Home Health & Hospice Week

Are your patients willing to be bathing guinea pigs?

More than four months into implementation of the drastically revised Home Health Conditions of Participation, home health agencies continue to struggle with the new regulations. And one of the changes proving most dangerous to HHAs' compliance is the change in 484.80(c)(1) regarding aide competency evaluations.

The requirement at 484.80(c)(1) Home Health Aide Services: Competency Evaluation spells out that a Registered Nurse must observe "an aide's performance of the task with a patient." The standard lists multiple tasks (see box, p. 123).

The previous iteration of the CoPs also required RN observation of an aide performing the task, notes attorney Robert Markette with Hall Render in Indianapolis. But the former Interpretive Guidelines clarified that performance could be on a "pseudo-patient such as another aide or volunteer in a laboratory setting."

Critical: Now, the new CoPs use the same "patient" language, but the draft IGs for 484.80(c)(1) issued last November specify only that "the tasks must not be simulated in any manner and the use of a mannequin is not an acceptable substitute," which was also in the former IGs. There is no mention of a pseudo-patient.

This difference is arguably the CoP change presenting agencies with the biggest challenge to compliance, says Melissa Abbott with 5 Star Consultants in Camdenton, Missouri. The areas that are most problematic are giving the patient a "Sponge, tub, and shower bath" and "hair shampooing in sink, tub, and bed" (emphasis added). The former CoPs said "or" instead of "and."

To begin with, sending RNs out with aides in the field to demonstrate competencies "is an exorbitant expense that we didn't have before," notes consultant Kathy Roby with Qualidigm based in Wethersfield, Connecticut.

And having aides make extraneous visits, when aides "are as scarce as hen's teeth," makes access to aide services even more challenging, Roby tells Eli.

But perhaps most problematic is that there simply are not enough patients on service who can take a tub bath for aides to be able to demonstrate on, Abbott says. "It is very unlikely that there would be a home care patient that requires a tub bath, as it usually is unsafe for the client and for the staff person involved," she notes.

What About Private Duty Patients?

HHAs have been trying to get creative to overcome this compliance challenge, but their options are limited.

Strategy #1: If there is someone on service who does get a bath, rotate your current aides to visit the patient in order to get competency completed, Abbott advises.

The problem: Patients can refuse to bathe if they wish, Markette tells Eli. And even when they are willing to let their own regular staff bathe them with their regular nurse observing, they generally hate being used as a "guinea pig" for multiple different aides to bathe, he adds.

Having aides demonstrate competencies on current patients only for tub bathing "is not a real solution," Markette says. Instead, it's an idea that's only workable "in the ivory tower" of CMS "in Baltimore," he criticizes.

Strategy #2: HHAs with a private duty unit have broached the idea of conducting the evals on their private duty patients, who may be in better health and thus more likely to be able to take a tub bath safely, Markette relates.

The problem: It's unclear from the new CoPs and draft IGs whether this would fulfill the requirement, since the standard says the task must be performed "with a patient." That language might mean a Medicare patient specifically, and/or one under a current Medicare plan of care, Markette notes.

Strategy #3: HHAs also theorize that perhaps, if the aide does not have to perform a certain task, she does not have to be evaluated on it, Markette says. Therefore, if an aide has no patients who can safely bathe in the tub, she won't have to perform tub-related tasks for evaluation. If an aide did serve a patient needing tub baths, then an RN would evaluate her competencies in those tasks as the need arose.

The problem: Again, it's unclear from the CoP and draft IG language whether this would fulfil the requirement, Markette allows.

The high rate of turnover among aides, particularly in some geographic areas, exacerbates the unworkability of these strategies, Markette adds.

HHAs Hold Out Hope For Final IG Rescue

As agencies struggle to comply with 484.80(c)(1), they also hope they may get some relief when CMS issues the final version of the IGs. If CMS would replace the "and"s in the task list with "or"s as with the previous iteration of the CoPs, the standard would be much more reasonable, Abbott says.

Or if CMS would go back to allowing aides to demonstrate competencies on pseudo-patients including peers or other volunteers, HHAs would no longer face insurmountable obstacles to compliance, experts agree. "We are hoping for clarity and correction in the final guidelines," Roby says.

Note: See the final rule on the new Home Health CoPs at www.gpo.gov/fdsys/pkg/FR-2017-01-13/pdf/2017-00283.pdf. For a free PDF copy of the draft IGs, email editor Rebecca Johnson at rebeccaj@eliresearch.com with "Draft IGs" in the subject line.