Initiation of Care Orders: The home health agency must receive written orders from the client’s primary HIV medical provider before initiation of care by the home health agency from a licensed practitioner to include the following:

• Doctor of Medicine (MD)
• Doctor of Osteopathy (OD)
• Nurse Practitioner (NP)
• Clinical Nurse Specialist (CNS)
• Physician Assistant (PA)

Note: Section 3708 of the CARES Act allows a nurse practitioner, clinical nurse specialist, or physician assistant who is working in accordance with State law to order or refer home health services. This applies on or after March 1, 2020..

Homebound Status: The ordering provider must certify the client is homebound or confined to home as applicable. To receive Home Health Services, the client must meet one or more of the following criteria:

• The client needs the aid of supportive devices, such as crutches, canes, wheelchairs, or walkers
• The client has a condition in which leaving the home is medically contraindicated
• Leaving the home would require a considerable and taxing effort

Note: If the client does leave the home, the client may still meet the definition of homebound if the absences from the home are infrequent or for periods of relatively short duration or are attributable to the need to receive health care treatment.

1. Percentage of clients with documentation of signed orders for home health care services by a qualified licensed practitioner before initiation of care by the home health agency.

2. Percentage of clients with documentation of certification of client homebound status by a licensed health care practitioner. (Pilot Measure)

Timely Initiation of Care: Staff must contact the client within 1 business day of the referral, and must initiate services at the time specified by the primary medical care provider or within 2 business days, whichever is earlier.

3. Percentage of clients with documentation of initiation of care within one of the following criteria:

   a. Within 1 business day of receipt of referral or order for services

   b. On the date specified by referring or ordering provider

   c. Within 2 days of the date specified by the provider

Initial Assessment: Agencies must complete a comprehensive assessment of the client’s psychosocial, functional, past medical history, current health status, to include:

• Assessment of access to medical care
• Ability to adhere to therapies
• Disease stage
• Symptom management and prevention
• Need for nursing and support services
• Family and or another support system
• Safety of living environment
• Level of risk for falls
• Medications
• Treatments
• Head-to-toe nursing assessment of body systems
• Ability to perform activities of daily living

4. Percentage of clients with documentation of a completed comprehensive assessment on initiation of care.

Implementation of Care Plan: 

Staff will complete a care based on the primary medical care provider's order that includes:

• Current assessment and needs of the client including medication, dietary, treatment, and activities orders
• Need for home health services
• Types, quantity, and length of time services are to be provided
• Signature of a clinical healthcare professional

Care providers will update the care plan at least every 60 calendar days.

5. Percentage of clients with documentation of care plans completed in accordance with the primary medical care provider’s order(s).
 

6. Percentage of clients with documentation of care plan reviewed or updated as necessary based on changes in the client’s situation at least every 60 calendar days.

Provision of Services: Professional staff will:

• Provide nursing and rehabilitation therapy care under the supervision and orders of the client’s primary medical care provider.
• Monitor the progress of the care plan by reviewing it regularly with the client and revising it as necessary based on any changes in the client’s situation.
• Advocate for the client when necessary. 
• Monitor changes in the client’s physical and mental health, and level of functionality.
• Work closely with the client’s other healthcare providers and effectively communicate and address client service-related needs, challenges, and barriers.
• Provide assurance that the services are provided in accordance with allowable modalities and locations under the definition of home health services.
• Write progress notes on the day service was rendered and incorporate progress notes into the client record within 14 working days.

The agency will maintain ongoing communication with the primary medical care provider.

7. Percentage of clients with documentation of completed progress notes within 14 working days of the service rendered in the client’s primary record.

8. Percentage of clients with documentation of ongoing communication and care coordination with the primary medical care provider.

Transfer/Discharge: Transfer and discharge of clients from home health care services should result from a planned and progressive process that considers the needs and desires of the client and the caregiver(s), family, and support network.

Agencies must develop a transfer plan when one or more of the following criteria are met:

• Agency no longer meets the level of care required by the client.
• Client transfers services to another service program.
• The client is not stable enough to be cared for outside of the acute care setting as determined by the agency and the client's primary medical care provider.
• The client no longer has a stable home environment appropriate for the provision of home health services as determined by the agency.
• Client is unable or unwilling to adhere to agency policies.
• An employee of the agency has experienced a real or perceived threat to safety during a visit to a client's home, in the company of an escort or not. The agency may discontinue services or refuse the client for as long as the threat is ongoing. 

9. Percentage of clients with documentation of a transfer plan developed in coordination with the client, caregiver(s), and multidisciplinary team with a referral to an appropriate service provider agency, as applicable.
 

10. Percentage of clients with documentation of a discharge plan developed with client, caregiver(s), and multidisciplinary team, as applicable. (Pilot Measure)

Notification of Transfer/Discharge: When a client is transferred or discharged from services, agencies must:

• Provide written notification to the client or the client’s parent, family, spouse, significant other, or legal representative.
• Notify the client’s attending physician or practitioner.
• Written notification must be delivered no later than 5 days before the date on which the client will be transferred or discharged.

11. Percentage of clients with documentation of notification of transfer or discharge within 5 days before the date of transfer or discharge as applicable to the following parties: (Pilot Measure)

   a. The client or legal representative

   b. The client’s attending practitioner, as applicable.