Opinion ID: 2102120
Heading Depth: 1
Heading Rank: 2

Heading: The Home Care Program: State Law

Text: In New York, personal home care services are furnished in accordance with the Federal mandate (Social Services Law § 365-a [2] [e]). Pursuant to State regulations implementing the statute, home care services may be authorized only after an extensive review process. The services must be (1) essential to maintaining the client's health and safety; (2) ordered by the attending physician; (3) based on an assessment of the client's needs and the appropriateness and cost effectiveness of the services; (4) provided by a qualified person in accordance with a plan of care; (5) supervised by a registered professional nurse; and (6) if required for more than 60 continuous days, provided in accordance with certain fiscal assessment procedures ( see generally, 18 NYCRR 505.14 [a] [1] et seq. ). The primary focus of this appeal concerns 18 NYCRR 505.14 (b) (3) (i) ( a ) ( 3 ), the regulation governing the treating physician's order for home care services. Pursuant to this regulation, a treating physician must file a form (the DS4359) with the local social services district that describes the patient's medical condition and the tasks for which the patient requires assistance (18 NYCRR 505.14 [b] [3] [i] [ a ]). However, physicians recommending personal care services must not recommend the number of hours    that the patient should be authorized to receive (18 NYCRR 505.14 [b] [3] [i] [ a ] [ 3 ]). Although the DSS-4359 form allows physicians to document a patient's specific needs, it also reinforces the regulatory prohibition on physicians from recommending the number of hours of home care. After a physician files the form, the local district must conduct a detailed review of the case, including social, nursing and home care assessments, an assessment of the appropriateness and cost-effectiveness of other types of home services or arrangements, and a fiscal assessment, if appropriate (18 NYCRR 505.14 [b] [2]). An independent medical review by a physician designated by the local district director or a physician under contract with the local social services department (an affiliated physician) also may be required (18 NYCRR 505.14 [b] [4]). The affiliated physician does not make the final determination of the level of care required by an individual client. State regulations restrict that determination to the local director or his or her designee (18 NYCRR 505.14 [b] [4] [ii]).