Chapter 7 - SERVICES

7.A. Physician Services

7.A.1. For those patients/clients whose reimbursement source requires physician supervision, the health care shall be under the supervision of a licensed physician who will see the patient/client as needed and shall furnish necessary medical care in case of emergency.

7.A.2. All treatment provided by physical therapists will be supervised by a physician, in accordance with the regulations of the Board of Physical Therapy, in order to be consistent with Title 32 MRSA §3002. All treatment provided by physical therapists will be provided under the orders of a licensed physician.

7.A.3. For those patients/clients whose reimbursement source requires physician orders, all treatment will be provided by appropriate health care personnel under the orders of a licensed physician.

7.A.4. All verbal orders must be signed by the physician within thirty (30) days. A facsimile order (fax) is acceptableif signed by a physician known to the staff.

7.A.5. Physicians who have significant ownership interest in, or significant financial or contractual relationship with a home health care services agency, may not establish or review a plan of care or certify or recertify the need for the home health care services.

7.B. Nursing Services

7.B.1. Nursing services will be directed by a registered professional nurse, who must have one (1) year of clinical experience and at least two (2) years of supervisory or administrative experience in home health care services.

7.B.2. Professional nursing services will be provided by a registered professional nurse who has had at least one (1) year of professional clinical nursing experience in home health care, or who has had at least one (1) year of professional nursing experience within the past three (3) years.

a. In accordance with Maine State Board of Nursing rules and regulations, duties of a registered professional nurse include, but are not limited to:

1. Making an initial evaluation visit;

2. Regularly evaluating the patient's/client's nursing needs;

3. Initiating and evaluating a plan of care and necessary revisions;

4. Providing those services requiring substantial and specialized nursing skills;

5. Initiating appropriate preventive and rehabilitative nursing procedures;

6. Preparing clinical and progress notes;

7. Coordinating services;

8. Informing the physician and other personnel if warranted, of changes in the patient's/client's condition and needs;

9. Counseling/teaching the patient/client, family and/or primary care giver in meeting nursing and related needs;

10. Participating in in-service programs;

11. Supervising and teaching other nursing personnel;

12. Assisting/teaching the patient/client family and/or significant other in learning appropriate self-care techniques.

7.B.3. Licensed practical nursing services, if available, will be provided by a licensed practical nurse who has had at least one (1) year of experience in home care or who has had at least one (1) year of practical nursing experience in the past three (3) years. Licensed practical nursing services will be provided under the supervision of a registered professional nurse.

Duties of a licensed practical nurse may include the following and must be provided in accordance with 32 MRSA,2102(3).

1. Providing service in accordance with agency policies, under the direction of the registered professional nurse,

2. Preparing clinical and progress notes; and

3. Assisting the patient/client in learning appropriate self-care techniques.

7.C. Other Health Care Professional Services

7.C.1. Physical therapy, occupational therapy, speech pathology, or social worker services will be provided by currently licensed physical therapists occupational therapists, speech pathologists or social workers.

Therapy Services: Therapy services provided by the Home Health Care Services provider, directly or under arrangement must be given by a qualified therapist or by a qualified therapist assistant under the supervision of a qualified therapist in accordance with the plan of care.

a. Duties of a qualified therapist include, but are not limited to:

1. Making an initial evaluation visit;

2. Regularly re-evaluating the patient's/client's therapy needs,

3. Initiating a plan of care and necessary revisions;

4. Providing those services requiring substantial and specialized therapy skills;

5. Initiating appropriate preventive and rehabilitative therapeutic procedures;

6. Preparing clinical and progress notes;

7. Coordinating services,

8. Informing the physician and other personnel of the patient's/client's condition and needs,

9. Counseling/teaching the patient/client, family and/or primary care giver in meeting therapeutic and related needs;

10. Participating in in-service programs,

11. Supervising therapist assistants,

12. Teaching therapist assistants and other personnel.

7.C.2. These therapy services may be provided by Home Health Care Services Provider employees or contracted by arrangement.

7.C.3. Written Agreement The facility shall have a written agreement, or its equivalent, for services provided by contact or sub-contract. The written agreement or its equivalent shall:

a. Be dated and signed by a representative of the Home Health Care Services Provider and by the person or agency providing the service,

b. Specify each party's responsibilities, functions and objectives, during the time which services are to be provided, the financial arrangements and charges, and the duration of the written agreement or its equivalent;

c. Specify that the Home Health Care Services Provider retain a administrative responsibility for services rendered, including subcontracted services;

d. Require that services are provided in accordance with these rules and that personnel providing services meet licensing training and experience requirements and are supervised in accordance with these rules; and

e. Require the provision of written documentation to the Home Health Care Services Provider including, but not limited to, documentation of services rendered by the person or agency providing the service.

