On January 23, 2019, CMS published a an addendum to the Home Health interpretive guidelines titled, Home Health Conditions of Participation Frequently Asked Questions (HHCoPs FAQs). This document answers and clarifies common questions that had been submitted to CMS since the revised Conditions of Participation went into effect on January 13, 2018.
The following bullets highlight information presented in this document:
Home health agencies are not required to have a Professional Advisory Committee.
Home health agencies are not required to transmit OASIS data to all patients seen by the agency. OASIS data only needs to be transmitted for all Medicare patients, Medicaid patients, and patients utilizing any federally funded health plan options that are part of the Medicare program (e.g., Medicare Advantage (MA) plans) – §484.45(a).
The difference between a patient’s legal representative and patient-selected representative is that a patient’s legal representative, such as a guardian is legally designated or appointed to make health-care decisions on the patient’s behalf. Evidence that there is a legal representative may include guardianship, a power of attorney for health care decision-making, or a designated health care agent. A patient-selected representative participates at the request of a patient in decisions related to the patient’s care or well-being but is not legally designated or appointed to do so. The patient determines the role of the patient-selected representative.
A physician’s order (verbal or written) is needed at or immediately after the start of care visit to confirm the plan of care before any direct care services can be provided by the agency.
The comprehensive assessment must be completed 5 days after the start of care (SOC) date or by day 6 of the episode.
If an agency is unable to meet the timeframe for the initial assessment visit that is performed to assess the patient’s eligibility and needs for home care, the agency should not accept the patient for services.
If the patient requests a delay in the start of care date, the agency should contact the physician to request a change in the start of care date and this change would need to be documented in the medical record – §484.55(a)(1).
If acceptable to the patient and family, a competent, bilingual family member may serve as an interpreter for the patient. If a family member is unwilling or unable to serve as an interpreter for a patient requiring language assistance, the agency must secure competent, bilingual translation services, or technology and telephonic interpretation services – §484.50(a)(1)(i).
The start of care date is considered to be the first visit where the agency actually provides hands on, direct care services or treatments to the patient. Generally, this date is the first billable visit – §484.55(b)(1).
A therapist that performs a drug regimen review must submit the list of patient medications to an agency nurse for review – §484.55(c)(5).
Mid-level providers, such as nurse practitioners and physician assistants, may not write or give orders for home care. Only a physician can supply verbal or written orders. Only physicians may establish and maintain the home health plan of care, including reviewing, signing, and ordering home health services (source: Section 1861(m) of the Social Security Act).
If an additional service is added after the initial plan of care has been approved by the responsible physician, the agency must update the plan of care to include these services. This may be done via a physician’s order that is then incorporated into the recertification plan of care if the patient is rectified for home health services. The plan of care does not need to be re-issued and signed by the responsible physician with every verbal order.
The plan of care must include a description of the risk for emergency department visits and hospital admission and all interventions to address risk factors. The CoPs do not include requirements for how the agency describes the patient’s risk.
All pertinent diagnoses must be included on the plan of care. “All pertinent diagnoses” means all known diagnoses – §484.60(a)(2) and not just those being addressed by the agency.
The CoPs do not require the physician ordering home health services to be the same physician responsible for the plan of care. However, the plan of care must be reviewed and revised by the physician responsible for the plan.
The CoPs require that the home health agency provide the patient with written instructions regarding home visits, medications, treatments, and the agency clinical manager contact information. The CoPs do not require the agency to provide the patient with a hard copy of the entire plan of care. When the visit schedule, frequency of visits, treatments, or medications change in the plan of care, the agency is expected to provide the patient with revised written information – 484.60(e).
Orders from relevant physicians involved in the patient’s plan of care must be incorporated into the plan of care. The agency is responsible for integrating orders from both the responsible physician and any relevant physicians. The
revised plan of care would then need to be approved by the responsible physician at the next recertification if those orders are still active at that time. The agency should have policies for the co-signature of orders for services to be provided until the plan of care is signed at the next recertification period.
A nurse aide who successfully completes a nurse aide training and competency evaluation program, and is found to be in good standing in the state nurse aide registry, is considered to have met the training and competency requirements for a HHA aide – §484.80(a)(1).
To be qualified as a home health aide, the training program must include classroom and supervised practical training in a practicum laboratory or other setting in which the aide demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. Alternative formats for classroom training, such as online course material or internet based interactive formats are acceptable delivery methods for the classroom training. These alternative formats should also provide an interactive component that permits students to ask questions and receive responses related to the training. Classroom and supervised practical training must total at least 75 hours – §484.80(b).
The CoPs require that certain aspects of the competency testing be completed on a patient of the HHA. The competencies that must be assessed on a patient and not on a pseudo-patient or lab setting include:
- Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff.
- Reading and recording temperature, pulse, and respiration.
- Appropriate and safe techniques in performing personal hygiene and grooming tasks that include:
- Bed bath
- Sponge, tub, and shower bath
- Hair shampooing in sink, tub, and bed
- Nail and skin care
- Oral hygiene
- Toileting and elimination
- Safe transfer techniques and ambulation
- Normal range of motion and positioning
The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient.
When both nursing and therapy services are involved, nursing must maintain the overall responsibility for the written patient care instructions, with input from the other skilled professionals as appropriate. For therapy-only cases, the skilled therapist may develop the plan for the aide and may perform the required aide supervision.
Home health aides must have annual on-site supervisory visit while the aide is performing care.
For patients receiving only aide services, a registered nurse must make an onsite supervisory visit to the location where the patient is receiving care, no less frequently than every 60 days. This visit must occur for each patient in order to observe and assess the aide while performing care – §484.80(h)(2).
The home health aide plan of care may include more than one option (such as sponge bath or tub bath), indicating the patient may choose, when multiple options exist for the particular task – §484.80(g).
The medical record should document the time care is delivered. ‘‘Timed’’ means the actual time that an event occurred, which is not necessarily the time when the documentation was entered into the record. The date and time requirement applies to all entries in the record.
There is no requirement for a physician signature on the discharge summary.
A patient’s clinical record (whether hard copy or electronic form) must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first). The 4 day clock starts from the time that the patient or representative makes an oral or written request for the clinical record.