Waiver for Certain Core Nursing Services

40.4.2.1 - Waiver for Certain Core Nursing Services (Rev. 141, Issued: 03-02-11, Effective: 01-01-11: Implementation: 03-23-11) The Conditions of Participation allow CMS to waive the requirement that a hospice provide nursing services directly, if the hospice is located in a non-urbanized area. The location of a hospice that operates in several areas is considered to be the location of its central office. The hospice must provide evidence to CMS that it has made a good faith effort to hire a sufficient number of nurses to provide services. CMS may waive the requirement that nursing services be furnished by employees based on the following criteria: • The location of the hospice's central office is in a non-urbanized area as determined by the Bureau of the Census. • There is evidence that the hospice was operational on or before January 1, 1983, including the following: • Proof that the organization was established to provide hospice services on or before January 1, 1983; • Evidence that hospice-type services were furnished to patients on or before January 1, 1983; and • Evidence that hospice care was a discrete activity rather than an aspect of another type of provider’s patient care program on or before January 1, 1983. • By virtue of the following evidence that a hospice made a good faith effort to hire nurses: • Copies of advertisements in local newspapers that demonstrate recruitment efforts; • Job descriptions for nurse employees; • Evidence that salary and benefits are competitive for the area; and • Any other recruiting activities (e.g., recruiting efforts at health fairs and contacts with appropriate personnel at other providers in the area). A waiver remains in effect for a 1-year period. A waiver may be extended for two additional 1-year periods. Prior to each additional year, the hospice must request the extension and certify that the employment market for appropriate personnel has not changed significantly since the initial waiver was granted if this is the case. No additional evidence is required with this certification. Waiver requests and any extensions with supporting documentation must be sent to the regional office for review. Regional offices have the authority to review, and approve, or deny the waiver application.