Title 7 . Health and Social Services

Chapter 43 . Hearings

Section 801. Requirements for home health care services

7 AAC 43.801. Requirements for home health care services

(a) The department will not pay for a home health care service, other than an initial visit for evaluation purposes, unless the provider has received prior authorization from the department. A request for home health care services may originate with a home health agency, an attending physician, a rural health clinic, a hospital, a skilled nursing facility, an intermediate care facility, or another person concerned with the care of the recipient.

(b) A request for prior authorization must be submitted on a form prescribed by the department, and must include a written statement from the attending physician setting out

(1) the reason for home health care services, including the reason services cannot be performed in a clinic, outpatient setting, or physician's office; and

(2) medical recommendations for a plan of care developed under (d) of this section for services provided

(A) on an ongoing basis; or

(B) after acute care; for services provided under this subparagraph, the written statement must include the expected decrease in need for skilled nursing services and home health aide visits.

(c) The department will not base eligibility to receive home health care services upon the recipient's

(1) need for institutional care;

(2) discharge from institutional care;

(3) homebound status, except as provided in 7 AAC 43.800(a) (2); or

(4) need for skilled nursing services.

(d) A physician shall develop a plan of care for a recipient of home health care services. The plan of care must include

(1) pertinent diagnoses, including mental status;

(2) types of services and equipment required; orders for therapy services must include the specific procedures and modalities to be used and the amount, frequency, and duration of those services;

(3) the frequency of visits;

(4) the prognosis for the recipient;

(5) an analysis of the recipient's rehabilitation potential;

(6) a description of the recipient's functional limitations;

(7) activities permitted to the recipient;

(8) the recipient's nutritional requirements;

(9) the recipient's medications and treatments;

(10) any safety measures to protect the recipient against injury; and

(11) instructions for a timely discharge and referral.

(e) If a physician refers a recipient under a plan of care that cannot be completed until after an evaluation visit, the physician shall make additions or modifications to the original plan of care as necessary to reflect the outcome of the evaluation.

(f) To determine the immediate care and support needs of the recipient, and except as provided in (h) of this section, a registered nurse shall complete an initial assessment of the recipient within 48 hours after the referral, within 48 hours after the recipient's return to the recipient's place of residence, or on the physician-ordered start-of-care date.

(g) Consistent with the recipient's immediate care and support needs, and except as provided in (h) of this section, a registered nurse shall complete a comprehensive assessment of the recipient no later than five days after the date care starts. The comprehensive assessment must include a review of each medication that the recipient currently uses in order to identify

(1) significant side effects, significant drug interactions, and potential adverse effects and drug reactions;

(2) ineffective drug therapy;

(3) duplicate drug therapy; and

(4) noncompliance by the recipient with drug therapy.

(h) If speech language pathology, physical therapy, or occupational therapy is the only service ordered by the physician,

(1) a speech language pathologist, physical therapist, or occupational therapist, as appropriate, may complete the initial and comprehensive assessments within the scope of the professional's license; and

(2) the department will not require a medication review as part of the comprehensive assessment under (g) of this section.

(i) The attending physician shall review the plan of care, initial assessment, and comprehensive assessment

(1) at least once during the prior authorization period established under 7 AAC 43.805(b) ;

(2) more frequently if a significant change occurs in the recipient's condition; and

(3) if a discharge of the recipient and return to the same home health agency occurs during a prior authorization period established under 7 AAC 43.805(b) .

(j) At least annually, a physician shall review a recipient's need for supplies. The department may require more frequent physician reviews for particular prescribed items.

History: Eff. 4/28/2005, Register 174

Authority: AS 47.05.010

AS 47.07.030

AS 47.07.040