CoP Educational Series Part 1: Introduction to Home Health CoPs

Posted on Friday, July 7, 2017 5:02 PM

CMS developed Home Health Conditions of Participation (CoPs) that organizations must meet in order to begin and continue participating in Medicare and Medicaid programs. These health and safety standards are the foundation for improving quality and protecting the health and safety of the beneficiaries being cared for. CMS also ensures that the standards of accrediting organizations, such as Joint Commission, CHAP and ACHC (which are recognized by CMS through a process called “deeming”) meet or exceed the Medicare standards set forth in the CoPs.

The CoPs have existed in their current state for over 30 years. A revision to the CoP’s rule was initially proposed in 1997, but was never finalized, despite a resurgence in 2006. Finally, with a renewed effort starting in 2014, the CoPs have been finalized, with the final rule being published in the Federal Register on 1/13/2017. The final CoP Rule has an effective implementation date of 1/13/2018.

The new Home Health CoPs are designed to develop a more continuous, integrated delivery of care across home health; based on patient centered assessment, planning of care, delivery of services and quality assessment and performance improvement. The CoPs also take into consideration safeguarding patient rights.

The new Home Health CoPs incorporate structural changes as well. These changes include:

1. Renaming and Renumbering
Included across three sections:
1. A – General Provisions 484.1 – 484.2
2. B – Patient Care (Administration) 484.40 – 484.80
3. C – Organizational Environment (Furnishing Services) 484.100 – 484.115.

In addition, several standards have been combined or incorporated into new CoPs and two new CoPs have been added. Each will be covered in detail.

Lastly, changes to the new CoPs also include the elimination of some standards.

There are many key changes across the newly finalized CoPs that will be covered in detail in the subsequent postings.

Written by Peggy Patton, Vice President of Education Services

CoP Educational Series Part 2: Subpart A – General Provisions

It is important to understand Subpart A – General Provisions and any changes included with the finalization of the new CoPs to better prepare your organization for the transition.

Subpart A – General Provisions has been reorganized to better clarify the basis and scope of this section of the CoPs. Part 484.1 is based on sections 1861(o) and 1891 of the Act, which establish the conditions that a home health agency must meet in order to participate in the Medicare program. Part 484.1 is also based on section 1861(z) of the Act, which specifies the institutional planning standards that home health agencies must meet. These provisions serve as the basis for survey activities for the purposes of determining whether an agency meets the requirements for participation in Medicare.

With the revision of the Home Health CoPs several new definitions were added, some were revised and others were eliminated. First, the definitions that were modified will be outlined.

The definition for “branch office”, which means an approved location or site from which a home health agency provides services within a geographic area the parent home health agency provides services was modified by adding the requirement of the parent agency to offer more than just the sharing of services. The definition now includes the parent agency to provide supervision and administrative control of branches on a daily basis to the extent the branch depends on the parent agency’s supervision and administrative control to meet the CoPs, and would not be able to do so independently. The definition no longer requires the branch office to be “sufficiently close”. The parent agency must be available to meet the needs of any situation and respond to issues that could arise with respect to patient care and/or the administration of the agency. A violation of a CoP in one branch office is a violation for the entire home health agency. 

Minor changes are also noted in the language of the current definitions for “clinical note,” “parent home health agency,” “proprietary agency,” and “subdivision.”  

Current definitions of the terms bylaws, supervision, progress notes and sub-units were eliminated.  As it relates to sub-units, on the effective date of the new CoPs, any existing subunits, which already operate under their own provider number, will be considered distinct HHAs and will be required to independently meet all CoPs, including having an independent governing body and administrator. Subject to state-specific laws and regulations, this federal regulatory change will permit a subunit to apply to become a branch of its existing parent HHA, if the parent provides “. . . direct support and administrative control” of the branch. The State Survey Agency and CMS Regional Office will continue to be responsible for approving home health agency applications for a branch office, in accordance with current CMS guidance as set forth in various survey and certification letters and the section of the State Operations Manual. No new subunits will be approved upon implementation of this regulation, only “branch offices.”

Several new definitions were added to the CoPs. 

“In advance” means the home health agency staff must complete the specified task before any hands on patient-care or patient education takes place.

“Quality Indicator” references a specific, valid and reliable measure of access, care outcomes or satisfaction, or a measure of a process of care.

“Representative” means the patient’s legal representative, such as a guardian, who makes health care decisions on the patient’s behalf, or a patient-selected representative who participates in making decisions related to the patient’s well-being, including but not limited to a family member or an advocate for the patient.

“Supervised practical training” means training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing the covered 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.

“Verbal Order” is a physician’s order that is spoken to appropriate personnel and put into writing to document and as well as establish or revise the patient’s plan of care.

Be sure to read Part 3 of the CoPs blog series which covers Subpart B – Patient Care.

