Sec. 10.09.27.04. Covered Services

A. The Program reimburses for home care services which include the following:

(1) Shift nursing services provided by a licensed registered nurse or a licensed practical nurse if:

(a) The complexity of the service or the condition of a participant requires the judgment, knowledge, and skills of a licensed nurse for a shift of 4 or more continuous hours;

(b) The services are delivered to the participant in the participant's home or other setting when normal life activities take the participant outside the home;

(c) Services are provided to a model waiver participant who is 21 years old or older;

(d) Services are rendered in accordance with COMAR 10.09.53;

(e) Services are rendered in accordance with Health Occupations Article, Title 8, Annotated Code of Maryland;

(f) Sufficient documentation concerning the services provided is maintained by the registered nurse or licensed practical nurse, including:

(i) Verification of the participant's receipt of services as documented by the participant's signature or the signature of the participant's witness on the provider's official forms; and

(ii) Signed and dated progress notes which are reviewed monthly by the nurse supervisor;

(g) The nurse is not scheduled to work for more than 16 consecutive hours and is off 8 or more hours before starting another shift;

(h) Services are rendered by a licensed registered or practical nurse certified in cardiopulmonary resuscitation and the certification is renewed every 2 years;

(i) Services are preauthorized in accordance with the criteria set forth in COMAR 10.09.53.06; and

(j) Supervisory visits are conducted at least monthly in the participant's home or another site where the participant is receiving nursing services with a minimum of two visits per year with the primary nurse present;

(2) Home care case management which includes:

(a) Arranging, monitoring, and coordinating the health-related services necessary to meet the identified needs of the participant as specified in the participant's plan of care;

(b) Establishing, in conjunction with the other members of the multidisciplinary team, the plan of care necessary to deinstitutionalize or maintain, or both of these, the participant at home;

(c) Reviewing the plan of care for appropriateness of the level, amount, type, quality, and frequency of services provided as well as monitoring the cost effectiveness of home care for each participant;

(d) Arranging for scheduled reviews and approval of the plan of care by the principal physician; and

(e) Providing for in-home assessments by the principal physician on a quarterly basis, or as determined necessary by the principal physician;

(3) Participation by the principal physician in the plan of care meetings including:

(a) Prescribing home care services; and

(b) Approving and signing the plan of care;

(4) Home health aide services which include:

(a) The performance of simple procedures as an extension of therapy services;

(b) Ambulation and exercise;

(c) Household services essential to health care at home;

(d) Assistance with medications that are ordinarily self-administered;

(e) Assistance with activities of daily living when performed in conjunction with other delegated nursing services;

(f) Other health care services properly delegated by a licensed nurse pursuant to Health Occupations Article, Title 8, Annotated Code of Maryland, if:

(i) The complexity of the service or the condition of a participant requires the judgment, knowledge, and skills of a home health aide for a shift of 4 or more continuous hours;

(ii) Services are provided by an unlicensed individual who meets all the conditions of participation specified by the Medicare program in 42 CFR §484.36 and Health Occupations Article, Title 8, Annotated Code of Maryland;

(iii) Services are rendered by a home health aide certified in cardiopulmonary resuscitation and the certification is renewed every 2 years;

(iv) The home health aide is not scheduled to work for more than 16 consecutive hours and has 8 hours or more off before starting another shift;

(v) Sufficient documentation is maintained by the home health aide including verification of the participant's receipt of services as documented by the participant's signature or the signature of the participant's witness on the provider's official forms; and signed and dated progress notes which are reviewed every 2 weeks by the nurse supervisor;

(vi) Supervisory visits are conducted every 2 weeks and documented by a registered nurse with a minimum of two visits with the primary aide present;

(vii) The services are included in the model waiver participant's plan of care developed by the case manager; and

(viii) Services are preauthorized by the Department;

(5) Certified nursing assistant services if:

(a) The certified nursing assistant is certified by the Maryland Board of Nursing and meets all the requirements to render services pursuant to Health Occupations Article, Title 8, Annotated Code of Maryland;

(b) The complexity of the service or the condition of a participant requires the judgment, knowledge, and skills of a certified nursing assistant for a shift of 4 or more continuous hours;

(c) The services provided include but are not limited to:

(i) Assistance with activities of daily living when performed in conjunction with other delegated nursing services; or

(ii) Other health care services properly delegated by a licensed nurse pursuant to Health Occupations Article, Title 8, Annotated Code of Maryland;

(d) Services are rendered by a certified nursing assistant certified in cardiopulmonary resuscitation and the certification is renewed every 2 years;

(e) The certified nursing assistant is not scheduled to work for more than 16 consecutive hours and has 8 hours or more off before starting another shift;

(f) Sufficient documentation concerning the services provided is maintained by the certified nursing assistant including:

(i) Verification of the participant's receipt of services as documented by the participant's signature or the signature of the participant's witness on the provider's official forms; and

(ii) Signed and dated progress notes which are reviewed every 2 weeks by the nurse supervisor;

(g) Supervisory visits are conducted every 2 weeks and documented by a registered nurse with a minimum of two visits with the primary aide present;

(h) The services are included in the model waiver participant's plan of care developed by the case manager; and

(i) Services are preauthorized by the Department.

(6) Medical day care when services are:

(a) Included in the Model Waiver participant's approved and signed plan of care; and

(b) Rendered in accordance with COMAR 10.09.07.

B. The Department will reimburse for the services listed in §A(1)-(2) and (4)-(6) of this regulation when they are:

(1) Ordered by the participant's principal physician as part of a written home care plan, which is included in the provider's permanent record for the participant and is reviewed by the principal physician in accordance with Regulation .01B(16) of this chapter;

(2) Medically necessary;

(3) Adequately described in progress notes in the participant's medical record, signed, and dated by the individual providing care;

(4) Provided instead of institutional care to recipients certified and annually recertified as requiring nursing facility care under the Program as specified in COMAR 10.09.10 or 10.09.11; and

(5) Provided in the amount, duration, and frequency specified in the plan of care subject to approval by the Program.