CHC is provided only during a period of crisis for a maximum
of five consecutive days to maintain an individual at the individual's
place of residence.
(1) A minimum of eight hours of CHC must be provided
during a 24-hour day that begins and ends at midnight. The care need
not be continuous. For example, four hours could be provided in the
morning and another four hours in the evening of that day.
(2) Skilled nursing care must be provided for the identified
crisis for more than half of the CHC period and must be provided by
either an RN or licensed vocational nurse. The RN or licensed vocational
nurse must be an employee of the hospice providing services. For an
individual residing in a nursing facility, the skilled nursing care
requirement is not met when facility staff provided skilled nursing
care for the crisis. For the purpose of CHC, skilled nursing care
includes at least one of the following:
(A) administration of intravenous or intramuscular
medications;
(B) insertion, sterile irrigation, and replacement
of catheters;
(C) initial clinical assessment for specific therapeutic
responses; or
(D) application of dressings involving prescription
medications.
(3) Homemaker, home health aide services, medical social
work, or chaplain services may be provided to supplement the nursing
care. The hospice must document why the physician considers social
work or chaplain services necessary to ameliorate the crisis and what
these services accomplished during CHC. On-call staff may be used
to provide CHC but must be on site, providing care to the individual
in the individual's place of residence to be considered for inclusion
in CHC hours.
(4) The hospice must have a signed physician's order
for skilled nursing care. The physician's order must:
(A) be specific to the identified crisis and be dated
before the initiation of CHC, but not more than three days before
the initiation of CHC;
(B) document the rationale for increased nursing needs
and care; and
(C) be in the individual's hospice record and plan
of care.
(5) The attending physician, hospice medical director
or his designee, and the IDT must establish the plan of care before
initiating CHC. The hospice RN must coordinate the plan of care. The
plan of care must:
(A) be updated when the individual's condition changes;
and
(B) include the following:
(i) a description of the specific crisis and how the
hospice plans to resolve the crisis;
(ii) the needs of the individual;
(iii) identification of the services needed to meet
the needs of both the individual and family, including management
of discomfort and symptom relief;
(iv) the scope and frequency of the services needed
to meet the needs of both the individual and family;
(v) documentation of daily physician care plan oversight;
and
(vi) clinical findings and documentation that support
the scope and frequency of crisis care needed.
(6) Before initiating CHC, the hospice must advise
and discuss with the family or responsible party that temporary alternate
placement may be necessary at the end of the five consecutive days.
The hospice must document the discussion with the family or responsible
party in the individual's records, including:
(A) the date and time of the discussion;
(B) the names and titles of the participating IDT members;
(C) at least one potential alternate placement; and
(D) any other outcomes of the discussion.
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