7.C.4. Documentation of these therapy services provided shall be made in accordance with Chapter 7.F. of these regulations.

7.D. Health Care Services

7.D.1. All referrals will be responded to by the Home Health Care Services Provider within twenty four (24) hours.

7.D.2. An agency that has home health care services provided by licensed practical nurses, home health aides, or certified nursing assistants shall also have a registered professional nurse assigned to the patient/client.

7.D.3. Supervision for licensed practical nurses will be consistent with Title 32 MRSA §2102, sub-§ 3.

7.D.4. Home health aides and certified nursing assistants will be supervised by a registered professional nurse not less than once every fourteen (24) calendar days. A registered professional nurse shall provide direct supervision as necessary and be readily available at other times by telephone The registered professional nurse shall be constantly evaluating the certified nursing assistant and/or home health aide in terms of that individual's ability to carry out assigned duties, to relate to the patient/client, and to work effectively as a member of the health care team.

The registered professional nurse shall make a supervisory visit to the patient's/client's residence at least every thirty days (30), to observe and assist, assess relationships determine whether goals are being met, evaluate the appropriateness of the plan of care and make changes as

appropriate. Alternate supervisory visits may be accomplished by telephone.

7.D.5. The decision to assign a home health aide or a certified nursing assistant to a particular patient/client shall be made by a registered professional nurse

in accordance with the plan of care. If the patient is not receiving skilled nursing care, but is receiving another skilled service (that is, physical therapy, occupational therapy, or speech/language pathology services), supervision of the home health aide may be provided by the appropriate therapist.

7.D.6. The Home Health Care Services Provider offering a home health aide and/or certified nursing assistant service shall provide at least one (1) registered professional nurse to be available for twenty-five (25) full-time equivalent home health aides or certified nursing assistants. In addition to their supervisory capacity, supervisors of certified nursing assistants or home health aides may also provide direct services to the same or other patients/clients. The registered professional nurse must be available the same hours during which care is being provided in the home by the health care paraprofessionals or be on call during that time for consultation and/or supervision of the health care paraprofessionals. Providers will be responsible for monitoring to determine that adequate supervision of paraprofessionals is carried out and documented.

7.D.7. The Home Health Care Services Provider must have equipment and supplies necessary to provide the services offered by the Provider.

7.D.8. The Home Health Care Services Provider must have policies and procedures relating to the assignment and supervision of students providing any services to patients/clients, if appropriate.

7.E. Plan of Care

7.E.1. All plans of care for patients/clients requiring nursing services shall be written, coordinated and completed by a registered professional nurse who has made an initial visit to the residence of the patient/client. At this initial visit, the registered professional nurse shall assess and evaluate the necessary care and/or services, required. The registered professional nurse will consult with the patient/client and/or the patient/client's family when developing the plan of care. For those patient's/client's with physician supervision, the plan of care will conform to the physician's orders.

Visit ranges are permitted and may not begin with zero (0) with the exception of PRN visit orders.

7.E.2. All plans of care for patients/clients requiring only the services of physical therapists, occupational therapists, speech pathologists or medical social workers shall be written, coordinated and completed by these licensed health care professionals who have made an initial visit to the residence of the patient/client. At this initial visit, the physical therapist, occupational therapist, speech pathologist, dietitian or medical social worker shall assess and evaluate the necessary care and/or services required. The licensed health care professional will consult with the patient/client, and/or the patient's/client's family when developing the plan of care. For those patients/clients with physician supervision the plan of care will conform to the physician's orders. Visit ranges are permitted and may not begin with zero (0) with the exception of PRN visit orders.

7.E.3. Each patient's/client's plan of care will be initiated within three (3) business days after admission to the Home Health Care Services Provider.

7.E.4. For those patients/clients with physician supervision, no alteration of the scope and limitations of services set forth in the plan of care will be made by a contracted provider of a home health care agency without the consent of the attending physician and notification of the agency.

7.E.5. Patients/clients are accepted for treatment on the basis of a reasonable expectation that the patient's/client's medical, nursing and social needs can be met adequately by the agency in the patient's/client's place of residence.

