Respite Care Service 525-05-30-55

(Revised 05/01/23 ML #3730)

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Purpose

Respite care is care to an eligible individual for a specified period of time for the purpose of providing temporary relief to the individual's primary (live-in) caregiver from the stresses and demands associated with constant care or emergencies.  This care is provided when there is a need for a specially trained caregiver.  Respite care may be provided in the individual's home, or outside the individual's home in either a Respite Care Provider's home or an enrolled Qualified Service Provider of Institutional Respite Care.

 

Service Eligibility, Criteria for

The individual receiving respite care service will meet the following criteria:

  1. Must be eligible for Medicaid Waiver for Home and Community Services, SPED, or ExSPED.
  2. The individual has a full time (live-in) primary caregiver OR the individual is a child under 22 years of age who is attending school AND the primary caregiver is responsible for providing full time care when the individual is not in school.  
  3. The relief is not for the primary caregiver's employment or enrollment/attendance of an educational program.
  4. Children three (3) months of age and under would be eligible only for SPED Respite Care for apnea monitoring.  See Limits section for infants over three months of age.  
  5. Individuals enrolled in a Hospice program are not eligible for institutional Respite Care but would be eligible for in-home intermittent Respite Care.
  6. For an individual whose full-time primary caregiver does not live with him/her but provides frequent on-site visits throughout the day which is essential to allow the individual to live independently, contact the HCBS Program Administrator for prior approval for Respite Care.
  7. The individual needs a qualified caregiver, or it would be inappropriate to use an unqualified caregiver in the absence of the primary caregiver.
    1. If laundry and/or housekeeping are the only service need, Respite Care authorization is unallowable.
  1. The primary caregivers need for relief is intermittent or occasional.
  2. If the prospective respite care provider lives with the individual, contact the HCBS Program Administrator for prior approval.
  3. An individual who is a resident of an Adult Foster Care home may choose their respite provider and is not required to use a relative of the Adult Foster Care provider for respite.

Service Location

Services will be administered in the most integrated setting consistent with the Person Centered Plan of Care, including (checked if allowable):

ü The individual's home

ü Respite Care provider's home

□ Other community service settings

 

Information Provided to the Respite Care QSP:

Case Management documentation should verify that the individual or legally responsible party are responsible to inform the Respite Care provider of the following:

  1. The Respite Care QSP shall be informed about the individual's daily routine. This may include strengths and weaknesses of the individual, what the individual enjoys doing, unique instructions for specific activities, or special assistance requirements.
  2. The primary caregiver will explain in writing situation(s) which may result in an emergency. The written information should clarify what might happen, the appropriate response, and who the Respite Care QSP should contact for assistance.  
  3. The primary caregiver shall identify to the Respite Care QSP the location of a first aid kit in the home, the location of the fuse box and spare fuses, the fire exit plan for the home and explain special instructions/restrictions on the operation of household appliances, kitchen equipment, etc.
  4. If client specific or global endorsements are required, the Respite Care QSP must meet the competencies for these tasks.

Service Activities, Authorized

The service tasks/activities within the scope of this service chapter are identified on the Authorization to Provide Service.

 

Service Activities, Not Allowed

Shopping, Community Integration, Social Appropriateness, Transportation are tasks that cannot be authorized under the Respite Care service.  

 

