Acceptance to Service

Administrative Policy Manual

Criteria for Patient/Client Admission and Recertification

Purpose

1. To ensure admission and recertification requests are reviewed for individual appropriateness for home care.
2. To ensure that the patient/client meets set criteria that determine admission is appropriate and that the Agency can meet the anticipated needs of the patient/client.

Policy

1. The Agency will review each request for admission and recertification for appropriate criteria for home care.
2. The Agency will accept a patient/client for treatment based on a reasonable expectation that the patient’s/client’s medical, nursing, rehabilitative, and social needs can be met adequately in the patient’s/client’s place of residence.
3. The Agency will assess current staffing levels, caseload, and case mix to determine availability of staff and appropriateness of acceptance of admission.
4. The Agency will ensure skills and competencies of the staff are adequate to provide appropriate care and service to the patient/client.
5. The Agency will consistently apply and annually review this policy to ensure acceptance-to-service criteria are established and maintained for patients/clients referred to home health care.
6. The Agency will obtain a signed written consent prior to performing services to include:
   1. Consent for treatment;
   2. Financial authorization;
   3. Release of records; and
   4. Services to be provided, who will be responsible for patient/client care, who will perform the care, and estimated frequencies.
7. The Agency will obtain a specific signed written informed consent prior to performing the following care, treatment, or services:
   1. Infusion therapy, if provided by the Agency;
   2. Delegation by a registered nurse (RN); and
   3. Photographing of wound(s).
8. The Agency will not discriminate in the provision of services with respect to race, color, national origin (including limited English proficiency and primary language), age, sex (includes, but is not limited to sex characteristics, including intersex traits; pregnancy or related conditions; sexual orientation; gender identity and sex stereotypes), disability, source of payment, marital status (including basis of relationship or association), religion, or any other characteristic protected by federal and state law.
   1. The Agency will refer to the Nondiscrimination Requirements policy located in the Rights and Ethics section of the Administrative Policy Manual.
9. Eligibility criteria for patient/client admission to the Agency:
   1. The patient/client is homebound if required by the payor source;
   2. The patient/client is under the care of a physician and/or non-physician practitioner;
   3. The patient/client has a qualifying need requiring the intermittent skills of a nurse or the skills of a therapist;
   4. The patient/client lives in the geographic area served by the Agency;
   5. The Agency is able to provide the level of care needed;
   6. The home environment is suitable and safe for providing care;
   7. The patient/client meets the face-to-face requirements, if required by the payor, to include documentation of an encounter with the physician and/or non-physician practitioner to support the reason for home care and homebound status, either:
      1. Within the past 90 days, or
      2. Agrees to see the physician and/or non-physician practitioner within 30 days of admission.
   8. The face-to-face visit is related to the primary reason the patient/client requires home health services and was performed by an allowed provider type. The certifying physician and/or non-physician practitioner must also document the date of the encounter.
10. The required face-to-face encounters for home health can be conducted via telehealth, 2-way audio and video telecommunications technology that allows for real-time interaction between the physician and/or non-physician practitioner and the patient/client when the patient/client is at home. Section I, Division B, Title II, Section 2207(a) of the Full-Year Continuing Appropriations and Extensions Act, 2025 allows for face-to-face encounters via telehealth services after the public health emergency ended through September 30, 2025.*