7.F. Patient/Client Records

7.F.1. Each Home Health Care Services Provider's patient/client shall have an identifiable clinical record initiated and maintained by the Home Health Care Services Provider in accordance with accepted professional standards. Patient/client records shall contain but not be limited to:

a. Appropriate identifying information about the patient/client, household members and caretakers, medical history and current findings, psychosocial history,

b. For those patients/clients with physician supervision, evidence that the health care of the patient/client is under the supervision of a physician who sees the patient/client as needed and would furnish necessary medical care in case of emergency;

c. A care plan for the patient/client developed by a registered professional nurse or, where appropriated, the physical therapist, occupational therapist. speech pathologist, dietitian medical social worker. For those patients/clients with physician supervision, this plan of care must be signed by the patient's/client's physician and reviewed at least every ninety (90) days;

d. A medication list with all medications listed with start and stop dates, side effects, contraindications, dated countersignatures by patient's/client's physician, and documentation that this information has been given to the patient/client;

e. Initial and periodic assessments for those patients/clients provided nursing services by the registered professional nurse. These assessments should include documentation of the patient's/client's functional status;

f. Initial and periodic assessments for those patients/clients provided only physical therapy, occupational therapy, speech pathology, nutritional or medical social worker services. These assessments should include documentation of the patient's/client's functional status;

g. Assessments made by other members of the Home Health Care Services Provider's multidisciplinary team;

h. Signed and dated clinical notes for each contact. These notes should be written on the day of service and incorporated at least weekly into the patient's/client's clinical record,

i. Reports of all patient/client home health care conferences;

j. For those patients/clients with physician supervision, reports of contacts by the home health care agency's off with the patient's/client's physician;

k. Written summary reports containing home health care services provided, the patient's/client's status, recommendations for revision of the plan of treatment, and the need for initiation, continuation or termination of services. For those patients/clients with physician supervision, these summary reports shall be sent to the patient's/client's physician as required by reimbursement sources and/or stipulated by the patient's/client's physician. At a minimum, these summary reports shall be sent to the patient's/client's physician every ninety (90) days;

l. For those patients/clients with physician supervision written, signed, and dated confirmation of the physicians verbal orders within thirty (30) days to the agency's licensed health care professionals regarding the patient/client;

m. Where appropriate, a dated and signed discharge summary giving a brief review of service, patient/client status, reason(s) for discharge, and plans for post-discharge needs of the patient/client;

n. A copy of appropriate patient/client transfer information, if the patient/client is transferred to a health facility or other health care agency,

o. Evidence of contingency provisions made in cooperation with the patient's/client's family or significant other to provide for a continuum of care in the event of the temporary unavailability of services provided by the home health care agency;

p. Evidence that the patient/client has been provided with a summary of the Home Health Care Services Provider's policies on advanced directives;

q. Documentation showing that the patient/client has been provided with a written notice of his/her rights before initiation of treatment;

r. Documentation showing that the patient/client was informed of the toll-free number of the Home Health Care Services Hotline for any complaints against Home Health Care Services Providers (7.H.6.).

s. A physician's rubber stamp signature for clinical record documentation is permitted if authorized by the Home Health Care Provider's policy. A signed statement from the physician is required attesting that he/she is the only one who has the stamp and may use it. This statement must be on file and available in the administrative offices of the Home Health Care Services agency.

7.F.2. Each How Health Care Services Provider shall have a written policy on patient/client records. These records shall be retained at the agency's main business or subunit office(s) for a minimum of five (5) years or for a period of time conforming to state and federal laws beyond the last date of service provided

7.F.3. Each Home Health Care Services Provider shall have a written policy and procedure fee the security and confidentiality of patient/client records. The policies/procedures will cover the storage, use of records, removal of records, and release of patient/client information

7.G. Patient/Client Transfer and Discharge

7.G.1. Each Home Health Care Services Provider must have written criteria for the transfer, referral and/or discharge of patients/clients. At the time of transfer, referral and/or discharge, the patient/client must meet at least one of the following criteria. Criteria must, but are not limited to:

a. The patient's/client's welfare and/or medical needs cannot be met by the Home Health Care Services Provider,

b. The patient's/client's health and/or functional abilities have improved so that the patient/client no longer needs the services provided by the Home Health Care Services Provider, as ordered by the patient's/client's physician, with agreement from all parties involved;

c. The health and safety of individuals providing services is endangered.

7.G.2. A written notice of discharge or transfer must be sent to patients/clients at least fourteen(14)days before services are terminated. A written notification of patients/clients' appeal rights must be included in this notice and must follow State and Federal requirements. The only written exceptions to this regulation are Chapter 7.G.1.b. and Chapter 7.G.1.c.

7.G.3. Each patient's/client's clinical record must contain documentation describing the criteria that necessitated the transfer, referral and/or discharge. Documentation must include, but is not limited to:

a. Signed and dated physician's orders for transfer, referral or discharge,

b. Multidisciplinary interventions that have been tried and failed to meet the patient's needs if applicable;

c. Notation of the cessation of operation of the Home Health Care Services Provider, if applicable, and

d. Incidents and/or circumstances where agency staffs' health and safety are endangered if applicable.

