New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60 - HOME CARE SERVICES › Subchapter 1 - GENERAL PROVISIONS › Section 10:60-1.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this chapter, shall have the following meaning, unless the context clearly indicates otherwise.
"Accreditation organization" means an agency approved by the Department of Human Services to provide quality oversight of Medicaid/NJ FamilyCare home care agencies and certify that services are being performed in accordance with acceptable practices and established standards. A current list of entities approved by the Department as accreditation organizations can be obtained by contacting the Department. Interested parties should ensure that the most current list is obtained before taking any action based on such a list. The Department can be contacted by calling (609) 292-3717 or online at
http://www.state.nj.us/humanservices/index.shtml
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"Activities of daily living (ADL)" means activities related to self-care, performed either independently or with supervision or assistance, which include, but are not limited to, dressing and undressing, bathing, eating, grooming, ambulation, transferring, toileting, and mobility. The inability to independently perform such tasks may be used as a measure to determine a person's level of disability.
"Annual cost threshold (ACT)" means the annualized long-term services and support portion of the capitation rate for residence in a nursing facility or special care nursing facility as appropriate to a beneficiary's needs as determined by the Office of Community Options. The ACT is determined by the Department of Health in accordance with N.J.A.C. 8:85.
"Calendar day" means from 12:00 A.M. up to, but not including, the following 12:00 A.M.
"Calendar work week" means the time parameters which constitute a work week for personal care assistant services. These time parameters are from Sunday at 12:00 A.M. to Saturday at 11:59 P.M.
"Class C boarding home" means a boarding home which offers personal assistance as well as room and board, as defined by the Department of Community Affairs (see N.J.A.C. 5:27).
"Complexity" means the degree of difficulty and/or intensity of treatment/procedures.
"Continuous ongoing" means that the beneficiary requires the provision of skilled nursing intervention, on an ongoing basis, up to 24-hours per day/seven days per week, where the beneficiary cannot be taught to self-perform the task and alternative support is not available.
"DDD" means the Division of Developmental Disabilities in the New Jersey Department of Human Services.
"DDS" means the Division of Disability Services in the New Jersey Department of Human Services.
"DoAS" means the Division of Aging Services in the New Jersey Department of Human Services.
"DHS" means the New Jersey Department of Human Services.
"DOH" means the New Jersey Department of Health.
"Dietitian" means a person who is a graduate of an accredited college or university with courses meeting the academic standards of the American Dietetic Association, plus a dietetic internship or dietetic traineeship or master's degree plus six months experience. A registered dietitian is one who has met current requirements for registration.
"Discharge planning" means that component part of a total individualized plan of care formulated by all members of the agency's health care team, together with the beneficiary and/or his or her family or interested person which anticipates the health care needs of the beneficiary in order to provide for continuity of care after the services of the home care agency have terminated. Such planning aims to provide humane and psychological preparation to enable the beneficiary to adjust to his or her changing needs and circumstance.
"DMAHS" means the Division of Medical Assistance and Health Services in the Department of Human Services.
"Early and periodic screening, diagnosis and treatment/private duty nursing (EPSDT/PDN)" means the private duty nursing services provided to Early and Periodic Screening, Diagnosis and Treatment Program beneficiaries under 21 years of age who live in the community and whose medical condition and treatment plan justify that need.
" Face-to-face encounter" means direct contact between a beneficiary and a physician/practitioner authorized to certify home care services.
"Field security cost" means costs incurred by a home health agency in providing security personnel to accompany medical care staff of a home health agency during onsite visits to the patient's home.
"Hands-on personal care" means physical assistance given to a Medicaid/NJ FamilyCare beneficiary with bathing, dressing, grooming, toileting, mobility/ambulation, feeding, and transfers.
"Health care service firm" means any person or entity who operates a firm, registered with the Division of Consumer Affairs, that employs individuals directly or indirectly for the purpose of assigning the employed individuals to provide health care or personal care services either directly in the home or at a care-giving facility, and who, in addition to paying wages or salaries to the employed individuals while on assignment; pays, or is required to pay, Federal Social Security taxes and State and Federal unemployment insurance; carries, or is required to carry, worker's compensation insurance; and sustains responsibility for the action of the employed individuals while they render health care services.
