Ga. R. & Regs. 111-8-31

Home Health Agencies

This regulation establishes the licensing procedures and operating standards for home health agencies in Georgia under the authority of O.C.G.A. § 31-7-150. Operators must obtain a license from the Department of Community Health, maintain a qualified governing body and administrator, and provide skilled nursing services plus at least one additional therapeutic service in patients' residences. The rules cover application requirements, certificate of need compliance, scope of services, patient care standards, clinical recordkeeping, inspections, fees, and enforcement.

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Department 111

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Chapter 111-8

» Subject 111-8-31

Subject 111-8-31 HOME HEALTH AGENCIES

Rule 111-8-31-.01 Purpose

Under the authority of O.C.G.A. § 
31-7-150
, the Department of
 Community Health is authorized and required to establish the licensing
 procedures and standards of operation for home health agencies operating in
 this State. These rules and regulations are provided for this
 purpose.

Rule 111-8-31-.02 Applications and Licenses

Each person, private or public organization, political
 subdivision, or other governmental agency desiring to operate a home health
 agency, as defined herein, must first apply for and obtain a license using the
 forms furnished by the Department of Community Health. A license is not
 assignable or transferable and is subject to suspension or revocation at any
 time for failure to comply with these rules and regulations.

(a)

 Applications. 

1.

 The governing body of the home health
 agency shall submit to the Department an application for a license of each
 agency and/or subunit. Such application(s) shall be signed by the executive
 officer of the governing body.

2.

 The application for a license shall be filed at least thirty (30) days prior to
 the anticipated date of opening and commencement of operation of a new home
 health agency.

3.

 Corporations
 shall submit a copy of their charter and the name and address of all owners
 with five percent or more of the stock and shall identify each corporate
 officer.

4.

 An application for a
 change in service(s) or service area(s) which is subject to review under
 O.C.G.A. § 
31-6-1
et seq.
 and
 applicable rules shall be accompanied by a letter of approval from the Office
 of Health Planning within the Division of Healthcare Facility Regulation,
 Department of Community Health.

(b)

 Licenses. 

1.

 To be eligible for a license, the home
 health agency must be in satisfactory compliance with these rules and
 regulations and other applicable Federal, State and local laws.

2.

 The license shall be returned to the
 Department when the home health agency ceases to operate, or is leased, or is
 moved to another location, or the ownership changes, or the license is
 suspended or revoked.

3.

 Any person
 or agency wishing to appeal the denial, suspension or revocation of a license
 is entitled to request a hearing under the provisions of the "Georgia
 Administrative Procedure Act."

4.

 Licenses will be renewed on an annual basis.

5.

 The license shall be prominently and
 appropriately displayed.

Rule 111-8-31-.03 Certificate of Need Review

Home health agencies which are required by state laws to
 obtain a certificate of need shall submit evidence that such requirements have
 been met when applying for a license.

Rule 111-8-31-.04 Exemptions

These rules and regulations shall not apply to services which
 are provided under the following conditions:

(a)

 Persons who provide personal or
 paraprofessional health services, either with or without compensation when
 there is no claim that the service is provided as a part of a licensed home
 health agency;

(b)

 Persons who
 provide professional services for which they are duly licensed under 
 
Georgia laws, when there is no claim that the service is
 provided as a part of a licensed home health agency;

(c)

 Services provided under the provisions of
 any other license issued by the State of 
 
Georgia when there is no claim that the service is provided
 as a part of a licensed or certified home health agency;

(d)

 Any home health agency certified in a
 federal program for reimbursement of Medicare or Medicaid services shall be
 exempt from an additional on-site licensure inspection upon presentation of
 evidence of such certification.

Rule 111-8-31-.05 Inspections

For the purpose of insuring compliance with these rules and
 regulations, each home health agency shall be subjected to periodic inspections
 by an authorized representative of the Department. Such inspections shall take
 place during reasonable hours and, if possible, during scheduled operating
 hours. The administrator or his representative shall accompany the Department
 representative on tours of inspection and shall sign the completed
 checklist.

