42 CFR §418.74

1. (a)A hospice located in a non-urbanized area may submit a written request for a waiver of the requirement for providing physical therapy, occupational therapy, speech-language pathology, and dietary counseling services. The hospice may seek a waiver of the requirement that it make physical therapy, occupational therapy, speech-language pathology, and dietary counseling services (as needed) available on a 24-hour basis. The hospice may also seek a waiver of the requirement that it provide dietary counseling directly. The hospice must provide evidence that it has made a good faith effort to meet the requirements for these services before it seeks a waiver. CMS may approve a waiver application on the basis of the following criteria:
   1. (1)The hospice is located in a non-urbanized area as determined by the Bureau of the Census.
   2. (2)The hospice provides evidence that it had made a good faith effort to make available physical therapy, occupational therapy, speech-language pathology, and dietary counseling services on a 24-hour basis and/or to hire a dietary counselor to furnish services directly. This evidence must include the following:
      1. (i)Copies of advertisements in local newspapers that demonstrate recruitment efforts.
      2. (ii)Physical therapy, occupational therapy, speech-language pathology, and dietary counselor job descriptions.
      3. (iii)Evidence that salary and benefits are competitive for the area.
      4. (iv)Evidence of any other recruiting activities (for example, recruiting efforts at health fairs and contact discussions with physical therapy, occupational therapy, speech-language pathology, and dietary counseling service providers in the area).
2. (b)Any waiver request is deemed to be granted unless it is denied within 60 days after it is received.
3. (c)An initial waiver will remain effective for 1 year at a time from the date of the request.
4. (d)If a hospice wishes to receive a 1-year extension, it must submit a request to CMS before the expiration of the waiver period and certify that conditions under which it originally requested the waiver have not changed since the initial waiver was granted.