Original Notice.

     Preproposal statement of inquiry was filed as WSR 01-03-096.

     Title of Rule: Amending WAC 388-551-2000 Home health services -- General, 388-551-2010 Home health services -- Definitions, 388-551-2020 Home health services -- Eligible clients, 388-551-2100 Covered home health services -- Nursing, 388-551-2110 Home health services -- Specialized therapy, 388-551-2120 Home health aid services, 388-551-2130 Noncovered home health services, 388-551-2200 Home health services -- Eligible providers, 388-551-2210 Home health services -- Provider requirements, 388-551-2220 Home health services -- Provider payments; and new section WAC 388-551-2030 Home health skilled services -- Requirements.

     Purpose: To meet the requirements of the Centers for Medicare and Medicaid Services (CMS), formerly Health Care Financing Administration (HCFA), the department is amending home health services sections in chapter 388-551 WAC that refer to "homebound" criteria. At the same time, the department is changing references to "plan of treatment (POT)" to "plan of care (POC)" to be consistent with Department of Health (DOH). Also, to update rule content, including the addition of a new section, and to reflect current department policy and business practices.

     Statutory Authority for Adoption: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500.

     Statute Being Implemented: RCW 74.08.090, 74.09.520, 74.09.530, and 74.09.500.

     Summary: The rules amend language in the home health services sections that refers to "homebound" criteria. The rules also clarify and update rule content to reflect current department policy, including POC requirements.

     Reasons Supporting Proposal: To meet the requirements of CMS to amend sections in the home health services sections that refer to "homebound" criteria. To update rule content to reflect current department policy.

     Name of Agency Personnel Responsible for Drafting: Kathy Sayre, P.O. Box 45533, Olympia, WA 98504, (360) 725-1342; Implementation and Enforcement: Pam Colyar, P.O. Box 45506, Olympia, WA 98504, (360) 725-1582.

     Name of Proponent: Department of Social and Health Services, governmental.

     Rule is not necessitated by federal law, federal or state court decision.

     Explanation of Rule, its Purpose, and Anticipated Effects: The proposed amendments incorporate into rule a mandate by CMS that requires the department to remove references to the "homebound" criteria from the home health services program and rule. In addition, the new rules update, clarify, and add new language to the home health services program.

     The purpose of these rules is to meet the mandate to remove the "homebound" requirement from the program's rule and provide clearly written language that is easier to understand.

     The anticipated effects are (1) to increase effectiveness of MAA's staff who administer and enforce home health services rules; (2) to improve the quality of home health service care provided to clients; (3) to reduce confusion and, consequently, provide savings to service providers in time and money due to the clarification of the format and content of the POC and what to add to it during a review; (4) to increase the quality of care that a client receives by assuring follow through with needed care from the DSHS case manager after the client discharges from home health services; and (5) to provide savings to home health agency providers by allowing the providers to utilize a client's DSHS case manager instead of their agency's social worker for services that are not MAA-covered services.

     Proposal Changes the Following Existing Rules: All references to "homebound" criteria are removed. The verbiage "plan of treatment (POT)" is changed to "plan of care (POC)." The proposal adds a new section WAC 388-551-2030 that incorporates existing MAA policy requirements for home health agency to provide home health skilled services.

     No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the new rules and concluded that no new costs will be imposed on businesses affected by them. The analysis is contained in the cost benefit analysis described below.

     RCW 34.05.328 applies to this rule adoption. Although the adoption of WAC 388-551-2030 (new section) meets the definition of a "significant legislative rule," this section and amendments to the other listed sections impose no additional costs to businesses. A cost benefit analysis was completed and is available upon request from Kathy Sayre, Medical Assistance Administration, P.O. Box 45533, Olympia, WA 98504-5533, phone (360) 725-1342, fax (360) 586-9727, e-mail SayreK@dshs.wa.gov.

     Hearing Location: Office Building - 2 (DSHS Headquarters) (parking off 12th and Jefferson), 1115 Washington, Olympia, WA 98504, on May 21, 2002, at 10:00 a.m.

     Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by May 17, 2002, phone (360) 664-6094, TTY (360) 664-6178, e-mail fernaax@dshs.wa.gov.

     Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, e-mail fernaax@dshs.wa.gov, by 5:00 p.m., May 21, 2002.

