The governing authority shall ensure that decisions
regarding patient referral, admission and discharge are made based on the
patient's assessed needs and the agency's ability to meet those needs in a
manner that protects and promotes the patient's health and safety and does not
jeopardize the safety of personnel. Such decisions shall reflect a commitment
to providing authorized practitioner ordered care and services while honoring
the patient's expressed needs and choices to the extent practicable and shall
be made in accordance with the provisions of this section. For the purposes of
this Part, authorized practitioner shall refer to a doctor of medicine, a
doctor of osteopathy, a doctor of podiatry or any other practitioner authorized
under Federal and State law and applicable rules and regulations to provide
medical care and services to the patient.
(a) The initial patient visit shall be made
within 24 hours of receipt and acceptance of a community referral or return
home from institutional placement unless:
(1)
the patient's authorized practitioner orders otherwise; or
(2) there is written documentation that the
patient or family refuses such a visit.
(b) A patient shall be admitted to the agency
after an assessment, using a form prescribed or approved by the department, is
performed during the initial patient visit, which indicates that the patient's
health and supportive needs can be met safely and adequately at home and that
the patient's condition requires the services of the agency.
(1) In determining whether a prospective
patient's health and supportive needs can be met safely at home, the agency
shall consider for admission a prospective patient who meets at least one of
the following criteria: is self- directing; is able to call for help; can be
left alone; or has informal supports or other community supports who are
willing, able and available to provide care and support for the patient in
addition to the services being provided by the agency. For purposes of this
section:
(i) a self-directing patient means
an individual who is capable of making choices about his/her clinical care and
activities of daily living, understanding the impact of the choice and assuming
responsibility for the results of the choice, or has informal supports willing
and able to provide advice and/or direction on behalf of the patient, if
needed, in accordance with State law;
(ii) a patient who is able to call for help
means an individual who is physically, mentally and cognitively capable of
initiating effective communication to individuals outside the immediate
presence of the patient who can provide timely assistance to the
patient;
(iii) a patient who can be
left alone means an individual who, based on his/her physical, mental and
cognitive capability, does not require the continuous presence of another
individual to meet his/her minimal ongoing health and safety requirements;
and
(iv) informal supports or other
community supports means friends, relatives or associates of the patient,
whether compensated or not, unaffiliated with the agency, who are able,
available and willing to provide needed care, support and other services to the
patient during the periods agency personnel are not present. Such supports may
include personnel of an adult care facility in which the patient
resides.
(2) The agency
shall not be required to admit a patient:
(i)
who does not meet any of the criteria of paragraph (1) of this
subdivision;
(ii) when conditions
are known to exist in or around the home that would imminently threaten the
safety of personnel, including but not limited to:
(a) actual or likely physical assault which
the individual threatening such assault has the ability to carry out;
(b) presence of weapons, criminal activity or
contraband material which creates in personnel a reasonable concern for
personal safety; or
(c) continuing
severe verbal threats which the individual making the threats has the ability
to carry out and which create in personnel a reasonable concern for personal
safety;
(iii) when the
agency has valid reason to believe that agency personnel will be subjected to
continuing and severe verbal abuse which will jeopardize the agency's ability
to secure sufficient personnel resources or to provide care that meets the
needs of the patient; or
(iv) who,
based on previous experience with the delivery of care from the agency, is
known to repeatedly refuse to comply with a plan of care or others interfere
with the patient's ability to comply with a plan of care agreed upon, as
appropriate, by: the patient; the patient's family; any legally designated
patient representative; the patient's physician; agency personnel and/or any
case management entity, and such non-compliance will:
(a) lead to an immediate deterioration in the
patient's condition serious enough so that home care will no longer be safe and
appropriate; or
(b) make the
attainment of reasonable therapeutic goals impossible;
(3) the assessment shall be
conducted by a registered professional nurse, except in those instances where
physical therapy or speech/language pathology is the sole service prescribed by
the patient's physician and the agency elects to have the therapist conduct the
assessment.
(c) At the
time a determination is made to deny a patient admission based on the criteria
listed in paragraph (b)(2) of this section, the agency shall determine whether
the patient appears to be eligible for services from the local protective
services for adults program in accordance with the criteria set forth in
section
457.1(b) of
Title 18 NYCRR.
(1) If the patient appears to
be eligible for such services, the agency shall make a referral to the
appropriate local protective services for adults program. Such referral shall
indicate the patient's ongoing care needs and the reason for the decision not
to admit.