Written by Peggy Patton, Vice President of Education Services

CoP Educational Series Part 3: Subpart B – Patient Care

This post is the first of 3 covering Subpart B – Patient Care. This session will highlight the requirements surrounding OASIS data collection and submission, although there are minimal changes to these specific conditions regarding OASIS.  CoP 484.55 Comprehensive Assessment of Patients will also be outlined in this session.

The objective of this session is to identify requirements related to 484.40, 484.45 and 484.55.

The OASIS is a key component of Medicare’s partnership with the home care industry to foster and monitor improved home health care outcomes and is an integral part of the revised Conditions of Participation for Medicare-certified home health agencies. Conditions 484.40 and 484.45 and the associated standards cover the release of patient identifiable information, including OASIS information and the reporting of OASIS information.

The Home Health Condition of Participation 484.40 (previously 484.11) – Release of patient identifiable outcome and assessment information set (OASIS) information has not changed with the revision and renumbering of the CoPs. The condition states the home health agency and any agent acting on the behalf of the agency in accordance with a written contract must ensure the confidentiality of all patient identifiable information contained in the clinical record, including OASIS data, and may not release patient identifiable information to the public. 

484.45 (previously 484.20) Reporting of OASIS information requires home health agencies to electronically report all OASIS data collected in accordance with CoP 484.55, Comprehensive Assessment of Patients.  The four standards associated with CoP 484.45 include:

a) Standard Encoding and transmitting OASIS data. Home health agencies must encode and electronically submit each completed OASIS assessment to the CMS system within 30 days of completing the assessment.
b) Standard Accuracy of encoded OASIS data. The encoded OASIS data must accurately reflect the patient’s status at the time of the assessment.
c) Standard Transmittal of OASIS data. The home health agency must:

1. Transmit the data for all completed assessments to the CMS collection site using electronic communications software that complies with the Federal Information Processing Standards. The reference to telephone connection has been removed from this standard.
2. Successfully transmit test data to the QIES ASAP System or to the CMS contractor.
3. Transmit data that includes the CMS-assigned branch ID as applicable.

d) Standard Data format. The home health agency must encode and transmit data using the software available from CMS or other software that conforms to the CMS standard electronic record layout, edit specifications, data dictionary, and that includes the current OASIS data set.

The Home Health Condition of Participation 484.55 Comprehensive Assessment of Patients states each patient must receive and the home health agency must provide a patient-specific comprehensive assessment. For those patients that are Medicare Beneficiaries, the agency must verify the patient’s eligibility for the Medicare home health benefit, including homebound status, both at the time of the initial assessment and the comprehensive assessment.

The standards associated with this CoP are:

a) Initial assessments of patients
b) Completion of the comprehensive assessment
c) Contents of the comprehensive assessment
d) Update of the comprehensive assessment

The requirements regarding initial assessments of the patients and the timing of this assessment has not changed. The same holds true for the completion of the comprehensive assessment. The contents of the comprehensive assessment, a new standard that incorporates elements from the current CoP including drug regimen review, incorporation of the OASIS data set and adds several new items.  This standard states the comprehensive assessment must accurately reflect the patient’s status and at a minimum must include the following information:

  • The patient’s current health, psychosocial, functional and cognitive status. This evaluation is to assist the home health agency in using this information in developing and implementing a patient-specific plan of care and so that agencies can potentially identify unmet patient needs that may need additional follow-up by another health care provider.  The intent of the evaluation of the cognitive status is to determine the extent in which the patient will be able to understand, remember and participate in the development and implementation of their own plan of care.  In general, it is felt there may be crossover between these items and items within the OASIS, although the items in the OASIS assessment may not always be sufficient for all patients.
  • The patient’s strengths, goals and care preferences including information that may be used to demonstrate the patients progress towards goals and measurable outcomes identified by the home health agency.
  • The continued need for home care services
  • The patient’s medical, nursing, rehabilitative, social and discharge needs
  • Full medication review to identify any potential adverse effects or drug reactions, identify ineffective drug therapy, significant side effects and/or drug interactions, duplicate drug therapy and non-compliance with drug regimen.
  • The comprehensive assessment must contain the patient’s primary caregiver, if any, and other available supports willingness and ability to provide care and their availability and schedules.
  • The patient’s representative/s if any.
  • Incorporation of the current version of the OASIS data set for all time points.

The last standard for this CoP is the requirement to update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the incorporation of the OASIS data set) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but no less frequently than the last 5 days of every 60-day period starting with the start of care date unless there is a Beneficiary elected transfer, a significant change in the patient’s condition or a discharge and return to the home health agency within the 60-day period. 

The comprehensive assessment must also be updated within 48-hours of a patient’s return to the home from a hospital admission of 24-hours or greater for anything other than diagnostic testing or on a physician’s ordered resumption of care. Lastly, it must be updated on discharge.

Home Health CoP 484.50 – Patient Rights will be outlined in our next post. Be sure to check the Insights page next week.

Written by Peggy Patton, Vice President of Education Services

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