"Home health agency" means a public or private agency or organization, either proprietary or nonprofit, or a subdivision of such an agency or organization, which qualifies as follows:
1. Is approved by the New Jersey State Department of Health, including requirements for Certificate of Need and licensure when applicable;
2. Is certified as a home health agency under the Title XVIII (Medicare) Program; and
3. Is approved for participation as a home health agency provider by the New Jersey Medicaid/NJ FamilyCare program or the Medicaid/NJ FamilyCare agent.
"Homemaker-home health aide" means a person who:
1. Successfully completes a training program in personal care assistant services and is certified by the New Jersey State Department of Law and Public Safety, Board of Nursing, as a homemaker-home health aide. A copy of the certificate issued by the New Jersey Department of Law and Public Safety, Board of Nursing or other documentation acceptable to the Division is retained in the agency's personnel file.
2. Successfully completes a minimum of 12 hours in-service education per year offered by the agency; and
3. Is supervised by a registered professional nurse employed by a Division approved home health agency provider.
"Hospice agency" means a public agency or private organization (or subdivision of such organization) that is Medicare certified for hospice care in accordance with N.J.A.C. 10:53A, and has a valid provider agreement with the Division to provide hospice services.
"Instrumental activities of daily living (IADL)" means those non-hands-on personal care assistance services that are essential to the beneficiary's health and comfort, including, but not limited to, housekeeping, food preparation, doing laundry, and shopping.
"Legally responsible relative" means the spouse or legal guardian of an adult or the parent or legal guardian of a minor child.
"Levels of care" means two levels of home health care services, acute and chronic, provided by a certified, licensed home health agency, as needed, to Medicaid/NJ FamilyCare fee-for-service beneficiaries, upon request of the attending physician/practitioner.
1. "Acute home health care" means concentrated and/or complex professional and non-professional services on a continuing basis where there is anticipated change in condition and services required.
2. "Chronic home health care" means either long or short-term uncomplicated, professional and nonprofessional services, where there is no anticipated change in condition and services required.
"Licensed practical nurse" means a person who is licensed by the State of New Jersey as a practical nurse, pursuant to N.J.A.C. 13:37, having completed formal accredited nursing education programs.
"Managed long-term services and supports (MLTSS)" means services that are provided under the Comprehensive Waiver through Medicaid/NJ FamilyCare managed care organization plans, the purpose of which is to support beneficiaries who meet nursing home level of care in the most appropriate setting to meet their specific needs.
"Medical Assistance Customer Center (MACC)" means one of the community-based Division offices located throughout the State.
"Minimal assistance" means non-weight bearing support with minimal physical assistance from the caregiver, when the beneficiary needs physical help in guided maneuvering of limbs or other non-weight bearing assistance such as getting in and out of the tub, dressing, or assistance in washing difficult to reach places.
"Moderate assistance" means weight bearing support, hand-over-hand assistance, in which the beneficiary is involved with physically performing less than 50 percent of the tasks on their own.
"National Plan and Provider Enumerations System (NPPES)" means the system that assigns National Provider Identifiers (NPIs), maintains and updates information about health care providers with NPIs, and disseminates the NPI Registry and NPPES downloadable file. The NPI Registry is an online query system that allows users to search for a health care provider's information.
"National Provider Identifier (NPI)" means a unique 10-digit identification number issued to health care providers by the Centers for Medicare and Medicaid Services (CMS).
"Non-routine supplies" means non-routine supplies defined in the Medicare Medical Review Supply List published August 1994 by United Government Services, incorporated herein by reference, as amended and supplemented. (A copy of the list may be obtained from United Government Services, 115 Stevens Ave., Valhalla, N.Y. 10595.)
"Nurse delegation" means that the registered professional nurse is responsible for the nature and quality of all nursing care, including the assessment of the nursing needs, the plan of nursing care, the implementation of the plan of nursing care, and the monitoring and evaluation of the plan. The treating registered professional nurse may delegate selected nursing tasks in the implementation of the nursing regimen to licensed practical nurses and ancillary nursing personnel, including certified nursing assistants (CNAs) and certified homemaker-home health aides (CHHA) pursuant to N.J.A.C. 13:37-6.2.