     Date of Intended Adoption: No sooner than May 22, 2002.

March 29, 2002

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     ((Home health services consist of skilled nursing and specialized therapies provided in a client's residence. Home health aide services may be provided in addition to these services. The client must be homebound, as determined by documentation submitted to MAA during the client's focused program review period.)) Home health skilled services are provided ((are)) for acute, intermittent, short-term, and intensive courses of treatment. See chapter 388-515 and 388-71 WAC for programs administered to clients ((needing)) who need chronic, long-term maintenance care.

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2000, filed 8/2/99, effective 9/2/99.]

     "Acute care" means care provided by a home health agency for clients who are not medically stable or have not attained a satisfactory level of rehabilitation. These clients require frequent intervention by a registered nurse or licensed therapist.

     "Brief skilled nursing visit" means a registered nurse, or a licensed practical nurse under the supervision of a registered nurse, performs only one of the following activities during a visit to a client:

     (1) An injection;

     (2) Blood draw; or

     (3) Placement of medications in containers.

     "Chronic care" means long-term care for medically stable clients.

     "Full skilled nursing visit" means a registered nurse, or a licensed practical nurse under the supervision of a registered nurse, performs one or more of the following activities during a visit to a client:

     (1) Observation;

     (2) Assessment;

     (3) Treatment;

     (4) Teaching;

     (5) Training;

     (6) Management; and

     (7) Evaluation.

     "Home health agency" means an agency or organization certified under Medicare to provide comprehensive health care on ((a)) an intermittent or part-time ((or intermittent)) basis to a patient in the patient's place of residence.

     "Home health aide" means an individual registered or certified as a nursing assistant under chapter 18.88 RCW who, under the direction and supervision of a registered nurse or licensed therapist, assists in the delivery of nursing or therapy related activities, or both, to patients of a home health or hospice agency, or hospice care center.

     "Home health aide services" means services provided by a home health aide when a client has an acute, intermittent, short-term need for the services of a registered nurse, physical therapist, occupational therapist, or speech therapist who is employed by or under contract with a home health agency. Such services are provided under the supervision of the previously identified authorized practitioners, and include ambulation and exercise, assistance with self-administered medications, reporting changes in a client's condition and needs, and completing appropriate records.

     "Home health skilled services" means skilled health care (nursing, specialized therapy, and home health aide) services provided in the client's residence on ((a part-time or)) an intermittent or part-time basis by a ((Title XVIII Medicare and Title XIX Medicaid home health provider)) Medicare-certified home health agency with a current medical assistance administration (MAA) provider number. See also WAC 388-551-2000.

     (("Homebound" means a physician has certified that the client is medically or physically confined to the home, and under normal circumstances, lacks the ability to leave home without a considerable and taxing effort. The client may be considered homebound if absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive medical treatment.))

     "Long-term care" is a generic term referring to various programs and services, including services provided in home and community settings, administered directly or through contract by the department's aging and adult services administration (AASA) or division of developmental disabilities (DDD).

     "Plan of ((treatment (POT))) care (POC)" (also known as "plan of ((care (POC))) treatment (POT)") means a written plan of ((treatment)) care that is established and periodically reviewed and signed by both a physician and a home health agency provider((, that)). The plan describes the home health care to be provided at the client's residence. See WAC 388-551-2210.

     "Residence" means a client's home or place of living , including an adult family home and/or boarding home, but not including a hospital, skilled nursing facility, or residential facility with skilled nursing services available.

     "Review period" means the three-month period the medical assistance administration (MAA) assigns to a home health agency, based on the address of the agency's main office, during which MAA reviews all claims submitted by that agency.

     "Specialized therapy" means skilled therapy services provided to ((homebound)) clients ((which)) that include((s)):

     (1) Physical;

     (2) Occupational; or

     (3) Speech/audiology services.

(See WAC 388-551-2110.)

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2010, filed 8/2/99, effective 9/2/99.]

     (a) Categorically needy program (CNP);

     (b) Limited casualty program - medically needy program (LCP-MNP);

     (c) General assistance expedited (GA-X) (disability determination pending); and

     (d) Medical care services (MCS) under the following programs:

     (i) General assistance - unemployable (GA-U); and

     (ii) Alcoholism and drug addiction treatment and support act (ADATSA) (GA-W).

