Sec. 10.09.27.01. Definitions

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

(1) "Certified nursing assistant" means an individual who:

(a) Is certified by the Maryland Board of Nursing; and

(b) Performs nursing tasks delegated by a registered nurse or licensed practical nurse pursuant to Health Occupations Article, Title 8, Annotated Code of Maryland.

(2) "Department" means the Maryland Department of Health as defined in COMAR 10.09.36.

(3) "Disabled child" means a chronically ill or severely impaired child, younger than 22 years old, whose illness or disability may not require 24-hour inpatient care, but which, in the absence of home care services, may precipitate admission to or prolong stay in a hospital, nursing facility, or other long term care facility.

(4) "Home care" means a comprehensive package of medical and health-related services provided under the Program, pursuant to the authority of a model waiver for certain disabled children, as an alternative to institutionalization.

(5) "Home care case management" means locating, coordinating, and monitoring home care services for disabled children and includes:

(a) Screening of referrals and identification of individuals requiring home care services;

(b) Completing a comprehensive assessment to determine the appropriateness of home care services;

(c) Convening the multidisciplinary team and coordinating the development of a comprehensive plan of care;

(d) Determining individual case cost effectiveness;

(e) Identifying and maximizing informal sources of care;

(f) Ongoing monitoring of the delivery of services specified in the plan of care to determine the appropriateness of the type, amount, and duration of services rendered;

(g) Completing the semiannual utilization review procedure specified in Regulation .03B(1)(c)(ii) of this chapter; and

(h) Providing in-home assessments as specified in Regulation .04A(2)(e) of this chapter.

(6) "Home care case manager" means the agency administering a program of services for disabled children authorized under Title V of the Social Security Act, or the agency's designee, which provides or arranges for the provision of home care case management services for participants, develops training and community education programs, and establishes standards and procedures for quality assurance and monitoring.

(7) "Home care provider" means the principal physician or the individual or agency providing nursing, home health aide services, medical supplies and equipment, or home care case management services to disabled children.

(8) "Home health agency" means an agency licensed by the Department in accordance with COMAR 10.07.10.

(9) "Home health aide" means an individual who meets all the conditions of participation specified in:

(a) 42 CFR §484.36; and

(b) Health Occupations Article, Title 8, Annotated Code of Maryland.

(10) "Medical Assistance Program" means the Medical Assistance Program as defined in COMAR 10.09.36.

(11) "Medical day care" has the meaning stated in COMAR 10.09.07.

(12) "Medical day care center" has the meaning stated in COMAR 10.09.07.

(13) "Medicare" means Medicare as defined in COMAR 10.09.36.

(14) "Model Waiver" means the document and any amendments to it submitted by the Department to, and approved by, the Department of Health and Human Services which authorize the waiver of certain statutory requirements limiting eligibility and covered services under the Medicaid State plan pursuant to §1915(c) of the Social Security Act.

(15) "Multidisciplinary team" means the group consisting of the participant or the participant's legal representative or representatives, or all of these, home care providers, and the participant's principal physician or the physician designated by the principal physician, and other providers of health-related services, as appropriate, that establishes and updates the plan of care under the overall direction and coordination of the home care case manager and assesses the appropriateness of the participant's discharge to or continuation of home care.

(16) "Necessary" means necessary as defined in COMAR 10.09.36.

(17) "Nurse" means a person who is licensed as a registered nurse or licensed practical nurse in the jurisdiction in which services are provided.

(18) "Nursing care plan" means a plan developed by a registered nurse that identifies:

(a) The patient's diagnoses and needs;

(b) The goals to be achieved; and

(c) The interventions required to meet the patient's medical condition.

(19) "Participant" means a recipient:

(a) Whose initial eligibility for services under this chapter is established as a disabled child certified by the Department or its designee as requiring nursing home care under the Program pursuant to COMAR 10.09.10 or COMAR 10.09.11, or inpatient hospital care pursuant to COMAR 10.09.92-10.09.95, but whose medical condition does not require 24-hour inpatient care unless home care services are not available;

(b) Who, once eligibility is established, remains eligible for services under this chapter as long as he or she continues to meet the certification and care requirements of §B(15)(a) of this regulation, regardless of age;

(c) Who, but for the services listed in Regulation .04 of this chapter, requires and would be receiving institutional care reimbursed under the Program;

(d) Who, before receipt of services under this chapter, was:

(i) A patient in a hospital, nursing facility, or other long-term care facility; or

(ii) Formerly a patient in a hospital, nursing facility, or other long-term facility who, upon discharge, has continuously received other insurance reimbursement for skilled nursing or home health aide services which has precluded the need for admission to the waiver;

(e) Whose disabilities and needs for home care cannot be adequately and appropriately addressed through provider services otherwise available under the Program; and

(f) Who meets the eligibility requirements of these regulations or was receiving services under this chapter as of December 1, 1988 or under COMAR 10.09.31 as of December 31, 1990 and continues to meet the certification and care requirements specified in this chapter.

(20) "Plan of care" means the written home care plan which is:

(a) Composed of a comprehensive assessment of the participant's health status including:

(i) All pertinent diagnoses;

(ii) Prognosis;

(iii) Functional status;

(iv) Level of activity permitted;

(v) Type, frequency, and duration of services required;

(vi) Treatment goals for each type of service;

(vii) Medications; and

(viii) Treatments;

(b) Established by the multidisciplinary team;

(c) Approved, signed, and dated by the participant's principal physician;

(d) Approved, signed, and dated by the participant or the participant's legally authorized representative, or both;

(e) Approved, signed, and date by the Department; and

(f) Revised 90 days after approval of the initial plan of care and semiannually thereafter, unless the home care case manager decides that a different review period is appropriate.

(21) "Principal physician" means the specialty physician who is part of the interdisciplinary team and who approves the plan of care for the participant.

(22) "Program" means the Program as defined in COMAR 10.09.36.

(23) "Progress note" means a dated written notation by a home care provider which:

(a) Summarizes facts about the care given and the patient's responses during a given period of time;

(b) Specifically addresses the established goals of treatment;

(c) Is consistent with the participant's plan of care;

(d) Is written and signed during the course of care; and

(e) Is provided to the home care case management agency to become a part of the agency's permanent record for the participant.

(24) "Provider" means a provider as defined in COMAR 10.09.36.

(25) "Provider agreement" means a contract between the Department and the provider of home care, specifying the services to be performed, methods of operation, and financial and legal requirements which shall be in force before Program participation.

(26) "Recipient" means a recipient as defined in COMAR 10.09.36.

(27) "Residential service agency" means an agency licensed by the Department in accordance with COMAR 10.07.05.

(28) "Secretary" means the Secretary of Health.

(29) "Specialty physician" means a licensed physician who meets one of the following criteria:

(a) Has been declared board certified, or board eligible, by a member board of the American Board of Medical Specialties, and has demonstrated experience in the care of disabled children; or

(b) Has been declared board certified, or board eligible, by a specialty board approved by the Advisory Board of Osteopathic Specialists and the Board of Trustees of the American Osteopathic Association, and has demonstrated experience in the care of disabled children.

(30) "Supervision" means:

(a) Authoritative procedural guidance by a licensed registered nurse for the accomplishment of a function or activity; and

(b) The process of critical watching, directing, and evaluating an individual's performance.

(31) "Waiver enrollment process" means those procedures necessary to establish participant eligibility pursuant to Regulation .05 of this chapter.

(32) "Witness" means the recipient or an individual who, on behalf of the recipient, is able to personally verify that the recipient received private duty nursing services, home health aide services, or certified nursing assistant services.