Rule 111-8-31-.06 Definitions

Unless a different meaning is required or given in the
 context, the following terms as used in these rules and regulations shall have
 the meaning respectively ascribed to them:

(a)

 "Administrator" means the full-time
 person by whatever title used, to whom the governing body has delegated the
 responsibility for day-to-day administration of the home health agency,
 including the implementation of the rules and policies adopted by the governing
 body, and who:

1.

 is a licensed physician;
 or

2.

 is a registered nurse;
 or

3.

 has training and experience
 in health service administration and at least one (1) year of supervisory or
 administrative experience in home health care or related health
 programs.

(b)

 "Board"
 means the Board of Community Health.

(c)

 "Branch Office" means a location or site
 identified in the application or endorsement thereto from which a home health
 agency provides services within a portion of the total geographic area served
 by the parent agency. The branch office is part of the home health agency and
 is located sufficiently close to share administration, supervision, and
 services in a manner that renders it unnecessary for the branch independently
 to meet the requirements of these rules and regulations.

(d)

 "By-Laws" means a set of rules adopted by
 a home health agency for governing the agency's operation.

(e)

 "Certificate of Need" shall have that
 meaning as defined in O.C.G.A. § 
31-6-1
et seq.
 and
 applicable rules. 

(f)

 "Clinical
 Note" means a dated and signed written notation by the providing member of the
 health team of a contact with a patient containing a description of signs and
 symptoms, treatment and drug given, the patient's reaction, and any changes in
 physical or emotional condition.

(g)

 "Department" means the Georgia Department
 of Community Health.

(h)

 "Governing
 Body" means the person or persons, natural or corporate, in which the ultimate
 responsibility, authority and accountability for the conduct of the home health
 agency is vested.

(i)

 "Health
 Professionals" means those professionals engaged in the delivery of health
 services Who are currently licensed to practice in the State of Georgia, or are
 certified, or practice under authority consistent with Georgia laws.

(j)

 "Home Health Agency" means: a public,
 non-profit, or proprietary organization; whether owned or operated by one or
 more persons or legal entities, which is engaged in providing home health
 services. 

(k)

 "Home Health
 Services" means those items and services provided to an individual, according
 to a written plan of treatment signed by the patient's physician, by a home
 health agency or others under arrangement with the home health agency on a
 visit or hourly basis, in a place of temporary or permanent residence used as
 the individual's home as follows:

1.

 part-time
 or intermittent skilled nursing care as ordered by a physician and provided by
 or under the supervision of a registered nurse and at least one other service
 listed below;

2.

 physical,
 occupational, or speech therapy;

3.

 medical social services;

4.

 home
 health aide services.

(l)

 "License" means a license issued by the
 Department.

(m)

 "Licensee" means
 the individual, corporation, or public entity with whom rests the ultimate
 responsibility for maintaining approved standards for the home health
 agency.

(n)

 "Licensed Practical
 Nurse or LPN" means an individual who is currently licensed as a licensed
 practical nurse in Georgia.

(o)

 "Occupational Therapist" means a qualified individual who: 

1.

 Is currently licensed as an occupational
 therapist in Georgia; and

2.

 Meets
 the federal conditions for participation.

(p)

 "Occupational Therapy Assistant" means a
 qualified individual who: 

1.

 Is currently
 licensed as an occupational therapy assistant in Georgia and assists in the
 practice of occupational therapy under the supervision and direction of a
 Georgia licensed occupational therapist; and

2.

 Meets the federal conditions for
 participation.

(q)

 "Parent Home Health Agency" means the agency that develops and maintains
 administrative controls of subunits or branch offices. 

(r)

 "Physical Therapist" means a qualified
 individual who:

1.

 Is currently licensed as a
 physical therapist in Georgia; and

2.

 Meets the federal conditions for
 participation.

(s)

 "Physical Therapy Assistant" means a qualified individual who: 

1.

 Is currently licensed as a physical
 therapy assistant in Georgia and assists in the practice of physical therapy
 under the supervision and direction of a Georgia licensed physical therapist;
 and

2.

 Meets the federal conditions
 for participation.

(t)

 "Physician" means an individual who is currently licensed or authorized to
 practice medicine and surgery in Georgia.

(u)

 "Plan of Treatment" means an individual
 plan written, signed, and reviewed at least every sixty days by the patient's
 physician prescribing items and services for the patient's condition.

(v)

 "Primary Home Health Agency" means the
 agency (parent or subunit) that is responsible for the service rendered to
 patients and for implementation of the plan of treatment.