     (2) Clients in the following emergency-only MAA programs are eligible to receive home health services, subject to the limitations described in this chapter. Coverage is ((also)) limited to two skilled nursing visits per eligibility enrollment period. Specialized therapy services and home health aide visits are not covered:

     (a) ((Categorically needy program ())CNP(()))-emergency((-)) medical only((.)); and

     (b) ((Limited casualty program - medically needy program ())LCP-MNP(()))- emergency medical only.

     See WAC 388-551-2100(3) for limitations of coverage under these programs.

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2020, filed 8/2/99, effective 9/2/99.]

     (2) Home health skilled services provided to eligible clients must:

     (a) Meet the definition of "acute care" in WAC 388-551-2010.

     (b) Provide for the treatment of an illness, injury, or disability.

     (c) Be medically necessary as defined in WAC 388-500-0005.

     (d) Be reasonable, based on the community standard of care, in amount, duration, and frequency.

     (e) Be provided under a plan of care (POC), as defined in WAC 388-551-2010 and described in WAC 388-551-2210. Any statement in the POC must be supported by documentation in the client's medical records.

     (f) Be used to prevent placement in a more restrictive setting. In addition, the client's medical records must justify the medical reason(s) that the services should be provided in the client's residence instead of a physician's office, clinic, or other outpatient setting. This includes justification for services for a client's medical condition that requires teaching that would be most effectively accomplished in the client's home on a short-term basis.

     (g) Be provided in the client's residence, as defined in WAC 388-551-2010. MAA does not reimburse for services if provided at the workplace, school, child day care, adult day care, skilled nursing facility, or any other place that is not the client's place of residence.

     (h) Be provided by a home health agency that is Title XVIII (Medicare) certified and state-licensed.

[]

     (d) For up to three home health visits per pregnancy)) listed in this section when furnished by a qualified provider. MAA evaluates a request for covered services that are subject to limitations or restrictions, and approves such services beyond those limitations or restrictions when medically necessary, under the standard for covered services in WAC 388-501-0165.

     (2) MAA covers the following home health acute care skilled nursing services, subject to the limitations in this section:

     (a) Full skilled nursing services that require the skills of a registered nurse or a licensed practical nurse under the supervision of a registered nurse if the services involve one or more of the following:

     (i) Observation;

     (ii) Assessment;

     (iii) Treatment;

     (iv) Teaching;

     (v) Training;

     (vi) Management; and

     (vii) Evaluation.

     (b) A brief skilled nursing visit if only one of the following activities is performed during the visit:

     (i) An injection;

     (ii) Blood draw; or

     (iii) Placement of medications in containers (e.g., envelopes, cups, medisets).

     (c) Home infusion therapy only if the client:

     (i) Is willing and capable of learning and managing the client's infusion care; or

     (ii) Has a volunteer caregiver willing and capable of learning and managing the client's infusion care.

     (d) Infant phototherapy for an infant diagnosed with hyperbilirubinemia:

     (i) When provided by an MAA-approved infant phototherapy agency; and

     (ii) For up to five skilled nursing visits per infant.

     (e) Limited high-risk obstetrical services:

     (i) For a medical diagnosis that complicates pregnancy and may result in a poor outcome for the mother, unborn, or newborn;

     (ii) For up to three home health visits per pregnancy if:

     (A) Enrollment in or referral to the following providers of First Steps has been verified:

     (I) Maternity support services (MSS); or

     (II) Maternity case management (MCM); and

     (B) The visits are provided by a registered nurse who has either:

     (I) National perinatal certification; or

     (II) A minimum of one year of labor, delivery, and postpartum experience at a hospital within the last five years.

     (3) MAA limits skilled nursing visits provided to eligible clients to two per day, except clients eligible under either of the emergency medical programs listed in WAC 388-551-2020 (2)(a) and (b) are limited to two skilled nursing visits within the eligibility enrollment period.

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2100, filed 8/2/99, effective 9/2/99.]

     (2) ((To receive)) MAA does not allow duplicate services for any specialized therapy ((services, a client must be homebound)) for the same client when both providers are performing the same or similar procedure(s).

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2110, filed 8/2/99, effective 9/2/99.]

