TITLE 8 SOCIAL SERVICES
CHAPTER 370 OVERSIGHT OF LICENSED HEALTHCARE FACILITIES
AND COMMUNITY BASED WAIVER PROGRAMS
PART 21 QUALITY MANAGEMENT SYSTEM AND REVIEW
REQUIREMENTS FOR
PROVIDERS OF COMMUNITY
BASED SERVICES
8.370.21.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.370.21.1
NMAC - N, 7/1/2024]
8.370.21.2 SCOPE: This
rule is applicable to persons,
organizations or legal entities that are under contract to provide services to the New Mexico health
care authority under the following programs:
developmental disability waiver (DDW), disabled and elderly waiver
(D&EW), medically fragile waiver (MFW), traumatic brain injury (TBI) and family,
infants and toddler (FIT) and any additional programs that may require
provider compliance with these requirements.
[8.370.21.2
NMAC - N, 7/1/2024]
8.370.21.3 STATUTORY AUTHORITY: Subsection E of Section 9-8-6 NMSA 1978 and Subsections
L, O, T and U of Section 24-1-3 of the Public Health Act, NMSA 1978 as amended.
Section
9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as a
single, unified department to administer laws and exercise functions relating health care purchasing and regulation.
[8.370.21.3
NMAC - N, 7/1/2024]
8.370.21.4 DURATION: Permanent.
[8.370.21.4
NMAC - N, 7/1/2024]
8.370.21.5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at
the end of a section.
[8.370.21.5
NMAC - N, 7/1/2024]
8.370.21.6 OBJECTIVE: This rule
establishes standards for provider compliance with health care authority (HCA)
requirements for quality assurance reviews of DDW, D&EW, MFW, TBI and FIT
programs and any additional programs that may require provider compliance with
these requirements and specifies that HCA authorized representatives shall have
timely access to records, personnel, service locations and clients.
[8.370.21.6
NMAC - N, 7/1/2024]
8.370.21.7 DEFINITIONS: For
purposes of these regulations, the following shall apply:
A. “Client” means any person who is
requesting or receiving services from one or more service providers subject to
these requirements.
B. “HCA” means the New Mexico health care
authority.
C. “Developmental disability waiver (DDW)” means a program offering community based services
under the administration of the HCA long term services division for persons
eligible based on the criteria described in Subsection B of 8.290.400.10 NMAC.
D. “Disabled
& elderly waiver (D&EW)”
means a program offering community based services under the administration of
the MAD for persons eligible based on the criteria described in Subsection A of
8.290.400.10 NMAC.
E. “Family
infant and toddler (FIT)” means a program offering community based
services under the administration of the HCA long term services division
for persons eligible based on the
criteria described in 7.30.8 NMAC.
F. “MAD” means the medical assistance
division of the New Mexico health care authority.
G. “Medically fragile waiver (MFW)” means a program offering community based services under the
administration of the HCA long term services division for persons eligible
based on the criteria described in Subsection C of 8.290.400.10 NMAC.
H. “Provider” means a person, organization or legal entity under contract with HCA
to provide services to clients eligible for services under one or more of the
following programs: developmental disability waiver (DDW), disabled and elderly
waiver (D&EW), medically fragile waiver (MFW); or traumatic brain injury
(TBI) and any additional programs that may require provider compliance
with these requirements.
I. “Timely
access” means physical or in-person, electronic or other access needed by
authorized representatives of the HCA to conduct a quality review
activity. Timely access means immediate
access upon request. If immediate access is not possible for a legitimate
reason, the access shall be as prompt as reasonably possible.
J. “Traumatic brain injury provider (TBI)” means a person, organization or other legal entity as
specified in Section 24-1-24 NMSA 1978, operating under the administration of
the HCA long term services division, which generally offers community based
services to eligible clients.
[8.370.21.7
NMAC - N, 7/1/2024]
8.370.21.8 STANDARD OF COMPLIANCE: The degree of compliance required throughout
these regulations is designated by the use of the
words “shall” or “must” or “may”.
“Shall” or “must” means mandatory.
“May” means permissive.
[8.370.21.8.NMAC
- N, 7/1/2024]
8.370.21.9 CONFIDENTIALITY: Client specific information reviewed or obtained in the course of quality assurance reviews of providers is
confidential in accordance with all applicable federal and state law and
regulation and with all applicable contract provisions. Other confidential information may include,
but is not limited to: personnel records, the provider’s internal incident
investigations, financial documents and proprietary business information.
[8.370.21.9
NMAC - N, 7/1/2024]
8.370.21.10 ACCESS
TO FACILITATE PROVIDER REVIEW QA ACTIVITIES:
A. HCA
shall review the quality of care delivered by providers subject to these
requirements. These reviews may be
either announced or unannounced.
B. Providers of services shall
facilitate timely physical or in-person access to:
C. Provider
records, regardless of media, including but not limited to: financial records,
all client records, ISPs, personnel records, board and or committee minutes,
incident reports, quality assurance activities, client satisfaction surveys and
agency policy/procedures manuals;
D. All provider
personnel;
E. Clients
currently receiving services from the provider;
F. Any information
relevant to accessing guardians, representatives and family members;
G. All records, regardless of
media, relating to former and deceased clients; and
H. All
administrative and service delivery sites.
I. Failure
to grant and facilitate timely physical or in-person access as defined in this
rule may subject the provider to all available penalties and sanctions as
provided in applicable federal, state or contract provisions.
[8.370.21.10 NMAC - N, 7/1/2024]
History of 8.370.21 NMAC: [RESERVED]