(w)

 "Progress Note" means a dated and signed
 written notation by the providing member of the health team, summarizing facts
 about care and the patient's response during a given period of time.

(x)

 "Registered Nurse or RN" means an
 individual who is currently licensed as a registered professional nurse in
 Georgia.

(y)

 "Service Area" means
 the geographical area in which a home health agency provides services, as
 defined by the State Health Planning and Development unit of the
 Department.

(z)

 "Social Work
 Assistant" means an individual who meets the federal conditions of
 participation and applicable Georgia laws.

(aa)

 "Social Worker" means an individual who
 meets the federal conditions of participation and applicable Georgia
 laws.

(bb)

 "Speech Pathologist"
 and/or "Audiologist" means a qualified individual who: 

1.

 Is currently licensed as a speech
 pathologist and/or audiologist in Georgia; and

2.

 Meets the federal conditions of
 participation.

(cc)

 "Subunit" means a semiautonomous organization, which serves patients in a
 geographic area different from that of the parent agency. The subunit by virtue
 of the distance between it and the parent agency is judged incapable of sharing
 administration, supervision, and services on a daily basis with the parent
 agency, and must, therefore, independently meet the licensing requirements for
 a home health agency, and shall be separately licensed.

(dd)

 "Supervision" means authoritative
 procedural guidance by a qualified person for the accomplishment of a function
 or activity with initial direction and periodic inspection of the actual act of
 accomplishing the function or activity.

Rule 111-8-31-.07 Administrative Standards

(1)

 Organizations, Services, Administration.
 Organizations, services provided, administrative control, and lines of
 authority for the delegation of responsibility down to the patient care level
 shall be clearly set forth in written policies and procedures. Administrative
 and supervisory functions shall not be delegated to another agency or
 organization. Services not provided directly shall be monitored and controlled
 by the primary agency, including services provided through subunits of the
 parent agency. If an agency has subunits, appropriate administrative records
 shall be maintained for each subunit.

(2)

 Governing Body. There shall be a
 governing body which assumes full legal authority and responsibility for the
 operation of each home health agency. The governing body shall appoint a
 qualified administrator, arrange for professional advice, adopt and
 periodically review written bylaws and oversee the management and fiscal
 affairs of the agency. The name and address of each officer, directors, and
 owner shall be disclosed to the Department. If the agency is a corporation, all
 ownership interests of five (5) percent or more (direct or indirect) shall also
 be disclosed.

(3)

 Group of
 Professional Personnel.

(a)

 A group of
 professional personnel, which shall include at least one physician and one
 registered nurse, with appropriate representation from other professional
 disciplines, shall establish and annually review the policies of each home
 health agency governing scope of services offered, admission and discharge
 policies, medical supervision and plans of treatment, emergency care, clinical
 records, personnel qualifications, and program evaluation. There must be at
 least one member of the group who is neither an owner nor an employee of the
 agency.

(b)

 The group of
 professional personnel shall meet at least once per quarter unless
 circumstances require more often to advise the agency on professional issues,
 to participate in the evaluation of the agency's program, and to assist the
 agency in maintaining liaison with other health care providers in the community
 and in its community information program. The minutes shall be documented by
 dated minutes.

(4)

 Administrator. The administrator (who may also be the supervising physician or
 registered nurse), is responsible for organizing and directing the agency's
 ongoing functions; maintaining ongoing liaison among the governing body, the
 group of professional personnel, and the staff; employing qualified personnel
 and ensuring adequate staff education and evaluations; ensuring the accuracy of
 public information, materials and activities; and implementing an effective
 budgeting and accounting system. A qualified person shall be authorized in
 writing to act in the absence of the administrator.

(5)

 Supervising Physician or Registered
 Nurse. Skilled nursing and other therapeutic services provided shall be under
 the supervision and direction of a physician or a registered nurse. This person
 or similarly qualified alternate shall be available at all times during
 operating hours and: participate in all activities relevant to the professional
 services provided, including the developing of qualifications and assignments
 of personnel.