     (2) MAA ((pays)) reimburses for home health aide services, as defined in WAC 388-551-2010, only when the services are provided under the supervision of, and in conjunction with, practitioners who provide:

     (a) Skilled nursing services; or

     (b) Specialized therapy services.

     (3) MAA covers home health aide services only when a registered nurse or licensed therapist visits the client's residence at least once every fourteen days to monitor or supervise home health aide services, with or without the presence of the home health aide.

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2120, filed 8/2/99, effective 9/2/99.]

     (a) ((Medical)) Chronic long-term care skilled nursing visits or specialized therapy visits for a medically stable client when a long-term care skilled nursing plan or specialized therapy plan is in place through the department of social and health services aging and adult services administration (AASA) or division of developmental disabilities (DDD).

     (i) MAA considers requests for interim chronic long-term care skilled nursing services or specialized therapy services for a client while the client is waiting for AASA or DDD to implement a long-term care skilled nursing plan or specialized therapy plan; and

     (ii) On a case-by-case basis, MAA may authorize long-term care skilled nursing visits or specialized therapy visits for a client for a limited time until a long-term care skilled nursing plan or specialized therapy plan is in place. Any services authorized are subject to the restrictions and limitations in this section and other applicable published WACs.

     (b) Social work services((;

     (b))).

     (c) Psychiatric skilled nursing services((;

     (c))).

     (d) Pre- and postnatal skilled nursing services, except as listed under WAC 388-551-2100(((10);

     (d) Additional administrative costs billed above the visit rate (these costs are included in the visit rate and may not be billed separately);))(2)(e).

     (e) Well-baby follow-up care((;)).

     (f) Services performed in hospitals, correctional facilities, skilled nursing facilities, or a residential facility with skilled nursing services available((;)).

     (g) Home health aide services that are not provided in conjunction with skilled nursing or specialized therapy services((;)).

     (h) Health care for a medically stable client (e.g., one who does not have an acute episode, a disease exacerbation, or treatment change)((;)).

     (i) Home health specialized therapies and home health aide visits for clients in the following programs:

     (i) CNP - emergency medical only; and

     (ii) LCP-MNP - emergency medical only((;)).

     (j) Skilled nursing visits for a client when a home health agency cannot safely meet the medical needs of that client within home health services program limitations (e.g., for a client to receive infusion therapy services, the caregiver must be willing and capable of managing the client's care)((;)).

     (k) More than one of the same type of specialized therapy and/or home health aide visit per day((;)).

     (l) MAA does not reimburse for duplicate services for any specialized therapy for the same client when both providers are performing the same or similar procedure(s).

     (m) Home health visits made without a written physician's order, unless the verbal order is:

     (i) ((Written)) Documented prior to ((or on the date of)) the visit; and

     (ii) The document is signed by the physician within forty-five days of the order being given.

     (2) MAA does not cover additional administrative costs billed above the visit rate (these costs are included in the visit rate and will not be paid separately).

     (3) MAA evaluates a request for any service that is listed as noncovered under the provisions of WAC 388-501-0165.

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2130, filed 8/2/99, effective 9/2/99.]

     (5) Is assigned a provider number.

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2200, filed 8/2/99, effective 9/2/99.]

     (1) The ((POT)) POC must:

     (a) Be documented in writing and be located in the client's home health medical record;

     (b) Be developed ((and)), supervised, and signed by a licensed registered nurse or licensed therapist;

     (c) Reflect the physician's orders and client's current health status;

     (d) Contain specific goals and treatment plans;

     (e) Be reviewed and revised by a physician at least every sixty((-two)) calendar days ((and)), signed by a physician within forty-five days of the verbal order, and returned to the home health agency's file;

     (((e) Contain specific goals and treatment plans;)) and

     (f) Be available to department staff or its designated contractor(s) on request.

     (2) The provider must include in the ((POT)) POC all of the following:

     (a) The primary diagnosis (the diagnosis that is most related to the reason the client qualifies for home health services) or the diagnosis that is the reason for the visit frequency;

     (b) ((The)) All secondary medical diagnoses ((and prognosis)), including date(s) of onset or exacerbation;

     (c) ((A discharge plan)) The prognosis;

     (d) The type(s) of equipment required;

     (e) A description of each planned service and goals related to the services provided;

     (f) Specific procedures and modalities;

     (g) A description of the client's mental status;

     (h) A description of the client's rehabilitation potential;

     (i) A list of permitted activities;

     (j) A list of safety measures taken on behalf of the client; and

     (k) A list of medications which indicates:

     (i) Any new prescription ((prescribed)); and

     (ii) Which medications are changed for dosage or route of administration.

