Home Health & Hospice Week

But changes need some fine-tuning to be practical for providers.

Home health aide supervision is a bigger hassle than ever for home health agencies thanks to the nursing shortage, but regulatory relief is on the horizon.

Reminder: In its home health payment proposed rule for 2022, the Centers for Medicare & Medicaid Services proposes making aide supervision flexibilities from the COVID-19 Public Health Emergency permanent. Under the current Medicare Conditions of Participation, “aides caring for a patient receiving skilled care from nurses or therapists must … have an on-site supervisory visit every 14 days, while aides caring for a patient who is not receiving skilled care must have an onsite supervisory visit every 60 days,” CMS describes in the rule.

Change No. 1: “It is important to permit HHAs to complete this assessment virtually, in the rare circumstance that an onsite visit cannot be coordinated within the 14-day time period,” CMS says. “We propose that HHAs be permitted to use interactive telecommunications systems for purposes of aide supervision, on occasion, not to exceed 2 virtual supervisory assessments per HHA in a 60-day period.”

The aide “does not need to be present during this supervisory assessment,” CMS adds. And “we are proposing [to] define interactive telecommunications systems as multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner.”

Change No. 2: For the 60-day supervisory visits, “we propose to maintain the first part of this requirement, that the registered nurse must make a visit in person every 60 days, but would remove the requirement that the RN must directly observe the aide in person during those visits,” the rule says. Like for the 14-day supervisory visit, the aide would not have to be present for the visit. However, “if a deficiency in the aide services are assessed, the agency must conduct and the home health aide must complete, retraining and a competency evaluation for the deficient and all related skills.”

CMS has proposed the change because “we continue to receive feedback that this requirement is overly burdensome for the patient and the HHA if multiple home health aides provide care to the same patient,” it explains. “For instance, if a patient has three different home health aides providing care, the nurse is currently required to observe and assess each of the three home health aides while the aide is giving care to the patient. This circumstance would entail three separate nursing supervision visits on the same patient every 60 days.”

HHAs and their representatives are all for these changes. For the 14-day supervisory visits, “we appreciate CMS’s proposal to give HHAs flexibility to use interactive telecommunications systems for purposes of aide supervision,” says Marcia Tetterton with the Virginia Association for Home Care and Hospice in her comment letter on the rule.

“We support and appreciate the flexibility CMS proposes for the HCA supervisory visits and agree that onsite HCA supervisory visits in conjunction with an occasional telecommunication HCA supervisory visit provide an appropriate balance for use of the two modalities to ensure compliance with 14-day HCA supervisory visit requirement,” says Lauren Reynolds, founder of and administrator for At Home Nursing Care Inc. in Encinitas, California, in her comment letter.

For the 60-day visits, the National Association for Home Care & Hospice “supports and appreciates CMS’ proposals for the HCA supervisory visits for patients receiving nonskilled service,” NAHC execs say in the trade group’s comment letter. “The change will significantly reduce the burden associated with a requirement for a 60-day on-site HCA supervisory visit, with the aide present,” they praise.

“Spectrum Health fully supports making the waivers related to the requirements for supervision of home health aides permanent,” says Grand Rapids, Michigan-based health system exec Matthew Cox in his comment letter.

But not everyone is happy with the proposed changes. “AARP is very concerned with CMS’s proposal to make permanent selected regulatory blanket waivers related to home health (HH) aide supervision that were issued to Medicare participating home health agencies during the COVID-19 public health emergency (PHE),” says AARP’s David Certner in the senior interest group’s comment letter. “This proposed change is inconsistent with the

provision of quality care,” Certner says of the telecommunications option for supervisory visits.

“An on-site supervisory visit is an important component to assess the quality of care and services provided by the aide,” Certner says of the 60-day supervisory visits.

“AARP believes more evaluation and study is needed to determine whether making these changes permanent would be in the best benefit of serving patients and protecting patient health and safety,” Certner says. “We ask that CMS reconsider these proposed policy changes.”

These Changes Are Needed, HHAs Say

While HHAs and their reps support the idea of the aide supervision flexibilities, they have many critiques and suggestions for improvement as well.

For the 14-day visits, “the proposal that limits home health agencies to two telecommunication visits in a 60-day period is much too low,” says Fawn Barrie with the Oregon Association for Home Care in the trade group’s comment letter.

“Limiting virtual supervisory visits to only 2 per agency every 60 days is of little practical value,” maintains Patricia Kelleher with the Home Care Alliance of Massachusetts. “It would be more cumbersome and costly for agencies to track these virtual supervisory visits than they might save through this flexibility,” Kelleher says in HCAM’s comment letter.

In fact, it can’t be done, NAHC insists. “It would be difficult, if not impossible, to track these visits at the agency level to ensure compliance,” its letter tells CMS.

The drawbacks are particularly true for larger providers, NAHC adds.

For such agencies, “tracking of such a limited accommo­dation may prove too difficult to actually be implemented in practice,” the American Occupational Therapy Association predicts.

Instead: “We support the flexibility that these visits offer and urge you to increase this cap,” Barrie says in OAHC’s letter.

NAHC and other commenters suggest changing the limit to one telecommunication aide supervisory visit per patient every 60 days, instead of two per agency in that time period. Kelleher, AOTA, and other commenters go bigger, suggesting the limit be two telecommunication visits per patient in that period.

“While in-person supervision should be the norm, we urge CMS to offer greater flexibility in the use of virtual supervisions,” Kelleher exhorts.

Change No. 3: For the 60-day visits, CMS wants to add a supervisory visit every six months seemingly in exchange for not requiring the aide to be present for the 60-day visits. “In order to ensure appropriate RN supervision of HHA aides caring for patients who are not receiving skilled services, we propose to add a new requirement … that would require the RN to make a semiannual on-site visit to the location where a patient is receiving care in order to directly observe and assess each home health aide while he or she is performing care,” the rule says. “This semi-annual in-person assessment would occur twice yearly for each aide, regardless of the number of patients cared for by that aide,” CMS proposes.

“Our members have concerns with the logistics of conducting a semi-annual onsite visit, aide present, for all HCAs,” Texas Association for Home Care & Hospice’s Rachel Hammon says in the trade group’s comment letter.

Instead: CMS should scrap the 60-day visits altogether and go with the semi-annual ones, Barrie, Kelleher, and other commenters urge.

Many commenters also want CMS to furnish more details about what will count as “related skills” that will require competency evaluation if a skill is found deficient at the 60-day aide supervisory visits. CMS should “provide more clarity around skills that would be considered related, such as additional examples, to promote consistency for applying this requirement,” Reynolds suggests.

Note: The 143-page proposed rule for 2022 is at https://www.govinfo.gov/content/pkg/FR-2021-07-07/pdf/2021-13763.pdf.