CMS SOM App. B, Tag G982

(1) Skilled nursing services and at least one other therapeutic service (physical

therapy, speech-language pathology, or occupational therapy; medical social

services; or home health aide services) are made available on a visiting basis, in a

place of residence used as a patient's home. An HHA must provide at least one of

the services described in this subsection directly, but may provide the second service

and additional services under arrangement with another agency or organization.

Interpretive Guidelines §484.105(f)

The HHA must provide skilled nursing services and at least one other therapeutic service.

However, only one service must be provided directly by the HHA.

An HHA is considered to provide a service “directly” when the persons providing the

service for the HHA are HHA employees. An individual who works for the HHA on an

hourly or per-visit basis may be considered an HHA employee if the HHA is required to

issue a form W-2 on the individual’s behalf with no intermediaries. An HHA is

considered to provide a service “under arrangements” when the HHA provides the

service through contractual or affiliation arrangements with other agencies or

organizations, or with an individual(s) who is not an HHA employee.

Contracted staffing may supplement, but may not be used in lieu of, HHA staffing for

services provided directly by the HHA. In addition, the use of contracted staff in a

service provided directly by the HHA may occur only on a temporary basis to provide

coverage for unexpected HHA staffing shortages, or to provide a specialized service that

HHA employees cannot provide.