11. Eligibility criteria for psychiatric patient/client admission to the Agency:
    1. The patient/client is under the care of the physician and/or non-physician practitioner who authorizes psychiatric home care.
    2. The patient/client has an appropriate mental diagnosis.
    3. The patient/client is homebound if required by the payor. Examples may include:
       1. Fearful/refusal to leave home due to agoraphobia, claustrophobia, or acrophobia;
       2. Fearful/refusal to leave home due to severe depression, isolative or withdrawn behavior;
       3. Fearful/refusal to leave home due to altered thought processes or perceptions with hallucinations, delusions, suspiciousness, paranoia, or poor reality testing;
       4. Fearful/refusal to leave home due to impaired judgment, emotionally labile, and obsessive or bizarre behavior;
       5. Fearful/refusal to leave home due to severe anxiety, panic attacks, and impaired capability of making life decisions;
       6. Unsafe to leave the home environment without the assistance of another due to agitation, confusion, forgetfulness, paranoia, or poor judgment; and
       7. May have a physical impairment that renders the patient/client homebound.
    4. The home environment is considered safe for both the patient/client and the staff.
    5. The patient/client lives in the geographic area served by the Agency.
    6. The Agency is able to provide the care needed by appropriately trained staff.
12. Criteria for patient/client recertification:
    1. The physician and/or non-physician practitioner must certify (attest) if required by the payor, that:
       1. The home health services are, or were, needed because the patient/client is, or was, confined to the home as defined by §30.1 in Chapter 7 of the Medicare Benefit Policy Manual.
       2. The patient/client needs, or needed, skilled nursing services on an intermittent basis (other than solely venipuncture for the purposes of obtaining a blood sample) or physical therapy, or speech-language pathology services or continues to need occupational therapy after the need for skilled nursing care, physical therapy, or speech-language pathology services ceased. Where a patient’s/client’s sole skilled service need is for skilled oversight of unskilled services (management and evaluation of the care plan as defined by §40.1.2.2 in Chapter 7 of the Medicare Benefit Policy Manual), the physician and/or non-physician practitioner must include a brief narrative describing the clinical justification of this need as part of the recertification, or as a signed addendum to the recertification.
       3. A plan of care has been established and is periodically reviewed by a physician and/or non-physician practitioner.
       4. The services are, or were, furnished while the patient/client is, or was, under the care of a physician and/or non-physician practitioner.
       5. If the narrative is part of the recertification form, then the narrative must be located immediately prior to the physician and/or non-physician practitioner signature.
13. The Agency will refer to and comply with all requirements regarding nondiscrimination.
    1. The Agency will refer to the following link for additional information regarding nondiscrimination requirements, including but not limited to the dates by which full compliance is expected (see chart at 45 CFR, Part 92, Section 92.1(b)): https://www.federalregister.gov/documents/2024/05/06/2024-08711/nondiscrimination-in-health-programs-and-activities

Procedure

1. At the time of referral, eligibility criteria will be reviewed to determine acceptance of the patient/client for home care.
2. The following eligibility criteria must be met for the patient/client to be admitted to home care services.
   1. The Agency must have the capacity to provide appropriate patient/client care and services.
   2. The Agency is able to meet the anticipated needs of the patient/client.
   3. The Agency’s caseload, case mix, and staffing levels are appropriate to provide the needed care and services for the patient/client.
   4. The Agency staff has completed appropriate skills and competencies to provide the needed and anticipated care and services for the patient/client
   5. If these criteria are not met by the Agency, the patient/client will not be admitted for services.
3. If the Agency determines the admission is not appropriate either upon referral, or after the initial visit, the patient/client, the patient’s/client’s physician and/or non-physician practitioner, and the referral source will be notified.
4. If it is determined that a patient/client is not appropriate for home care upon admission or throughout the course of care, the patient/client will be referred to alternative care options (i.e., hospice, assisted living, nursing home, etc.).

Reference

1. The Joint Commission Comprehensive Home Care Accreditation Manual
2. PC 01.01.01 EP 2, EP 13
3. PC 01.02.01 EP 1

1. Code of Federal Regulations, Title 42, Part 484
2. §484.60
3. §484.55
4. §484.105(i)

1. Code of Federal Regulations, Title 45, Subtitle A, Subchapter A, Part 92, Subpart B
2. §92.8(b)
3. §92.101
4. §92.209

1. Medicare Benefit Policy Manual Chapter 7 – Home Health Services
2. Section 30


3. *HHS Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency
   https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html


4. *Home Health Agencies: CMS Flexibilities to Fight COVID-19
   https://www.cms.gov/files/document/home-health-agencies-cms-flexibilities-fight-covid-19.pdf


5. *Office of Civil Rights: FAQs on Telehealth and HIPAA during the COVID-19 nationwide public health emergency
   https://www.hhs.gov/sites/default/files/telehealth-faqs-508.pdf


6. *American Relief Act 2025
   https://www.congress.gov/bill/118th-congress/house-bill/10545/text


7. * Section I, Division B, Title II, Section 2207(a) (Extension of Certain Telehealth Flexibilities)
   Full-Year Continuing Appropriations and Extensions Act, 2025
   https://www.congress.gov/bill/119th-congress/house-bill/1968/text?s=2&r=1&q=%7B%22search%22%3A%22telehealth%22%7D#toc-H1605045683F94C959D531FAF6124375C