptin f experience prviding Respite Services (nt t exceed 1 Page) Cpy f apprpriate license r certificate indicating respite prvider type Each participating prvider is required t sign a MassHealth Prvider Agreement by which it agrees t cmply with the Federal and State laws, regulatins, and plicies gverning the ABI Waiver, including the standards fr the specific Medicaid waiver service the prvider will deliver. Fr rganizatinal prviders, the standards include, but are nt limited t: Fr each emplyee prviding Respite services, maintain the fllwing recrds: CORI Reference Checks Resume Training/in-service certificates Cpy f Prfessinal License (if applicable) Perfrmance evaluatins Tuberculsis Screening &Testing Prgram Plicies and Prcedures inclusive f: Cnfidentiality and Release f Infrmatin Incident Reprting Human Rights Mandatry Reprting Cmplaint Reslutin Jb Descriptins and Salary Scales Universal Precautins Plicy that prhibits wrkers frm handling participants mney Page 11 f 17

12 University f Massachusetts Medical Schl SERVICE SPECIFIC REQUIREMENTS Specialized Medical Equipment Specialized Medical Equipment - Organizatin Devices cntrls r appliances t increase abilities in activities f daily living, r t cntrl r cmmunicate with the envirnment. A prvider must be an individual r entity engaged in the business f furnishing durable medical equipment, medical/surgical supplies, r custmized equipment, r a prvider participating in MassHealth under 130 CMR r a pharmacy participating in MassHealth under 130 CMR ; OR An entity engaged in the business f furnishing durable medical equipment, medical/surgical supplies, r custmized equipment Staff members shall have the ability t cmmunicate effectively in the language and cmmunicatin style f the Participant t whm they prvide services and his r her family Dcuments t be submitted: Descriptin f experience being a Specialized Medical Prvider r similar service prvider (nt t exceed 1 Page) DME prviders must have dcumentatin that they meet requirements set frth in 130 CMR 409 If nt a DME prvider, a list f cntracted manufacturers used fr purchased prducts Cpy f current accreditatin letters Fr PERS prviders nly, a cpy f dcumentatin demnstrating cmpliance with UL Standards 1637 in accrdance with 130 CMR (C) Cpy f Massachusetts Bard f Registratin in Pharmacy license (Pharmacy nly) Each participating prvider is required t sign a MassHealth Prvider Agreement by which it agrees t cmply with the Federal and State laws, regulatins, and plicies gverning the ABI Waiver, including the standards fr the specific Medicaid waiver service the prvider will deliver. Fr rganizatinal prviders, the standards include, but are nt limited t: Fr each emplyee wrking with ABI participants, maintain the fllwing recrds: CORI Reference Checks Resume Training/in-service certificates Cpy f Prfessinal License (if applicable) Perfrmance evaluatin Fr mbility prviders nly, a cpy f current Rehabilitatin Engineering and Assistive Technlgy Sciety f Nrth America Assistive Technlgy Prfessinal (RESNA ATP) certificate fr each certified staff persn. Prgram Plicies and Prcedures inclusive f: Cnfidentiality and Release f Infrmatin Incident Reprting Human Rights Mandatry Reprting Cmplaint Reslutin Page 12 f 17