"Nutritionist" means a person who has graduated from an accredited college or university, with a major in foods or nutrition or the equivalent course work for a major in the subject area, and two years of full-time professional experience in nutrition. Successful completion of a dietetic internship of traineeship in hospital or community nutrition approved by the American Dietetic Association, or completion of a master's degree in the subject area may be substituted for the two years of full-time experience.
"Occupational therapist" means a person, who is registered by the American Occupational Therapy Association, or a graduate of a program in occupational therapy approved by the Council on Medical Education of the American Medical Association and engaged in the supplemental clinical experience required before registration by the American Occupational Therapy Association. If treatment and/or services are provided in a state other than New Jersey, the occupational therapist shall meet the practice requirements of that state including licensure, if applicable, and shall also meet all applicable federal requirements.
"On-site monitoring" means a visit by Division of Medical Assistance and Health Services or Division of Disability Services staff, or an agent designated by either Division, to a home health agency, accredited health care services firm, or hospice agency to monitor compliance with this chapter.
"Performance standards" for the purpose of this chapter means the criteria established by this Division in order to measure the beneficiary/caregiver's satisfaction with the quality, quantity and appropriateness of the services delivered.
"Personal care assistant" means a person who:
1. Successfully completed a training program in personal care services and is certified by the New Jersey State Department of Law and Public Safety, Board of Nursing, as a homemaker-home health aide. A copy of the certificate or other documentation issued by the New Jersey Department of Law and Public Safety, Board of Nursing is retained in the agency's personnel file.
2. Successfully completes a minimum of 12 hours in-service education per year offered by the agency; and
3. Is supervised by a registered professional nurse employed by a Division-approved healthcare services firm, home health agency, or hospice agency.
"Personal care assistant (PCA) services" means health related tasks associated with the cueing, supervision, and/or the completion of the activities of daily living, as well as instrumental activities of daily living (IADL) related tasks performed by a qualified individual in a beneficiary's home, or at a place of employment or post-secondary educational or training program, under the supervision of a registered professional nurse, certified as medically necessary, in accordance with a beneficiary's written plan of care.
"Physical therapist" means a person who meets all the applicable Federal requirements, and
1. If practicing in the State of New Jersey, is licensed by the State of New Jersey; or
2. If treatment and/or services are provided in a state other than New Jersey, meets the requirements of that state, including licensure, if applicable.
"Physician" means a doctor of medicine (M.D.) or osteopathy (D.O.) licensed to practice medicine and surgery by the New Jersey State Board of Medical Examiners, or similarly licensed by comparable agencies of the state in which the physician practices.
"Plan of care" means the individualized and documented program of health care services provided by all members of the home health agency, health care services firm, or hospice agency involved in the delivery of home care services to a beneficiary. The plan includes short-term and long-term goals for rehabilitation, restoration or maintenance made in cooperation with the beneficiary and/or responsible family members or interested person. Appropriate instruction of beneficiary, and/or the family or interested person as well as a plan for discharge are also essential components of the treatment plan. The plan shall be reviewed periodically and revised appropriately according to the observed changes in the beneficiary's condition.
"Practitioner" means advanced practice nurses and physician assistants who, within the scope of their license, are permitted to prescribe home health care services.
"Practitioner Orders for Life Sustaining Treatment (POLST)" means a form that enables patients to indicate their preferences regarding life-sustaining treatment. This form, signed by a patient's attending physician, advanced practice nurse, or physician assistant, provides instructions for health care personnel to follow for a range of life-prolonging interventions. This form becomes part of a patient's medical records, following the patient from one healthcare setting to another, including hospital, nursing home, or hospice.
"Preadmission screening (PAS)" means that process by which all eligible Medicaid/NJ FamilyCare fee-for-service beneficiaries, and individuals who may become Medicaid/NJ FamilyCare eligible within 180 days following admission to a Medicaid/NJ FamilyCare certified nursing facility, and who are seeking admission to a Medicaid/NJ FamilyCare certified nursing facility or requesting MLTSS services under the comprehensive waiver program receive an in-person standardized assessment by professional staff designated by the DoAS to determine nursing facility (NF) level of care and to provide counseling on options for care.
