4123-6-38. Payment for home health nursing services

(A) Employment of nursing service.

(1) The need for nursing services must be the direct result of an allowed injury or occupational disease.

(2) Except as described in rule 4123-6-38.1 of the Administrative Code, home health nursing services shall be provided by registered nurses and licensed practical nurses employed by a home health agency meeting the qualifications specified in paragraph (C) of rule 4123-6-02.2 of the Administrative Code.

(B) Fees for home health agency nursing services.

Fees for home health agency nursing services will determined by the bureau. Payment will be made for home health nursing services in accordance with rule 4123-6-10 of the Administrative Code.

(C) Authorization for home health nursing services.

(1) Authorization for home health nursing services shall be considered only in cases where the claimant, as the direct result of an allowed injury or occupational disease, is bedfast or otherwise confined to the home, is mentally incapable of self-care or requires home care services ordered for hospital discharge follow-up.

(2) The request for authorization from the physician of record or treating physician must identify the reason for home health nursing services, the period of time the services will be required, the specific services and the number of hours per day that are required.

(3) In addition to skilled nursing services provided by a registered nurse or licensed practical nurse, the claimant may be approved for home health aide services. If he/she is unable to independently perform activities of daily living, including, but not limited to, feeding, bathing, dressing, providing personal hygiene, and transferring from bed to chair. Household, personal or other duties related to maintaining a household, including but not limited to care or upkeep to the inside or outside of the residence, washing clothes, preparing meals, or running errands are not considered nursing services and will not be reimbursed, except to the extent such services are incidental to care of the claimant.

(4) Authorization must be obtained prior to rendering home health nursing services, except in cases of emergency or where the claimant's allowed condition could be endangered by the delay of services.

(D) All covered home health services must be rendered on a part-time or intermittent care basis, in accordance with the written treatment plan and the bureau standard of care. Part-time or intermittent care means that services are generally rendered for no more than eight hours per day. Home health services rendered on a full time or continuous care basis are not covered. More appropriate alternative settings will be considered for claimants requiring more than eight hours per day of care, where medical necessity is documented. Exceptional cases may be reviewed by the bureau.

(E) A review of the claim or assessment of the injured worker will be conducted at least annually to ensure that nursing services are necessary as a direct result of the allowed injury or occupational disease.

(F) Documentation requirements for home health agencies.

Home health agency providers must maintain records which fully document the extent of services provided to each claimant. All records must be maintained in accordance with the conditions of participation required for medicare certification, joint commission accreditation, or community health accreditation program (CHAP) accreditation, or accreditation through an organization that has been granted deeming authority by the centers for medicare and medicaid services (CMS). The provider may be required to furnish detailed hourly descriptions of care delivered to a claimant to review care needs and medical necessity.

Effective: 11/13/2015
Five Year Review (FYR) Dates: 08/26/2015 and 08/25/2020
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Prior Effective Dates: 2/12/97, 2/14/05, 2/1/10, 7/1/13