Home Health & Hospice Week

Will your vendors be as ready as you are?

While home health agencies are happy that the feds have confirmed a six-month reprieve for the Home Health Conditions of Participation, they still have a mountain of work to do to get in compliance with the new regulation — and some serious trouble spots to tackle.

When the Centers for Medicare & Medicaid Services finalized the six-month postponement to the CoPs deadline in a rule published in the July 10 Federal Register, it also announced that the Interpretive Guidelines for surveyors wouldn’t be out until December (see Eli’s HCW, Vol. XXVI, No. 25). That will exacerbate many of the top challenges that HHAs face in preparing for the new CoPs that take  effect in January, experts fear.

HHAs would be wise to place these items at the top of their CoP prep lists:

1. Plan of Care changes. The CoPs will require many changes to the POC’s content and how agencies formulate and document it. “One of the most difficult components of the new CoPs is the changes in the POC regarding incorporating patient goals in addition to patient outcomes,” judges consultant Pam Warmack with Clinic Connections in Ruston, Louisiana. “That may prove very difficult for providers.”

Another troublesome POC addition will be emergency preparedness planning, Warmack adds.

Reminder: HHAs must have plans for their patients “during a natural or man-made disaster,” CMS spells out in the CoPs final rule published in the Jan. 13 Federal Register. “Individual plans for each patient must be included as part of the comprehensive patient assessment.”

Integrating the emergency preparedness plans into the POC will be a challenge, Warmack expects.

2. Physician signatures. In the final rule at 484.55(d), CMS adopts this standard: “Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than —

(1) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a —

(i) Beneficiary elected transfer;
(ii) Significant change in condition; or
(iii) Discharge and return to the same HHA during the 60-day episode.

(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician-ordered resumption date;

(3) At discharge.

In responding to comments on the proposed rule, CMS said that “in order to effectively assure the development, implementation, and updates of the individualized plan of care, there would have to be communication with all physicians involved in the plan of care and integration of orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient. The requirement to integrate orders from all physicians would include those orders related to medications.”

CMS’s interpretation of the order integration and signature requirement could cause major problems, worries Judy Adams with Adams Home Care Consulting in Durham, North Carolina. Agencies are concerned about “the interpretation of the requirement to continually update the Plan of Care and what that means for obtaining a physician’s signature on the updated POCs,” Adams explains.

Worry: HHAs can accept orders from multiple physicians involved in the patient’s care and have one certifying physician who is responsible for care plan oversight, Adams tells Eli. “If the certifying MD will be required to sign off on updated plans that include orders from multiple physicians more than every 60 days, this will be a true headache,” she predicts. “It is already difficult to get physicians to sign orders and plans of care in a timely manner and many, many physicians balk at signing a plan of care that includes orders from other physicians.”

3. Technology breakdowns. Be sure your emergency preparedness plans address technology malfunctions. “Be prepared to address issues that arise when technology fails,” urges attorney Robert Markette Jr. with Hall Render in Indianapolis. “A hospital out west is currently being sued for not addressing failing technology.”

4. QAPI & governing bodies. CMS granted HHAs an additional six months to initiate their quality assessment and performance improvement projects under the new CoPs (see Eli’s HCW, Vol. XXVI, No. 25). But agencies still will have some big challenges ahead in this area.

“The governing body is going to have to be more familiar with a lot more than in years past in order to understand and execute their role in QAPI,” Markette tells Eli. “Agencies will need to assess the current level of understanding, educate the members of the governing body, verify they understand, develop tools to report data to QAPI, etc.”

Plus: “The governing body will need to learn to carefully document its efforts, for survey purposes,” Markette adds. (For more on governing bodies and QAPI, see Eli’s HCW, Vol. XXVI, No. 6.)

5. Vendors. It’s not just you that has to be ready for the new CoPs — your vendors do also. Getting your information systems provider to make changes in the existing plan of care and assessment forms that are in the electronic records is crucial, Adams says. “Most IS vendors offer a POC [form] that is based on the old OMB-approved 485 and no longer meets the requirements for the POC or even the certification statement,” Adams contends. “CMS has not required this form since the early 2000s and it is inadequate for the expanded POC requirements in the new regulations.”

Tip: CMS has suggested a new certification statement in the Medicare Benefits Manual “that better meets requirements for F2F documentation since 2011 and certification and recertification requirements since 2015,” Adams offers.

6. Language services. The CoPs’ “accessibility components will be a challenge for agencies that have not already implemented 1557,” Markette cautions. Section 1557 of the Affordable Care Act encourages providers to implement language access plans, CMS notes on its website.

In the new Patient Rights CoP finalized in January, CMS says home health agencies must provide a written patient rights notice that is “understandable to persons who have limited English proficiency” before care commences; a verbal patient rights notice “in the individual’s primary or preferred language and in a manner the individual understands” by the end of the second visit; and information on their right to language services and how to access them. (For more on your language access duties under the new CoP, including providing interpreter services, see Eli’s HCW, Vol. XXVI, No. 16.)

7. Interpretive Guidelines. Failing to issue the guidance until the CoPs are nearly in effect — or maybe even after — is a major problem for HHAs.  “CMS claims the revised CoPs are intended to have enough flexibility to allow for ‘HHA innovation’ in complying with the regulations, since the emphasis is not on structure but outcomes,” the National Association for Home Care & Hospice says. “NAHC only hopes that the state surveyors apply the same flexibility in determining compliance with revised regulations,” the trade group says in its member newsletter.

Do this: Agencies should “implement the revised CoPs to the best of their ability with information from the current IGs where applicable, the revised regulations, and the clarifying discussions within the final rule,” NAHC recommends. But they should understand “that once the IGs are issued, some modification for compliance might be needed.”

Note: See the CoPs final rule at www.gpo.gov/fdsys/pkg/FR-2017-07-10/pdf/2017-14347.pdf.