(6)

 Personnel
 Policies. Personnel practices shall be supported by appropriate, written
 personnel policies. Individual personnel records shall include job
 descriptions, qualifications, licenses, performance evaluations, and health
 examinations, and shall be kept current. If personnel under hourly or per visit
 contracts are utilized by the home health agency, there shall be a written
 contract between such personnel and the agency clearly designating: 

(a)

 that patients are accepted for care only
 by the primary home health agency;

(b)

 the services to be provided;

(c)

 the necessity to conform to all
 applicable agency policies including personnel qualifications;

(d)

 the responsibility for participating in
 developing plans of treatment;

(e)

 the manner in which services will be controlled, coordinated, and evaluated by
 the primary agency;

(f)

 the
 procedures for submitting clinical and progress notes, scheduling of visits,
 periodic patient evaluation; and

(g)

 the procedure for determining charges and
 reimbursement.

(7)

 Planning and Budget. A home health agency, under the direction of the governing
 body, shall prepare an overall plan and budget which provides for an annual
 operating budget. If capital expenditures are anticipated, a three-year capital
 expenditure plan shall be provided and updated annually. The overall plan,
 budget and capital expenditure plan shall be reviewed and updated at least
 annually. 

(8)

 Evaluation. 

(a)

 A home health agency shall have written
 policies requiring an overall evaluation of the agency's total program at least
 once a year by the group of professional personnel (or a committee of this
 group), home health agency staff, and consumers; or by professional people
 outside the agency working in conjunction with consumers. The evaluation shall
 consist of an overall policy and administrative review and a clinical record
 review. The evaluation shall assess the extent to which the agency's program is
 appropriate, adequate, effective and efficient. Results of the evaluation shall
 be reported to the governing body and maintained separately as administrative
 records. Mechanisms shall be established in writing for the collection of
 pertinent data to assist in this evaluation. This data to be considered may
 include but is not limited to: 

1.

 number of
 patients receiving each service offered;

2.

 number of patient visits;

3.

 reasons for discharge;

4.

 breakdown by diagnosis;

5.

 sources of referral;

6.

 number of patients not accepted with
 reasons; and

7.

 total staff days
 for each service offered.

(b)

 At least quarterly, appropriate health
 professionals representing at least the scope of the program, shall review a
 sample of both active and closed clinical records to assure that established
 policies are followed in providing services (direct services as well as
 services under arrangement). Evidence of this review shall be documented by
 dated minutes.

Rule 111-8-31-.08 Scope of Services

A home health agency shall provide part-time or intermittent
 skilled nursing services and at least one other therapeutic service, e.g.,
 physical, speech, or occupational therapy; medical social services; or home
 health aide services. Services shall be made available on a visiting basis, in
 a place of residence, as a patient's home.

(a)

 Nursing Services. A home health agency
 shall provide skilled nursing service by or under the supervision of a
 registered nurse and in accordance with the plan of treatment. 

1.

 Duties of the Registered Nurse (RN). A
 registered nurse shall make the initial evaluation visit, regularly reevaluate
 the patient's nursing needs, initiate the plan of treatment and necessary
 revisions, provide those services requiring substantial specialized nursing
 skill, initiate appropriate preventive and rehabilitative nursing procedures,
 prepare clinical and progress notes, coordinate services inform the physician
 and other personnel of changes in the patient's condition and needs, counsel
 the patient and family in meeting nursing and related needs, participate in
 inservice programs, and supervise and teach other personnel.

2.

 Duties of the Licensed Practical Nurse
 (LPN). The licensed practical nurse shall provide services in accordance with
 agency policies, prepare clinical and progress notes, assist the physician
 and/or registered nurse in performing specialized procedures, prepare equipment
 and materials for treatments observing aseptic technique as required and assist
 the patient in learning appropriate self-care techniques.

(b)

 Therapy Services. All therapy services
 offered by the home health agency directly or under arrangement shall be given
 by a qualified therapist in accordance with the plan of treatment. The
 qualified therapist shall assist the physician in evaluating level of function,
 help develop the plan of treatment (revising as necessary), prepare clinical
 and progress notes, advise and consult with the family and other agency
 personnel, and participate in inservice programs. Therapy services include, but
 are not limited to:

1.

 Physical
 Therapy;

2.

 Occupational
 Therapy;

3.

 Speech
 Therapy;

4.

 Audiology.