13 University f Massachusetts Medical Schl SERVICE SPECIFIC REQUIREMENTS Supprted Emplyment Supprted Emplyment - Organizatin Regularly scheduled services that enable Participants, thrugh training and supprt, t wrk in integrated wrk settings in which individuals are wrking tward cmpensated wrk, cnsistent with the strengths, resurces, pririties, cncerns, abilities, capabilities, interests, and infrmed chice f the individuals. Human Service rganizatin with experience prviding supprted emplyment r similar services Emply staff that have a cllege degree and experience in prviding cmmunity-based services r at least 2 years experience prviding services t individuals with disabilities CPR certificatin fr all direct care staff Have direct experience wrking ne-t ne with individuals with an ABI r similar disabilities Staff members shall have the ability t cmmunicate effectively in the language and cmmunicatin style f the Participant t whm they prvide services and his r her family Dcuments t be submitted: Descriptin f experience prviding Supprted Emplyment services r similar services (nt t exceed 1 Page) Staff Rster which includes: staff name, and psitin Resume f Prgram Directr Each participating prvider is required t sign a MassHealth Prvider Agreement by which it agrees t cmply with the Federal and State laws, regulatins, and plicies gverning the ABI Waiver, including the standards fr the specific Medicaid waiver service the prvider will deliver. Fr rganizatinal prviders, the standards include, but are nt limited t: Fr each emplyee prviding Supprted Emplyment services, maintain the fllwing recrds: CORI Reference Checks Resume Training/in-service certificates Cpy f Prfessinal License (if applicable) Perfrmance evaluatins Tuberculsis Screening &Testing Prgram Plicies and Prcedures inclusive f: Cnfidentiality and Release f Infrmatin Incident Reprting Human Rights Mandatry Reprting Cmplaint Reslutin Jb Descriptins and Salary Scales Universal Precautins Plicy that prhibits wrkers frm handling participants mney Page 13 f 17

14 Page 14 f 17 University f Massachusetts Medical Schl SERVICE SPECIFIC REQUIREMENTS Therapy Services (2 pages) Therapy Services (Occupatinal, Physical and Speech Therapy) - Organizatins r Self-Emplyed Prviders Therapy services, including diagnstic evaluatin and therapeutic interventin, designed t imprve, develp, crrect, rehabilitate, r prevent the wrsening f physical r speech/language cmmunicatin and swallwing disrders functins that affect the activities f daily living that have been lst, impaired, r reduced as a result f acute r chrnic medical cnditins, cngenital anmalies, r injuries. Hmecare Agency r Individual licensed in Massachusetts t prvide Occupatinal, Physical, r Speech Therapy Occupatinal Therapy An individual Occupatinal Therapist under MassHealth 130 CMR ; OR A hme health agency perating under 130 CMR Physical Therapy An individual Physical Therapist under MassHealth 130 CMR ; OR A hme health Agency participating in MassHealth under 130 CMR Speech Therapy An individual Speech Therapist under MassHealth 130 CMR ; OR A speech/hearing center under MassHealth 130 CMR ; OR A hme health agency under MassHealth 130 CMR All ccupatin therapy services must be prvided by a licensed ccupatinal therapist r by a licensed ccupatinal therapy assistant under the supervisin f a licensed ccupatinal therapist All physical therapy services must be prvided by a licensed physical therapist r by a licensed physical therapy assistant under the supervisin f a licensed physical therapist All speech therapy services must be prvided by a licensed speech therapist Dcuments t be submitted by Organizatins: Descriptin f experience prviding therapy services (nt t exceed 1 Page) Staff Rster which includes staff name, psitin, and # hurs per week that they perfrm the abve listed service Certificate as a prvider f hme health services; OR DPH Speech and Hearing Center License; OR American Speech-Language-Hearing Assciatin (ASHA) Certificate (Cntinued t next page) Each participating prvider is required t sign a MassHealth Prvider Agreement by which it agrees t cmply with the Federal and State laws, regulatins, and plicies gverning the ABI Waiver, including the standards fr the specific Medicaid waiver service the prvider will deliver. Fr rganizatinal prviders, the standards include, but are nt limited t: Fr each emplyee prviding Therapy services, maintain the fllwing recrds: CORI Reference Checks Resume Training/in-service certificates Cpy f Prfessinal License Perfrmance evaluatins Tuberculsis Screening &Testing Prgram Plicies and Prcedures inclusive f: Cnfidentiality and Release f Infrmatin Incident Reprting Human Rights Mandatry Reprting Cmplaint Reslutin Jb Descriptins and Salary Scales Universal Precautins Plicy that prhibits wrkers frm handling participants mney Fr self-emplyed prviders, the standards include, but are nt limited t: Maintain dcumentatin f cmpleted trainings Maintain a recrd fr each participant receiving care r services as required in CMR Maintain a recrd f Tuberculsis Screening & Testing Wrk with UMMS Credentialing staff t establish plicies and prcedures