     (3) The provider must include in or attach to the ((POT)) POC:

     (a) A description of the client's functional limits and the effects;

     (b) Documentation that justifies why the medical services should be provided in the client's residence instead of a physician's office, clinic, or other outpatient setting;

     (c) Significant clinical findings;

     (((c))) (d) Dates of recent hospitalization; ((and

     (d) If the client is not homebound, a description of why home health services are necessary. The description must include:

     (i) A written statement noting coordination with, or referral to, the client's department of social and health services-assigned case manager; or

     (ii) An assessment of the client and the client's access to community resources, including attempts to use appropriate alternatives to meet the client's home health needs))

     (e) Notification to the DSHS case manager of admittance; and

     (f) A discharge plan, including notification to the DSHS case manager of the planned discharge date and client disposition at time of discharge.

     (4) The individual client medical record must comply with community standards of practice, and must include documentation of:

     (a) Visit notes for every billed visit;

     (b) Supervisory visits for home health aide services ((per)) as described in WAC 388-551-2120(3);

     (((b))) (c) All medications administered and treatments provided;

     (((c))) (d) All physician orders, new orders, and change orders, with notation that the order was received prior to treatment;

     (((d))) (e) Signed physician new orders and change orders;

     (((e))) (f) Home health aide services as indicated by a registered nurse or licensed therapist in a home health aide care plan;

     (((f))) (g) Interdisciplinary and multidisciplinary team communications;

     (((g))) (h) Inter-agency and intra-agency referrals;

     (((h))) (i) Medical tests and results; ((and

     (i))) (j) Pertinent medical history; and

     (k) Notations and charting with signature and title of writer.

     (5) The provider must document at least the following in the client's medical record:

     (a) Skilled interventions per the ((POT)) POC;

     (b) Client response to the POC:

     (c) Any clinical change in client status;

     (((c))) (d) Follow-up interventions specific to a change in status with significant clinical findings; and

     (((d))) (e) Any communications with the attending physician.

     (6) The provider must include the following documentation in the client's visit notes when appropriate:

     (a) Any teaching, assessment, management, evaluation, ((patient)) client compliance, and client response;

     (b) Weekly documentation of wound care, size (dimensions), drainage, color, odor, and identification of potential complications and interventions provided; ((and))

     (c) Referral to a wound care specialist, if wound is not healing; and

     (d) The client's physical system assessment as identified in the ((POT)) POC.

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2210, filed 8/2/99, effective 9/2/99.]

     (2) Payment to home health providers is:

     (a) A set rate per visit ((rate)) for each discipline provided to a client;

     (b) Based on the county location of the providing home health agency; and

     (c) Updated by general vendor rate changes.

     (((2))) (3) For clients eligible for both Medicaid and Medicare, MAA may pay for services described in this chapter only when Medicare does not cover those services. The maximum payment for each service is Medicaid's maximum payment.

     (((3))) (4) Providers must submit documentation to ((the department during any MAA focused program)) MAA during the home health agency's review period. Documentation includes, but is not limited to, the requirements listed in WAC 388-551-2210.

     (((4))) (5) After MAA receives the documentation, the MAA(('s)) medical director or designee reviews the client's medical records for program compliance and quality of care.

     (((5))) (6) MAA may take back or deny payment for any insufficiently documented home health care service when the MAA medical director or designee determines that:

     (a) The service ((was not medically necessary (defined in WAC 388-500-0005) or reasonable;

     (b) Clients were able to receive care outside of the home (see definition of homebound in this chapter and WAC 388-551-2100(3)); or

     (c))) did not meet the conditions described in WAC 388-550-2030; or

     (b) The service was not in compliance with program policy.

     (((6))) (7) Covered home health services for clients enrolled in a Healthy Options managed care plan are paid for by that plan.

[Statutory Authority: RCW 74.08.090 and 74.09.530. 99-16-069, § 388-551-2220, filed 8/2/99, effective 9/2/99.]

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