(c)

 Medical Social Services.
 Medical social services, when provided, shall be given by a qualified social
 worker in accordance with the plan of treatment. The social worker shall assist
 the physician and other team members in understanding the significant social
 and emotional factors related to the health problems, participate in the
 development of the plan of treatment, prepare clinical and progress notes, work
 with the family, utilize appropriate community resources, participate in
 discharge planning and inservice programs, and act as a consultant to other
 agency personnel.

(d)

 Home Health
 Aide Services.

1.

 Home health aides shall be
 selected on the basis of such factors as a sympathetic attitude toward the care
 of the sick; ability to read, write, and carry out directions; and maturity and
 ability to deal effectively with the demands of the job. Aides shall be
 carefully trained in at least the following areas: methods of assisting
 patients to achieve maximum self-reliance, principles of nutrition and meal
 preparation, the aging process and emotional problems of illness, procedures
 for maintaining a clean, healthful, and pleasant environment, recognizing
 changes in a patient's condition that should be reported, work of the agency
 and the health team; ethics, confidentiality, and recordkeeping. Aides shall be
 closely supervised to assure their competence in providing care.

2.

 A home health aide shall be assigned to a
 particular patient by a registered nurse. Written instructions for patient care
 shall be prepared by a registered nurse or therapist as appropriate. Home
 health aide duties shall be limited to the performance of simple procedures
 such as an extension of therapy services, personal care, ambulation and
 exercise, household services essential to health care at home, assistance with
 medications that are ordinarily self-administered, reporting changes in the
 patient's condition and needs, and completing appropriate records.

3.

 A registered nurse, or other appropriate
 professional staff member, if other services are provided, shall make a
 supervisory visit to the patient's residence at least every two weeks, either
 when the aide is present to observe and assist, or when an aide is absent, to
 assess relationships and determine whether goals are being met. A record of the
 supervisory visit shall be dated and documented by a clinical note in the
 patient clinical record.

(e)

 Coordination of Patient Services. All
 personnel providing services shall maintain a liaison with the home health
 agency to assure that their efforts effectively complement one another and sup-
 port the objectives outlined in the plan of treatment. The clinical record
 shall contain dated minutes of case conferences verifying that effective
 interchange, reporting, and coordinated patient evaluation does occur. A
 written summary report of clinical and progress notes for each patient shall be
 sent to the attending physician at least every sixty (60) days and upon
 discharge. A copy of these reports shall become a permanent part of the
 patient's clinical record.

(f)

 Services Under Arrangements. All services provided under arrangements shall be
 subject to a written contract. Contracts for home health services shall conform
 with the specific requirements of Rule
 
111-8-31.07(6)(a)through(g)
.

Rule 111-8-31-.09 Standards for Patient Care

Patients shall be accepted for treatment on the basis of a
 reasonable expectation that the patient's medical, nursing, and social needs
 can be met adequately by the agency in the patient's place of residence.
 Patients shall not be denied services because of their age, sex, race,
 religion, or national origin. Care shall follow a written plan of treatment
 established and periodically reviewed by a physician, and shall continue under
 the supervision of a physician.

(a)

 Plan of Treatment. An individual plan of treatment shall be developed for each
 patient in consultation with agency staff, and shall cover all pertinent
 diagnosis, including mental status, types of services and equipment required,
 frequency of visits, prognosis, rehabilitation potential, functional
 limitations, activities permitted, nutritional requirements, medications and
 treatments, safety measures to protect against injury, instructions for timely
 discharge or referral, and other appropriate items. If a physician refers a
 patient under a plan of treatment which cannot be completed until after an
 evaluation visit, the physician shall be consulted to approve additions or
 modifications to the original plan. Orders for therapy services shall specify
 the procedures and modalities to be used, and the amount, frequency, and
 duration.

(b)

 Periodic Review of
 Plan of Treatment. The total plan of treatment shall be reviewed by the
 attending physician and home health agency personnel as often as the severity
 of the patient's condition requires, but at least once every sixty (60) days.
 Date of the review and approval of the plan shall be documented by the
 physician's signature. Agency professional staff shall promptly alert the
 physician to any changes that suggest a need to alter the plan of
 treatment.