15 University f Massachusetts Medical Schl THERAPY SERVICES (cnt d) Dcuments t be submitted by Self-emplyed prviders : Descriptin f experience prviding either Occupatinal, Physical r Speech Therapy services (nt t exceed 1 page) Tw (2) letters f prfessinal reference Cpy f state license, i.e. OT, PT, SL/P CORI Request Frm Page 15 f 17

16 University f Massachusetts Medical Schl SERVICE SPECIFIC REQUIREMENTS Transprtatin Transprtatin - Organizatin Cnveyance f participants by vehicle frm their residence t and frm the site f ABI Waiver services and ther cmmunity services, activities and resurces, including physical assistance t participants while entering and exiting the vehicle. An rganizatin engaged in the business f transprting persns with disabilities, which must: Ensure that vehicles are leased r cntrlled by the prvider Maintain wrkers cmpensatin insurance fr drivers and mnitrs Emply drivers that are at least 19, have a valid driver s license and 3 years driving experience Ensure vehicles are insured and liability insurance dcumentatin is prvided Ensure vehicles are registered with the MA RMV Ensure that accessible vehicles are equipped with safety equipment t secure wheelchairs Dcuments t be submitted: Descriptin f experience prviding transprtatin t individuals with disabilities (nt t exceed 1 Page) Organizatin plicy n driver safety training Cmpany Hiring Plicy Rster f Drivers Each participating prvider is required t sign a MassHealth Prvider Agreement by which it agrees t cmply with the Federal and State laws, regulatins, and plicies gverning the ABI Waiver, including the standards fr the specific Medicaid waiver service the prvider will deliver. Fr rganizatinal prviders, the standards include, but are nt limited t: Fr each emplyee prviding Transprtatin services, maintain the fllwing recrds: CORI Reference Checks Resume Training/in-service certificates Cpy f Prfessinal License (if applicable) Perfrmance evaluatins Tuberculsis Screening & Testing Cpy f Valid Massachusetts Driver s License Prgram Plicies and Prcedures inclusive f: Cnfidentiality and Release f Infrmatin Incident Reprting Human Rights Mandatry Reprting Cmplaint Reslutin Jb Descriptins and Salary Scales Universal Precautins Plicy that prhibits wrkers frm handling participants mney Certificatin f vehicle maintenance (including age f vehicle, capacity, seatbelts, list f safety equipment, air cnditining/heating) fr each vehicle RMV inspectin fr each vehicle Cmpleted lg indicating that fr vehicles with lifts, the lifts are cycled daily Inspectin f vehicles that demnstrates: First Aid kits Snw Tires in the winter 2-Way cmmunicatin Page 16 f 17

17 CERTIFICATION University f Massachusetts Medical Schl I certify under the pains and penalties f perjury that the infrmatin n this frm and any attached statement that I have prvided has been reviewed and signed by me, and is true, accurate, and cmplete, t the best f my knwledge. I als certify that I am the prvider r, in the case f a legal entity, duly authrized t act n behalf f the prvider. I understand that I may be subject t civil penalties r criminal prsecutin fr any falsificatin, missin, r cncealment f any material fact cntained herein. Prvider s signature (signature and date stamps, r the signature f anyne ther than the prvider r a persn legally authrized t sign n behalf f a legal entity, are nt acceptable) Printed legal name f prvider: Printed legal name f individual signing: (if the prvider is a legal entity) Date: MAIL TO: ABI WAIVER UNIT UMASS Medical Schl ABI Waiver Unit Attn: Prvider Netwrk Manager 333 Suth Street Shrewsbury, MA Page 17 f 17