"Primary caregiver" means an adult relative or significant other adult, at least 18 years of age, who resides with the beneficiary and accepts 24-hour responsibility for the health and welfare of the beneficiary. For the beneficiary to receive private duty nursing services under MLTSS or EPSDT, the primary caregiver must reside with the beneficiary and provide a minimum of eight hours of care to the beneficiary in any 24 hour period.
"Prior authorization" means the process of approval by the Division for certain services prior to the provision of these services. Prior authorization also may be applied in other service areas in situations of an agency's continued non-compliance with program requirements. In accordance with N.J.A.C. 10:60-2.1, if a patient is enrolled in an HMO, authorization for reimbursement is required by the HMO prior to rendering any service.
"Private duty nursing" means individual and continuous nursing care, as different from part-time or intermittent care, provided by licensed nurses in the home to beneficiaries under MLTSS, as well as eligible EPSDT beneficiaries.
"Private duty nursing agency" means either a licensed Medicare-certified home health agency, an accredited home health care services firm, or a hospice agency, approved by DMAHS to provide private duty nursing services under MLTSS and to eligible EPSDT beneficiaries. The private duty nursing agency shall be located/have an office in New Jersey and shall have been in operation and actively engaged in home health care services in New Jersey for a period of not less than one year prior to application.
"Public health nurse" means a person licensed as a registered professional nurse, who has completed a baccalaureate degree program approved by the National League for Nursing for public health preparation, or post-baccalaureate study which includes content approved by the National League for Nursing for public health nursing preparation.
"Quality assurance," for the purpose of this chapter, means a system by which Division staff shall conduct post payment reviews to determine the beneficiary/caregiver's satisfaction with the quality, quantity, and appropriateness of home health care services provided to Medicaid/NJ FamilyCare fee-for-service beneficiaries.
"Registered professional nurse" means a person who is licensed by the State of New Jersey as a registered professional nurse, pursuant to N.J.A.C. 13:37.
"Residential health care facility (RHCF)" means a facility, licensed in accordance with N.J.A.C. 8:43, which provides food, shelter, supervised health care and related services to four or more persons 18 years of age or older who are unrelated to the owner or administrator.
"Routine supplies" means routine supplies defined in the Medicare Medical Review Supply List published August 1994 by United Government Services, incorporated herein by reference, as amended and supplemented.
"Skilled nursing interventions" means procedures that require the knowledge and experience of a licensed registered nurse. The needed services are of such complexity that the skills of a registered nurse (RN) or a licensed practical nurse (LPN) under the supervision of a registered nurse are required to furnish the services. Services must be so inherently complex that they can be safely and effectively performed only by, or under the supervision of, professional or technical personnel. The term "professional or technical personnel" refers to the RN who is responsible for the provision of the skilled nursing intervention, or the delegation of these duties to an LPN who provides the service under the supervision of the RN. The registered nurse shall determine if the intervention could be or should be taught to and delegated to a caregiver who could safely perform it so as to not endanger or risk the beneficiary's health and safety.
"Social worker" means a person who is licensed by the State of New Jersey as a licensed social worker or licensed clinical social worker, pursuant to N.J.S.A. 45:15BB-1 et seq. and N.J.A.C. 13:44G.
"Social work assistant" means a person who has a baccalaureate degree in social work, or psychology, or sociology or other field related to social work and has had at least one year of social work experience in a health care setting.
"Speech-language pathologist" means a person who meets all applicable Federal requirements, and
1. If practicing in the State of New Jersey, is licensed by the State of New Jersey; or
2. If treatment and/or services are provided in a state other than New Jersey, meets the requirements of that state, including licensure, if applicable.
"Taxonomy code" means a code that describes the provider or organization's type, classification, and the area of specialization.
"Telehealth technology" means the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient, and professional health-related education, public health, and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.
"Therapy session" means an occupational, physical, cognitive, or speech therapy, hands-on and/or face-to-face, interaction of the participant and therapist, performed individually or in group settings, not including the preparation of reports or progress notes. A session is equal to a unit of service for billing purposes.
"Type 1 NPI" means a code that describes an individual provider in the NPPES system.
"Type 2 NPI" means a code that describes an organizational provider in the NPPES system.
"Visit" means any combination of units of home health services which are provided when the home health agency staff arrives at the Medicaid/NJ FamilyCare fee-for-service beneficiary's residence and ends when the home health agency staff leaves the beneficiary's residence.