(c)

 Conformance with
 Physician's Orders. Drugs and treatment shall be administered by agency staff
 only as ordered by the physician. The nurse or therapist shall immediately
 record and sign oral orders and forward the written order within five (5)
 business days to the physician for countersignature. Documentation of the
 physician's countersignature must appear in the patient's medical record within
 thirty (30) days of the verbal order. Professional agency staff shall check all
 medicines a patient may be taking to identify possible ineffective drug therapy
 or adverse reactions, significant side effects, drug allergies, and
 contraindicated medication, and shall promptly report any problems to the
 physician.

(d)

 Clinical Records. 

1.

 A clinical record shall be established and
 maintained on each patient in accordance with accepted professional standards
 and shall contain:

(i)

 pertinent past and
 current findings;

(ii)

 plan of
 treatment;

(iii)

 appropriate
 identifying information;

(iv)

 name
 of physician;

(v)

 drug, dietary,
 treatment and activity orders;

(vi)

 signed and dated clinical and progress notes (clinical notes are written the
 day service is rendered by the providing member of the health team and
 incorporated no less often than weekly);

(vii)

 copies of case conferences;

(viii)

 copies of summary reports sent to the
 physician; and

(ix)

 a discharge
 summary.

2.

 If a patient
 transfers to another home health agency or a health facility, a copy of the
 record or abstract shall be furnished to accompany the patient.

3.

 Sufficient space and equipment for record
 processing, storage and retrieval shall be provided.

4.

 Policies and procedures shall be written
 and implemented to assure organization and continuous maintenance of the
 clinical records system.

(e)

 Retention of Records. Clinical records
 shall be retained for a period of six years after the last patient encounter
 for adults, and for six years after a minor reaches the age of majority. These
 records may be retained as originals, microfilms, or other usable forms and
 shall afford a basis for complete audit of professional information. If the
 home health agency dissolves or changes ownership, a plan for record retention
 shall be developed and placed into effect. The Department shall be advised of
 the disposition and/or location of said records.

(f)

 Protection of Records. Clinical record
 information shall be safeguarded against loss or unauthorized use. Written
 procedures shall govern the use and removal of records and conditions for
 release of information. A patient's written consent is required for release of
 information not authorized by law.

Rule 111-8-31-.10 Penalties

Any person who operates a home health agency without first
 obtaining a license pursuant to the provisions of the Georgia Home Health
 Agency Act shall be deemed guilty of a misdemeanor, and upon conviction shall
 be fined not to exceed $500.00 or imprisoned for a period not to exceed six
 months or both.

Rule 111-8-31-.11 Fees

Each application for initial and annual renewal licenses
 shall be accompanied by a fee as prescribed by the
 Department.

Rule 111-8-31-.12 Enforcement

The administration and enforcement of these rules and
 regulations shall be as prescribed in the "Georgia Administrative Procedure
 Act," O.C.G.A. § 
50-13-1
et
 seq.

Rule 111-8-31-.13 Applicability of Regulations

These regulations are applicable only to home health agencies
 as defined herein and the services they provide, and do not modify or revoke
 any of the provisions of other published rules of the
 Department.

Rule 111-8-31-.14 Severability

In the event that any rule, sentence, clause or phrase of any
 of these rules and regulations may be construed by any court of competent
 jurisdiction to be invalid, illegal, unconstitutional, or otherwise
 unenforceable, such determination or adjudication shall in no manner affect the
 remaining rules or portions thereof and such remaining rules or portions
 thereof shall remain of full force and effect, as if such rule or portions
 thereof so determined, declared or adjudged invalid or unconstitutional were
 not originally a part hereof. It is the intent of the Board of Community Health
 to establish rules and regulations that are constitutional and enforceable so
 as to safeguard the health and well being of the people of the
 State.

Rule 111-8-31-.01 Purpose
Rule 111-8-31-.02 Applications and Licenses
Rule 111-8-31-.03 Certificate of Need Review
Rule 111-8-31-.04 Exemptions
Rule 111-8-31-.05 Inspections
Rule 111-8-31-.06 Definitions
Rule 111-8-31-.07 Administrative Standards
Rule 111-8-31-.08 Scope of Services
Rule 111-8-31-.09 Standards for Patient Care
Rule 111-8-31-.10 Penalties
Rule 111-8-31-.11 Fees
Rule 111-8-31-.12 Enforcement
Rule 111-8-31-.13 Applicability of Regulations
Rule 111-8-31-.14 Severability

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