7.G.4. Patient/Client Rights

The patient/client has the right to be informed of his/her rights. The Home Health Care Services provider must protect and promote the exercise of these rights.

a. Notice of Rights

1. The Home Health Care Services Provider must provide the patient/client with a written notice of the patient's/client's rights in advance of furnishing care to the patient/client or during the initial evaluation visit before the initiation of treatment.

2. The Home Health Care Services Provider must provide the patient/client with a written notice of the toll-free number of the Long Term Care Ombudsman Program in advance of furnishing care to the patient/client or during the initial evaluation before the initiation of treatment. When the Provider accepts the patient/client for treatment or care, the Home Health Care Services Provider must advise the patient/client in writing that the purpose of the Ombudsman Program is to advocate for consumer rights and to receive complaints or questions about the home heath care services.

b. Exercise of Rights and Respect for Property and Person

1. The patient/client has the right to exercise his/her rights as a patient/client of the Home Health Care Services Provider.

2. In the case of a patient/client adjudicated incompetent under the laws of the State by a court of competent jurisdiction, the rights of the patient/client are exercised by the person appointed under State law to act on the patient's/client's behalf

3. The patient/client has the right to have his/her property treated with respect.

4. The patient/client has the right to voice grievances regarding treatment or care that is (or fails to be) furnished, or regarding the lack of respect for property by anyone who is furnishing services on behalf of the Home Health Care Services Provider and must not be subjected to discrimination or reprisal for doing so.

5. The Home Health Care Services Provider must investigate complaints made by a patient/client or the patient's/client's family or guardian regarding treatment or care that is (or fails to be) furnished, or regarding the lack of respect for the patient's/client's property by anyone furnishing services on behalf of the Home Health Care Services Provider and must document both the existence of the complaint and the resolution of the complaint.

c. Right to be Informed and to participate in planning Care and Treatment

1. The patient/client has the right to participate in the planning of the care. The Home Health Care Services Provider must advise the patient/client in advance of the right to participate in planning the care or treatment and in planning changes in the care or treatment.

a. The Home Health Care Services Provider must advise the patient/client in advance of the disciplines that will furnish care and the frequency of visits proposed to be furnished.

b. The Home Health Care, Services Provider must advise the patient/client, in advance of any change in the plan of care before the change is made.

d. Confidentiality of Medical Records

The patient/client has the right to confidentiality of their clinical records maintained by the Home Health Care Services Provider The Home Health Care Services Provider must advise the patient/client of the agency's policies and procedures regarding disclosure of clinical records.

e. Patient/Client Liability for Payment

1. The patient/client has the right to be advised, before care is initiated, of the extent to which payment for the Home Health Care Services Provided may be expected and the extent to which payment may be expected from the patient/client. Before the care is initiated, the Home Health Care Services Provider must inform. the patient/client, orally and in writing, of

a. The extent to which payment may be expected from Medicare, Medicaid or any other Federally funded program known to the Home Health care Services Provider,

b. The charges for services that will not be covered; and

c. The charges that the patient/client may have to pay.

2. The patient/client has the right to be advised orally and in writing of any changes in this section when they occur. The Home Health Care Services Provider must advise the patient/client of these changes orally and in writing as soon as possible, but no later than thirty (30) calendar days from the date that the Home Health Care Services Provider becomes aware of a change.

f. Home Health Care Services Hotline

The patient/client has the right to be advised of the availability of the toll-free Home Health Care Services Hotline in the State of Maine. When the Provider accepts the patient/client for treatment or care, the Home Health Care Services Provider must advise the patient/client in writing of the telephone number of the Home Health Care Services Hotline established by the State of Maine, the hours of its operation and that the purpose of the hotline is to receive complaints or questions about home health care services.

g. Complaints

The patient/client has the right to be advised that they may file a complaint with the Division of Licensing and Certification, the Bureau of Elder and Adult Services or the Long Term Care Ombudsman Program concerning patient/client abuse, neglect and misappropriation of patient/client property and other violations of his/her rights.

7.H. Records and Review

The Department shall be afforded full access to, and the right to examine and copy, either manually or by photocopy, all records, documents and reports required to be kept under licensure regulations, at no expense to the Department.

7.I. Behavioral Services (Community Support Services)

Home Health Care Services that provide Community Support Services must comply with the requirements in the Mental Health Agency Licensing Standards under Community Support Service Standards and The Rights of Recipients of Mental Health Services Who Are Children in Need of Treatment.

The Mental Health Agency Licensing Standards under Community Support Services Standards and The Rights of Recipients of Mental Health Services Who Are Children in Need of Treatment rules shall have the same force and effect as if fully set out herein, and full compliance with those rules shall be a condition of full licensure. Copies of The Rights of Recipients of Mental Health Services Who are Children in Need of Treatment regulations may be obtained from the Maine Department of Health and Human Services, formerly known as the Maine Department of Behavioral and Developmental Services.

Notes