Va. DMAS Hospice Provider Manual ch. IV, General Hospice Services

Hospice is responsible for the provision of all covered services through one of the above

categories of care. Any covered services provided after the individual’s election of the

hospice benefit becomes the financial responsibility of hospice provider. Hospice must

ensure that substantially all of the core services (physician, nursing care, social work, and

counseling) are routinely provided directly by hospice employees to the individual. An

individual or designated representative may refuse home health aides or homemaker

services, social work, or counseling services, but the reason must be clearly documented

in the medical record and identified in the plan of care. If appropriate, when due to a

change in the individual’s needs, the service should be re-introduced to the individual, or

his or her responsible party, and the results of this discussion documented in the medical

record.

Hospice may use contracted home health aides or homemaker services, if necessary, to

supplement hospice employees to meet the needs of individuals during periods of peak

patient loads or under extraordinary circumstances. If contracting is used, the hospice

provider must maintain professional, financial, and administrative responsibility for the

services and ensure the qualifications of staff and services provided meet all

requirements. Documentation must be maintained by the provider to ensure the

contracted aide has been fully trained in hospice philosophy and the provision of palliative

care prior to any individual contact. Hospice maintains responsibility of nursing

supervisory visits of any contracted aide.

Hospice is required to have a legally binding, written agreement for the provision of

arranged services such as x-rays, laboratory, and pharmaceutical services for individuals

enrolled under their Medicaid hospice benefit. Hospice retains financial responsibility for

these services. Although the services are provided to an individual enrolled in Medicaid,

since the hospice provider retains financial responsibility, there is no obligation on the

part of the service provider to accept the Medicaid-allowable payment on the basis of the

individual’s eligibility status. Provision of and payment for these services should be

included in the contractual agreement between the hospice provider and the service

provider.

All services must be performed by appropriately qualified personnel, but it is the nature

of the service, rather than the qualification of the person who provides it, that determines

the coverage category of the service. The following services are covered hospice

services:

• Nursing Care - Nursing care must be provided by a licensed registered nurse, or

licensed practical nurse under the supervision of a licensed registered nurse, who

is a graduate of an approved school of professional nursing. On January 1, 2005,

Virginia joined the Nurse Licensure Compact. Under the Code of Virginia, the

Nurse Licensure Compact authorizes licensed practical nurses and registered

nurses licensed and residing in a compact state to practice in other compact states,

without the necessity of obtaining an additional license. The Virginia Board of

Nursing

website

(http://www.dhp.virginia.gov/nursing/)

provides

detailed

information as to which states are considered compact states and an explanation

of “primary state of residence.” Nursing services must be directed and staffed to

ensure the nursing needs of individuals are met. Patient care responsibilities of

nursing personnel must be specified. Services must be provided in accordance

with recognized standards of practice.

• Homemaker/Home Health Aide Services - Home health aides must meet the

federal and state qualifications specified for home health aides. Home health aide

and homemaker services must be available and adequate to meet the needs of

the individuals. Home health aides may provide personal care services. Aides

may also perform household services to maintain a safe and sanitary environment

in areas of the home used by the individual, such as changing the bed or light

cleaning and laundering essential to the comfort and cleanliness of the individual.

Homemaker services may include assistance in personal care, maintenance of a

safe and healthy environment, and services to enable the individual to carry out

the plan of care. Home health aide and homemaker services must be provided

under the general supervision of a registered nurse. A registered nurse must visit

the home site at least every two weeks when aide services are being provided and

the visit must include an assessment of the aide services. Written instructions for

the individual’s care must be prepared by a registered nurse. Documentation of

all services provided by the home health aide under the hospice benefit must be

maintained in the individual’s medical chart.

An individual in the CCC Plus Waiver can receive personal care, respite care, adult

day health care, and Personal Emergency Response System (PERS) services in

conjunction with hospice services. This is applicable regardless of whether the

hospice provider receives reimbursement from Medicare or Medicaid for the

services covered under the hospice benefit. Waiver services are authorized and

coordinated under Cardinal Care managed care organizations. For members

enrolled in the Cardinal Care program, please refer to the CCC Plus Waiver

Manual for specific requirements and enrollment information.

