California Code of Regulations › Title 28 - Managed Health Care › Division 1 - The Department of Managed Health Care › Chapter 2 - Health Care Service Plans › Article 8 - Self-Policing Procedures › Section 1300.68.2 - Hospice Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				  For purposes of this section, the following definitions shall apply:
(1) "Bereavement services" means those
				  services available to the surviving family members for a period of at least one
				  year after the death of the enrollee. These services shall include an
				  assessment of the needs of the bereaved family and the development of a care
				  plan that meets these needs, both prior to, and following the death of the
				  enrollee.
(2) "Hospice service" or
				  "hospice program" means a specialized form of interdisciplinary health care
				  that is designed to provide palliative care, alleviate the physical, emotional,
				  social and spiritual discomforts of an enrollee who is experiencing the last
				  phases of life due to the existence of a terminal disease, to provide
				  supportive care to the primary care giver and the family of the hospice
				  patient, and which meets all of the following criteria;
(A) Considers the enrollee and the enrollee's
				  family, in addition to the enrollee, as the unit of care.
(B) Utilizes an interdisciplinary team to
				  assess the physical, medical, psychological, social and spiritual needs of the
				  enrollee and the enrollee's family.
(C) Requires the interdisciplinary team to
				  develop an overall plan of care and to provide coordinated care which
				  emphasizes supportive services, including, but not limited to, home care, pain
				  control, and short-term inpatient services. Short-term inpatient services are
				  intended to ensure both continuity of care and appropriateness of services for
				  those enrollees who cannot be managed at home because of acute complications or
				  the temporary absence of a capable primary caregiver.
(D) Provides for the palliative medical
				  treatment of pain and other symptoms associated with a terminal disease, but
				  does not provide for efforts to cure the disease.
(E) Provides for bereavement services
				  following the enrollee's death to assist the family to cope with social and
				  emotional needs associated with the death of the enrollee.
(F) Actively utilizes volunteers in the
				  delivery of hospice services.
(G)
				  To the extent appropriate based on the medical needs of the enrollee, provides
				  services in the enrollee's home or primary place of
				  residence.
(3) "Hospice"
				  or "Hospice Agency" means an entity which provides hospice services to
				  terminally ill persons and holds a license, currently in effect, as a hospice
				  pursuant to Health and Safety Code section
				  1747
				  or a home health agency with federal medicare certification pursuant to Health
				  and Safety Code sections
				  1726
				  and
				  1747.1.
(4) "Home health aide services" means those
				  services providing for the personal care of the terminally ill patient and the
				  performance of related tasks in the patient's home in accordance with the plan
				  of care in order to increase the level of comfort and to maintain personal
				  hygiene and a safe, healthy environment for the patient. Home health aide
				  services shall be provided by a person who is certified by the state Department
				  of Health Services as a home health aide pursuant to Chapter 8 of Division 2
				  (Section 1725 et seq.) of the Health and
				  Safety Code.
(5) "Homemaker
				  services" means services that assist in the maintenance of a safe and healthy
				  environment and services to enable the enrollee to carry out the treatment
				  plan.
(6) "Interdisciplinary team"
				  means the hospice care team that includes, but is not limited to, the enrollee
				  and the patient's family, a physician and surgeon, a registered nurse, a social
				  worker, a volunteer, and a spiritual caregiver.
(7) "Medical direction" means those services
				  provided by a licensed physician and surgeon who is charged with the
				  responsibility of acting as a consultant to the interdisciplinary team, a
				  consultant to the enrollee's attending physician and surgeon, as requested,
				  with regard to pain and symptom management, and liaison with physicians and
				  surgeons in the community. For purposes of this section, the person providing
				  these services shall be referred to as the "medical director."
(8) "Plan of care" means a written plan
				  developed by the attending physician and surgeon, the medical director or
				  physician and surgeon designee, and the interdisciplinary team that addresses
				  the needs of an enrollee and family admitted to the hospice program. The
				  hospice shall retain overall responsibility for the development and maintenance
				  of the plan of care and quality of services delivered. However, nothing in this
				  section shall be construed to limit a health care service plan's obligations
				  with respect to its QA program as required under Section
				  1300.70.
(9) "Skilled nursing services" means nursing
				  services provided by or under the supervision of a registered nurse under a
				  plan of care developed by the interdisciplinary team and the enrollee's
				  physician and surgeon to an enrollee and his or her family that pertain to the
				  palliative, supportive services required by an enrollee with a terminal
				  illness. Skilled nursing services include, but are not limited to, enrollee
				  assessment, evaluation and case management of the medical nursing needs of the
				  enrollee, the performance of prescribed medical treatment for pain and symptom
				  control, the provision of emotional support to both the enrollee and his or her
				  family, and the instruction of caregivers in providing personal care to the
				  enrollee. Skilled nursing services shall provide for the continuity of services
				  for the enrollee and his or her family. Skilled nursing service shall be
				  available on a 24-hour on-call basis.
(10) "Social service/counseling services"
				  means those counseling and spiritual services that assist the enrollee and his
				  or her family to minimize stresses and problems that arise from social,
				  economic, psychological, or spiritual needs by utilizing appropriate community
				  resources, and maximize positive aspects and opportunities for
				  growth.
(11) "Terminal disease" or
				  "terminal illness" means a medical condition resulting in a prognosis of life
				  of one year or less, if the disease follows its natural course. This definition
				  is not intended to limit the ability of health plans and hospices to develop
				  and utilize comprehensive, evidence-based medical and psychosocial criteria or
				  "best practice" guidelines for hospice referrals that are not dependent upon an
				  estimated time of death, that are predictive of the need and appropriateness of
				  palliative care and that are consistent with standards among palliative care
				  professionals.
(12) "Volunteer
				  services" means those service provided by trained hospice volunteers who have
				  agreed to provide service under the direction of a hospice staff member who has
				  been designated by the hospice to provide direction to hospice volunteers.
				  Hospice volunteers may be used to provide support and companionship to the
				  enrollee and his or her family during the remaining days of the enrollee's life
				  and to the surviving family following the enrollee's death.