(a) Continuous home care. Continuous care is to be provided only during periods of crisis to maintain the recipient at the recipient's place of residence. A period of crisis is a period in which a recipient requires continuous care that is primarily skilled nursing care to achieve palliation or management of acute medical symptoms.   (1) A minimum of eight hours of continuous home care must be provided during a 24-hour day that begins and ends at midnight. The care need not be continuous, for example, four hours could be provided in the morning and another four hours in the evening of that day.   (2) Skilled nursing care must be provided for more than half of the continuous home care period and must be provided by either a registered nurse or licensed vocational nurse.   (3) Homemaker, home health aide services, medical social work, or chaplain services may be provided to supplement the nursing care. The provider must document why social work or chaplain services were needed and what was accomplished during continuous home care. While on-call staff may be used to provide continuous home care; staff, however, must be on site, providing care to the recipient in their place of residence to be considered for inclusion in continuous home care hours.   (4) The services may be provided for up to five consecutive days. The Texas Department of Human Services (DHS) may review multiple continuous home care episodes within a consecutive 30-day period.   (5) The provider must have a physician's order and a documented medical need for skilled nursing care in the recipient's record and in the plan of care. The plan of care must be established by the attending physician, hospice medical director or his designee, and the interdisciplinary team, and coordinated by the hospice registered nurse. The plan of care must include the needs of the recipient; identification of the services, including management of discomfort and symptom relief; and the scope and frequency of the services needed to meet the needs of both the recipient and family.   (6) For purposes of this section, the following definitions apply:     (A) Nursing services--Nursing tasks that could not reasonably be delegated to family members or nurse aides.     (B) Crisis--A sudden paroxysmal intensification of symptoms that appropriate medical intervention and nursing services could reasonably be expected to ameliorate.   (7) Prior to providing continuous home care, the provider must advise and discuss with the family or responsible party that temporary alternate placement may be necessary at the end of the five consecutive days. The provider must document the discussion with the family or responsible party in the recipient's records.   (8) If the provider believes that the crisis period will extend beyond the five consecutive days, the interdisciplinary team must discuss the temporary placement alternatives available to meet the needs of the recipient during the crisis period, such as a hospital or nursing facility. This discussion must be documented. If, after this discussion, the provider believes that an extension of continuous home care is necessary instead of alternative placement, the provider must submit a written request for an extension of continuous care to DHS. Faxed submissions will not be considered.     (A) The written request must be sent to Texas Department of Human Services, Long-Term Care Policy Section, Attention Medicaid Hospice, P.O. Box 149030, Mail Code W-519, Austin, Texas, 78714-9030. Overnight mail must be sent to the Long-Term Care Policy Section, Texas Department of Human Services, 701 West 51st Street, Mail Code W-519, Austin, Texas 78751.     (B) The written request must include:       (i) description of the specific crisis and how the provider plans to resolve the crisis;       (ii) documentation of all continuous home care provided during the previous four days;       (iii) physician's orders;       (iv) documentation of daily physician care plan oversight;       (v) documentation that skilled nursing care was provided as more than half of the care given in a 24-hour period for each of the four days of continuous care;       (vi) the number of days of continuous home care requested for the extension; and       (vii) documentation of the interdisciplinary team's discussion regarding alternate placement, including why continuous home care must be extended and why temporary alternate placement is not presently warranted.   (9) The continuous home care request will be denied if documentation is incomplete. Documentation mailed on or before the fifth consecutive day of the crisis period will be reviewed by DHS within 16 work hours of the time the documentation is received in the Long-Term Care Policy Section, at the address identified in paragraph (8)(A) of this subsection. Documentation mailed after the fifth consecutive day will be reviewed by DHS within 10 calendar days of the time the documentation is received in the Long-Term Care Policy Section, at the address identified in paragraph (8)(A) of this subsection.   (10) Multiple requests for extensions for the same period of crisis will not be considered. If multiple requests are received, DHS will consider only the first written request.   (11) DHS may extend continuous home care if it deems it medically necessary. Providers will be notified in writing of DHS's decision within the time frames outlined in paragraph (9) of this subsection after DHS's receipt of the written request and documentation at the address outlined in paragraph (8)(A) of this subsection. DHS will fax the response to the provider if the provider includes a fax number with the extension request.   (12) If DHS denies the request for an extension of continuous home care, the provider will be paid at the routine home care rate or inpatient care rate, if applicable, for subsequent days of care.   (13) Request for reconsideration. If the provider does not agree with DHS's denial of the request for an extension of continuous home care, the provider may request a reconsideration of the decision at the state office level. The written request for reconsideration and all supporting documentation must be submitted to DHS at the address in paragraph (8)(A) of this subsection no later than the tenth calendar day after the provider's receipt of the denial of the request for an extension. DHS's reconsideration will be limited to a review of the documentation submitted. DHS will complete the reconsideration no later than the tenth calendar day after receipt of the request for reconsideration. (b) Respite care.   (1) Respite care is short-term inpatient care provided to the individual at home only when necessary to relieve the family members or other persons caring for the individual at home.   (2) Respite care may not be reimbursed for more than five consecutive days.   (3) Respite care can be provided by:     (A) a hospice that meets the condition of participation for providing inpatient care directly; or     (B) a hospital or nursing facility that also meets the Medicare standards regarding 24-hour nursing service and patient areas.   (4) Respite care may be provided only on an occasional basis and may not be reimbursed for more than five consecutive days at a time.   (5) Respite care may not be provided when the hospice patient is a nursing home resident.

Source Note: The provisions of this §30.54 adopted to be effective March 1, 2001, 26 TexReg 1549; amended to be effective May 1, 2002, 27 TexReg 3585; amended to be effective March 1, 2003, 28 TexReg 1396