Sec. 10.09.53.04. Covered Services

A. The Program shall cover services rendered by a nurse, CNA, or HHA when the:

(1) Services are ordered by the participant’s primary medical provider and renewed every 60 days after that;

(2) Services are directly related to the plan of care;

(3) Services are described in the nursing care plan and progress notes;

(4) Services are of a scope that is more individual and continuous than what is available under the home health program;

(5) Services are delivered in the recipient's home, or other setting when normal life activities take the recipient outside the home;

(6) Services include supervision of family caregivers in the home while family caregivers practice the skills necessary to provide care to the recipient in accordance with the established plan of care;

(7) Services are determined medically necessary after the provider has completed an initial nursing assessment;

(8) Services are preauthorized in accordance with Regulation .06 of this chapter;

(9) Services are received by the participant as documented by the signature of the participant or the participant’s representative on the nursing provider’s official form; and

(10) Participant has at least one caregiver willing and able to accept responsibility for the participant’s care when the nurse, CNA, or HHA is not available.

B. The Program shall cover nursing services rendered by a registered nurse when:

(1) The complexity of the services or the condition of a participant requires the judgment, knowledge, and skills of a registered nurse in accordance with COMAR 10.27.09 and the services cannot be:

(a) Performed by a licensed practical nurse in accordance with COMAR 10.27.10; and

(b) Delegated to a CNA or HHA pursuant to Health Occupations Article, Title 8, Annotated Code of Maryland and in accordance with COMAR 10.27.11;

(2) Sufficient documentation is maintained by the registered nurse including signed and dated progress notes which are reviewed by the registered nurse supervisor;

(3) Supervisory visits are conducted and documented by the registered nurse supervisor based on acceptable standards of practice; and

(4) Services are preauthorized by the Department.

C. The Program shall cover nursing services rendered by a licensed practical nurse when:

(1) The complexity of the services or the condition of a participant requires the judgment, knowledge, and skills of a licensed practical nurse in accordance with COMAR 10.27.10 and the services:

(a) Do not require the knowledge and skills of a registered nurse in accordance with COMAR 10.27.09; and

(b) Cannot be delegated to a CNA or HHA pursuant to Health Occupations Article, Title 8, Annotated Code of Maryland, and in accordance with COMAR 10.27.11;

(2) Sufficient documentation is maintained by the licensed practical nurse including signed and dated progress notes which are reviewed by the registered nurse supervisor;

(3) Supervisory visits are conducted and documented by the registered nurse supervisor based on acceptable standards of practice; and

(4) Services are preauthorized by the Department.

D. The Program shall cover delegated nursing services provided by a CNA or HHA who is also certified as a CMT when:

(1) The complexity of the service or the condition of a participant requires the judgment, knowledge, and skills of the CNA or HHA for at least 2 or more continuous hours;

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

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

(b) Other nursing services properly delegated by a nurse pursuant to Health Occupations Article, Title 8, Annotated Code of Maryland, and in accordance with COMAR 10.27.11;

(3) Sufficient documentation is maintained by the CNA or HHA including signed and dated progress notes which are reviewed by the nurse supervisor; and

(4) Supervisory visits are conducted and documented by a registered nurse supervisor in accordance with COMAR 10.27.09 and 10.27.11.

E. The Program shall cover a provider's initial assessment of a participant's medical need for services when the assessment:

(1) Is 3 hours or less;

(2) Does not require preauthorization;

(3) Demonstrates:

(a) A comprehensive assessment of the recipient's health status;

(b) An assessment of the need for services;

(c) An assessment of the scope and duration of services to be provided;

(d) An assessment of the recipient's residence; and

(e) Consultation with the primary medical provider, and a multidisciplinary team if the participant is receiving services under COMAR 10.09.27, to confirm the need for services and to develop a plan of care; and

(4) Is conducted by a licensed registered nurse.

F. If a need for services is confirmed during a participant's initial assessment, the registered nurse, in conjunction with the participant's primary medical provider, shall develop a care plan. When a participant also receives services under COMAR 10.09.27, the nurse or registered nurse supervisor shall participate as a member of the multi-disciplinary team and recommend a plan of care. The care plan shall be reviewed and updated to reflect the current service orders and shall include:

(1) Prognosis;

(2) Diagnoses;

(3) Treatment;

(4) Treatment goals;

(5) Services required, including specific nursing procedures;

(6) Frequency of visits (that is, hours of nursing care ordered for each day);

(7) Duration of treatment;

(8) Functional limitations;

(9) Permitted and prohibited activities;

(10) Diet;

(11) Medications;

(12) Mental status;

(13) A list of medical supplies related to each nursing procedure and how these are to be used in the participant's care:

(14) A list of durable medical equipment related to each nursing procedure and how the equipment is to be used in the participant's care;

(15) Safety measures to protect against injury;

(16) Emergency plan;

(17) Contingency plan for back-up coverage;

(18) Nurse's role in including the family in the provision of care;

(19) Plan to decrease services when the participant's condition improves or as the caregivers become better able to meet the participant's needs; and

(20) Other appropriate items.

G. The Department may preauthorize on a short-term basis services for assessment purposes only, when medical information is insufficient to determine medical necessity;

H. Services shall be decreased as the caregivers become better able to meet the participant's needs.

I. The Program shall cover nursing services ordered by the participant’s primary medical provider when the primary medical provider is an individual who is enrolled as a provider in the Program with an active status on the date of service.