Limits

  1. Non-institutional Respite Care is capped at the daily swing-bed rate https://www.hhs.nd.gov/sites/www/files/documents/2023-swing-bed-fee-schedule.pdf regardless of whether an overnight stay is included. Respite Care providers must bill using the Procedure Code for a 15-minute unit, not to exceed the daily swing-bed rate. Only providers of Institutional Respite Care can bill using the Procedure Code for a daily rate.  
  2. Twenty-four hour care shall be allowed in an emergency and cannot exceed the Respite Care cap without prior approval of the HCBS Program Administrator.
  3. Respite Care may be provided for up to three (3) months to an infant requiring apnea monitoring if other SPED Program eligibility criteria are met, AND an apnea monitor is recommended by the applicant’s physician.
  4. An applicant requiring apnea monitoring is eligible upon the HCBS Program Administration receiving the SFN 1820, Data for SPED Program Pool Entry/Denial, with the notation the individual is on apnea monitoring. The effective date of service will be the date requested by the HCBS Case Manager. Coverage under the SPED program can be extended beyond three (3) months upon written request to the Program Administrator documenting the continued need for Respite Care as a result of continued need for apnea monitoring.
  5. The total allowable monthly maximum for Respite Care must be prorated for all residents in the Adult Foster Care home (regardless of private or public pay). The number of public and private pay AFC residents in a home should be evaluated quarterly during the quarterly contact. Any changes in the amount of respite should be updated at that time.
  6. The total allowable maximum for respite care must be prorated for all individuals receiving and living in the same Family Home Care setting.
  7. If multiple individuals live in the same home and have the same primary caregiver, the respite cap must be divided by the number of individuals in the home.
  8. The department may grant approval to exceed the service cap if the individual has special or unique circumstances; the need for additional services does not exceed 3 months; and the total need for service does not exceed the individualized budget amount. Under emergency circumstances, the Department may grant a one-time extension not to exceed an additional three months. The case manager must make participants aware of the service cap.

Providers

Respite Care may be provided by the following individual QSP's or employees of a QSP agency (checked if allowable):

□ Guardian

□ Legally Responsible Person - Legal spouse or parent of a minor child.

üRelative within the definition of Family Home Care under subsection 4 of N.D.C.C. 50-06.2-02.

 

Institutional Respite Care

Institutional respite care is care provided in a residential setting by a provider who is enrolled to provide Institutional Respite Care Services as a Qualified Service Provider of Institutional Respite Care.

  1. Placement/Admission: Institutions providing Respite Care are required to follow licensing rules for long term care facilities in North Dakota. Respite care provided in an institutional setting requires the minimum of an overnight stay. Therefore, the facility accepting the individual for the provision of Respite Care must provide the same sleeping accommodations available to residents or patients of the facility.

The facility cannot exceed their licensed or approved capacity. The individuals receiving Respite Care must be included in determining whether the license or approved bed capacity would be exceeded.

  1. Staff:  Because the facility must meet staffing patterns as defined by their licensing or Medicare-approval authority, the care staff of the facility will not be required to meet the specific standards of this chapter. The facility must make available evidence the care staff meet the requirements of their licensing or Medicare-approval authority upon request of the case manager and/or representative of the Department.
  2. Records:  The facility shall maintain such individual chart or records as is required for residents/patients of the facility.

Adult Foster Home for Respite Care

Adult Foster Homes that are also enrolled as Respite Care Homes and are providing services for individuals who are not current Adult Foster Care recipients bill their established Respite Care unit rate; the total cost per day cannot exceed the current swing bed rate.

 

When an individual who is a current Adult foster Care recipient receives overnight care in another licensed foster care home, the rate for that individual is the current established foster care rate and the Adult Foster Care procedure code is used.

 

Respite Care in QSP's Home

The form, Respite Home Evaluation, SFN 659, must be completed to provide evidence that the Respite Care QSP's home meets the standards for home Respite Care in addition to being an enrolled Qualified Service provider for Respite Care Service. The case manager is responsible for completing the evaluation and forwarding a copy to the HCBS Program Administrator.

  1. A minimum of one (1) home visit to the Respite Care QSP's home shall be made by the case manager to complete the form Respite Home Evaluation.
  2. Upon determining the respite care QSP's home meets the standards as outlined in SFN 659, a copy of the completed SFN 659 approving such compliance shall be issued to the respite care QSP to be effective for no more than two (2) years. The Respite Care Home QSP must sign an agreement to maintain the standards and keep a copy of the standards on the premises of the home. The approval shall apply to only the home at the address evaluated.  Should the Respite Care QSP move, another evaluation is required.
  3. The case manager shall maintain records of the evaluation, the decision, and the reason for that decision.