N.J. Admin. Code § 10:60-1.8

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:60-1.8 - Standards of performance for concurrent and post payment quality assurance review

(a) An initial visit to evaluate the need for home health services or personal care assistant (PCA) services for a fee-for-service beneficiary shall be made by the provider. For PCA services, the provider agency shall request prior authorization using form FD-365 and a State-approved PCA Assessment tool in accordance with procedures as described at N.J.A.C. 10:60-3.9. PCA services for fee-for-service beneficiaries shall not be rendered until authorization is provided by DDS.

1. On a random selection basis, MACC staff may conduct post-payment quality assurance reviews. At the specific request of the MACC, the provider shall submit a plan of care and other documentation for those Medicaid/NJ FamilyCare fee-for-service beneficiaries selected for a quality assurance review.

2. Upon completing the post-payment quality assurance review, the MACC shall forward a performance report to the provider, based on compliance with the standards described in this section.

(b) The professional staff from the MACC will use the standards listed at (c) through (j) below to conduct a post-payment quality assurance review of home care services as provided to the Medicaid/NJ FamilyCare fee-for-service beneficiary.

(c) Skilled nursing services and visits shall be based on a comprehensive assessment performed by a registered professional nurse to identify care needs and required services and shall be provided as designated by the plan of care.

1. Home visits for nursing services shall be provided to the beneficiary as ordered by the physician/practitioner and as designated by the standards of nursing practice.

2. The nurse shall make home visits as appropriate and as scheduled in the plan of care. Supervision of home health aide services is an integral component of these visits.

3. Services shall be within the scope of practice of personnel assigned.

4. Appropriate referrals for required services shall be instituted on a timely basis.

5. Nursing progress notes and plans of care shall reflect the significant changes in condition which require changes in the scope and timeliness of service delivery.

(d) Home health aide and personal care assistant services shall be provided by the agency in accordance with the plan of care.

1. The aide shall arrive and leave each day as scheduled by the agency.

2. The agency shall strive for consistency when assigning staff to beneficiaries with the intent of assuring continuity of care for the beneficiary, unless there are unusual documented circumstances, such as a difficult beneficiary/caregiver relationship, difficult location, or personal reasons of aide or beneficiary/caregiver.

3. Services shall be within the scope of practice of personnel assigned.

4. Appropriate training and orientation shall be provided by licensed personnel to assure the delivery of required services.

5. The aide shall provide appropriate services as reflected in the plan of care and identified on the assignment sheet;

6. Home care services shall be provided to the beneficiary to maintain the beneficiary's health or to facilitate treatment of an illness or injury.

7. Registered nurse delegated tasks shall be provided by licensed practical nurses (LPN), certified nursing assistants (CNA), or certified home health aides (CHHA).

(e) Physical therapy, occupational therapy, or speech-language pathology services shall be provided as an integral part of a comprehensive medical program. Such rehabilitative services shall be provided through home visits for the purpose of attaining maximum reduction of physical or mental disability and restoration of the individual to the best functional level.

1. The services shall be provided with the expectation, based on the assessment made by the physician/practitioner of the beneficiary's rehabilitation potential, that the condition of the individual shall improve materially in a reasonable and generally predictable period of time, or that the services are necessary towards the establishment of a safe and effective maintenance program.

2. The complexity of rehabilitative services is such that it can only be performed safely and effectively by a therapist. The services shall be consistent with the nature and severity of the illness or injury. The amount and frequency of these services shall be reasonable and necessary, and the duration of each visit shall be a minimum of 30 minutes.

3. The services shall be specific and effective treatment for the beneficiary's condition and shall be provided in accordance with accepted standards of medical practice.

4. For physical therapy standards, see 10:60-2.1(d)5 ii(1)(E).

(f) Visits of social service professionals are necessary to resolve social or emotional problems that are, or may be, an impediment to the effective treatment of the individual's medical condition or rate of recovery.

1. Medical social services shall be provided as ordered by the physician/practitioner and furnished by the social worker.

2. Plan of care shall indicate the appropriate action taken to obtain the available community resources to assist in resolving the beneficiary's problems or to provide counseling services which are reasonable and necessary to treat the underlying social or emotional problems which are impeding the beneficiary's recovery.

3. The services shall be responsive to the problem and the frequency of the services shall be for a prescribed length of time.

(g) Visits of a dietitian or nutritionist shall be provided as needed to resolve nutritional problems which are, or may be, an impediment to the effective treatment of the beneficiary's medical condition or rate of recovery.

1. Nutritional services shall be provided as ordered by the physician/practitioner and furnished by a dietitian or nutritionist in accordance with accepted standards of professional practice.

2. The plan of care shall indicate the nutritional care needs and the goals to meet those needs.

3. Services shall be provided to the beneficiary and/or the family/interested others involved with the beneficiary's nutritional care.

4. The services shall be specific and for a prescribed period of time.

5. The progress notes and care plan shall reflect significant changes or problems which require changes in the scope and timeliness of service delivery visits.

(h) The services shall be provided to the satisfaction of the beneficiary/caregiver.

1. There shall be documented evidence that the beneficiary/caregiver has participated in the development of the plan of care.

2. Identified problems shall be resolved between the agency and the beneficiary/caregiver, when possible.

3. The agency shall make appropriate referrals for unmet beneficiary needs.

4. The beneficiary/caregiver shall be promptly informed of changes in aides and/or schedules.

5. Beneficiaries/caregivers shall be aware of the agency name, telephone number, and contact person in the event of a problem.

(i) The home health agency shall be aware of the beneficiary's need for, and shall make the appropriate arrangements for, securing medical equipment, appliances, and supplies, as follows:

1. The agency shall assist the beneficiary in obtaining equipment, appliances, and supplies when needed under Medicare and/or Medicaid/NJ FamilyCare guidelines;

2. The agency shall monitor equipment, appliances and supplies to assure that all items are serviceable and used safely and effectively; and

3. The agency shall be responsible for contacting the provider for problems relating to the utilization of equipment, appliances and supplies.

(j) Recordkeeping shall be timely, accurate, complete and legible, in accordance with this chapter, and as follows:

1. There shall be a current aide assignment sheet for each beneficiary, available either in the home or at the agency, dated and signed by the nurse. The assignment shall be based on a nursing assessment of the beneficiary's needs and shall list the aide's duties as required in the plan or care;

2. The agency shall document significant changes in health and/or social status, including recent hospitalization, in the progress notes and make appropriate changes in the plan of care as needed;

3. Initial evaluations and progress notes shall be provided to the MACC upon request for all nursing services; and

4. Initial evaluations, progress notes and goals shall be provided to the MACC upon request for physical, occupational and speech-language therapies and social services.

N.J. Admin. Code § 10:60-1.8

Amended by 50 N.J.R. 1992(b), effective 9/17/2018

Amended by 54 N.J.R. 1721(a), effective 9/6/2022