(2) If the local
protective services for adults program accepts the referral, takes action to
address the problems preventing admission and notifies the agency that such
problems have been resolved, the agency shall reassess the patient to determine
whether admission has become appropriate or remains inappropriate.
(d) Any patient who is assessed or
reassessed as inappropriate for agency services shall be assisted by the
agency, in collaboration with the discharge planner, the local social services
department and other case management entity, as appropriate, with obtaining the
services of an alternate provider, if needed, and the patient's authorized
practitioner shall be so notified. If alternate services are not immediately
available, and the local protective services for adults program, the Office of
Mental Retardation and Developmental Disabilities, the Office of Mental Health
or other official agency requests that home care services be provided on an
interim basis, the agency may provide home care services which address
minimally essential patient health and safety needs for a period of time agreed
upon by the agency and the requesting entity, provided that the patient and
family or informal supports, as appropriate, have been fully informed of the
agency's intent to transfer the patient to an alternate service, when
available, and have been consulted in the development of an interim plan of
care.
(e) Services which the agency
provides shall be available to all persons without regard to age, race, color,
creed, sex, national origin, disability, service need intensity, location of
patient's residence in the service area, or source of payment.
(f) Services shall not be diminished or
discontinued solely because of the change in the patient's source of payment or
the patient's inability to pay for care.
(g) A discharge plan shall be initiated prior
to agency discharge to assure a timely, safe and appropriate transition for the
patient.
(h) A patient may be
discharged by the agency only after consultation, as appropriate, with the
patient's authorized practitioner, the patient, the patient's family or
informal supports, any legally designated patient representative and any other
professional personnel including any other case management entity involved in
the plan of care. If the agency determines that the patient's health care needs
can no longer be met safely at home due to the circumstances specified in
paragraphs (4) and (5) of this subdivision, the agency must continue to provide
home health services only to the extent necessary to address minimally
essential patient health and safety needs until such time as an alternative
placement becomes available and such placement is made or the patient or the
patient's legal representative, who has the authority to make health care
decisions on behalf of the patient, makes an informed choice to refuse such
placement. As appropriate, the patient and family or informal supports, any
legally designated patient representative and any other professional personnel
including any case management entity involved, shall be fully informed of the
agency's intent to discharge the patient to an alternate service, when
available, and shall be consulted in the development of an interim plan of
care. Discharge shall be appropriate when:
(1) therapeutic goals have been attained and
the patient can function independently or with other types of community support
services;
(2) conditions in the
home imminently threaten the safety of the personnel providing services or
jeopardize the agency's ability to provide care as described in subparagraphs
(b)(2)(ii)-(iii) of this section;
(3) all agency services are terminated by the
patient;
(4) the patient, the
patient's family, informal supports or any legally designated patient
representative is non-compliant or interferes with the implementation of the
patient's plan of care and the scope and effect of such non-compliance or
interference:
(i) has led to or will lead to
an immediate deterioration in the patient's condition serious enough that home
care will no longer be safe and appropriate; or
(ii) has made attainment of reasonable
therapeutic goals at home impossible; and
(iii) the likely outcome of such
non-compliance or interference has been explained to the patient, or the
patient's legally designated patient representative, family or informal
supports, and any case management entity, as appropriate, and the patient
continues to refuse to comply with, or others continue to interfere with the
implementation of, the plan of care; or
(5) the availability of home health services
or community support services is no longer sufficient to meet the patient's
changing care needs and to assure the patient's health and safety at home and
the patient requires the services of a health care institution or an alternate
health care provider. An agency may determine that the patient's health care
needs can no longer be met safely at home by the agency if none of the criteria
or circumstances of paragraph (b)(1) of this section apply any longer to the
patient.
(i) If a
patient is to be discharged in accordance with subdivision (h) of this section,
and the agency believes there will continue to be a substantial risk to the
patient's health and safety subsequent to discharge, a referral shall be made
to the appropriate local protective services for adults program or other
official agency, as appropriate, at the time the discharge determination is
made.
(1) If the local protective services
for adults program or other official agency to which the patient has been
referred accepts the referral, takes action to address adequately the problems
leading to the discharge determination and notifies the home care agency that
such problems have been resolved, the agency shall reassess the
patient.
(2) After reassessment,
the home care agency shall determine whether action to discharge the patient
should be discontinued or the discharged patient should be
readmitted.