If an individual is currently receiving services under the CCC Plus waiver and

elects the hospice benefit, both the personal care provider and hospice provider

must communicate to determine the most appropriate plan for aide services. The

individual and/or caregiver must be included in the formation of the plan and

informed of the hours permitted for personal and hospice care. Although each

provider maintains their separate record documentation, it is required that this

documentation reveal a collaboration of services provided by both providers.

Once an individual elects the hospice benefit, the hospice provider becomes

responsible for establishing an interdisciplinary plan of care designed to meet

individual’s needs. If, at the time of the hospice assessment, the individual’s needs

indicate waiver services might be appropriate to supplement those services

provided by hospice and these hours cannot be met by hospice staff, volunteers,

the family support system, or other community resources, the individual should be

referred to a preadmission screening team (PAS) to evaluate whether the

individual meets the criteria for the CCC Plus waiver.

When waiver services are requested in addition to the services being provided

under the hospice benefit, PAS teams must:

❑ Authorize the waiver, based on existing preadmission screening criteria, as

long as the individual will be safe in the home setting with the total amount

of care available through waiver services, hospice, and informal supports.

Preadmission screening teams do not authorize services, but determine if

criteria is met for LTSS waiver programs, which is a pre-determination of a

need for the waiver service. The waiver provider determines the amount,

duration, and scope of each waiver service and requests authorization from

the appropriate entity.

Hospice must coordinate with the waiver provider to establish and agree upon one

plan of care for both providers which reflects the hospice philosophy and is based

on an assessment of the individual’s needs and unique living situation. The

individual and service providers must be involved in any and all decisions that affect

the individual’s care.

Hospice and the waiver provider must agree upon any collection of the patient pay

from the individual each month. This is an agreement which should be established

at the onset of care to determine which provider (whether it be the hospice or waiver

provider) will be responsible for collection of the monthly patient pay. If the person

is choosing to use consumer directed services through one of the waiver programs,

the hospice provider will need to coordinate the collection of the patient pay with

the individual directly.

After admission to hospice services, the individual may continue to receive

community-based respite. The hospice benefit only provides coverage for facility-based respite and is limited to five (5) consecutive days. The decision to choose

this option is the individual’s. If the individual wants community-based respite

services it must be coordinated in accordance with CCC Plus waiver policies.

• Medical Social Services - Medical social services must be provided by a social

worker who has at least a bachelor's degree from a school accredited or approved

by the Council on Social Work Education and who is working under the direction

of a physician. The social worker must meet all qualifications as outlined by the

Virginia Department of Licensure and Certification.

• Physician Services - Physician services must be performed by a professional

who is legally authorized to practice, is acting within the scope of his or her license,

and is a doctor of medicine or osteopathy, a doctor of dental surgery or dental

medicine, a doctor of podiatric medicine, a doctor of optometry, or a chiropractor.

The hospice medical director, or the physician member of the interdisciplinary

team, must be a licensed doctor of medicine or osteopathy.

Attending physician means a physician who is a doctor of medicine or osteopathy

and is identified by the individual or representative, at the time the individual elects

to receive hospice care, as having the most significant role in the determination and

delivery of the individual's medical care.

• Counseling Services - Counseling services are required to be provided as part

of the “core services” of a hospice program. Medicaid will not provide direct

reimbursement to the hospice, or any other provider, for counseling services.

Counseling services must be provided to individuals enrolled in hospice and their

family member(s), or other persons caring them. Counseling may be provided for

the purpose of training the family or other caregivers to provide care and/or for the

purpose of helping the individual and the individual’s caregivers adjust to the

approaching death. Hospice must give notice to the individual as to the availability

of clergy to provide spiritual counseling.

• Dietary Counseling- Dietary counseling, when required, must be provided by a

qualified professional and described in the plan of care. Other counseling services

may be provided by members of the interdisciplinary team, or other qualified

professionals, as determined by the hospice provider.

• Bereavement Counseling – Bereavement counseling consists of services

provided to the individual’s family up to one year after the individual’s death.

“Family” means the individual’s immediate kin, including spouse, brother, sister,

child, parent, or any other relation or individual with significant personal ties to the

individual who, by mutual agreement with the individual, family, and hospice,

participated in care. The plan of care must reflect the following: family needs,

services to be provided, frequency of service delivery, and a clear delineation of

who is to provide the bereavement counseling.

• Short-Term Inpatient Care - Short-term inpatient care, which is also referred to

as inpatient respite care, may be provided in a participating Medicaid hospice

facility, in-patient unit, or a participating Medicaid hospital or nursing facility, to

relieve the primary caregiver(s) providing at-home care for the individual enrolled

in hospice. No more than five (5) consecutive days of respite care will be covered.

• General In-Patient Care - General in-patient care may be required for procedures

necessary for pain control or acute/chronic symptom management which cannot

be provided in other settings. It may be provided in an approved facility

(freestanding hospice facility, hospital, or nursing facility).

NOTE: Individuals enrolled in hospice care are exempt from the preadmission

screening process for nursing facility requirements. For example: If an

individual enrolled in hospice enters a nursing facility and remains under the

hospice benefit, a preadmission screening is not required for the individual to

enter the nursing facility. However, if the individual revokes the hospice benefit

prior to entering the nursing facility, all of the preadmission screening

requirements will apply. All preadmission screening requirements apply if the

individual wants to enroll in the CCC Plus waiver. If the individual was not

screened prior to entering the nursing facility, the preadmission screening

team (PAS) may go into the nursing facility to complete the screening for CCC

Plus waiver enrollment.

• Durable Medical Equipment (DME) and Supplies - Durable medical equipment,

as well as other self-help and personal comfort items related to the palliation or

management of the individual's terminal illness, are covered. The written plan of

care must include any supplies and equipment that are necessary to provide

hospice care to the individual. Medical supplies and appliances must be provided

as needed for the palliation and management of the terminal illness and related

conditions. For additional information, refer to the Virginia Medicaid DME Manual.

• Drugs and Biologicals - Only drugs used primarily for the relief of pain and

symptom control related to the individual's terminal illness are covered. All drugs

and biologicals must be administered in accordance with accepted standards of

practice. Hospice must have a policy for the disposal of controlled drugs

maintained in the individual's home when those drugs are no longer needed by the

individual. Drugs and biologicals must be provided as needed.

• Rehabilitation Services - Rehabilitation services include physical and

occupational therapies and speech-language pathology services used for

purposes of symptom control, or to enable the individual to maintain activities of

daily living and basic functional skills. Rehabilitative services must be available

and, when provided, offered in a manner consistent with accepted standards of

practice.

Rehabilitative services shall be specific and provide symptom management related

to the individual’s terminal diagnosis in accordance with accepted standards of

medical practice. This includes the requirement that the amount, frequency, and

duration of the services shall be reasonable.

Physical therapy services can only be performed by a physical therapist licensed

by the Board of Medicine in the state in which the hospice provider is located, or a

physical therapy assistant who is licensed by the Board of Medicine and under the

direct supervision of a physical therapist licensed by the Board of Medicine.

Occupational therapy services are covered only when performed by an

occupational therapist registered and certified by the American Occupational

Therapy Certification Board or an occupational therapy assistant certified by the

American Occupational Therapy Board, under the direct supervision of an

occupational therapist as defined above.

Speech-language therapy services can only be performed by a speech-language

pathologist licensed by the Board of Audiology and Speech Pathology in the state

in which the hospice provider is located.

For additional information on rehabilitation services, refer to the Rehabilitation

provider manual issued by DMAS.