Home Health & Hospice Week

Agencies’ have their work cut out for them in avoiding survey deficiencies.

Some Interpretive Guideline changes are for the worse and some are for the better, but final IG sections that remained unchanged from the draft put home health agencies in danger of survey citations, alternative sanctions, and even termination.

Here are some of the top IG sections that the Centers for Medicare & Medicaid Services left mostly unchanged, which pose a hazard:

• Missed visits. In the Conditions of Participation, §484.60(a)(1) says Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan.

The final IG language under tag G572 remains nearly the same as the draft IG: “The patient’s physician orders for treatments and services are the foundation of the plan of care. If the HHA misses a visit or a treatment or service as required by the plan of care, which results in any potential for clinical impact upon the patient, then the HHA must notify the responsible physician of such missed treatment or service. The physician decides whether the treatment or service may be skipped or whether additional intervention is required by the HHA due to the clinical impact on the patient. If the patient or the patient’s representative refuses care that could impact the patient’s clinical wellbeing (such as dressing changes or essential medication) on more than one occasion, then the HHA must attempt to identify the reason for the refusal. If the HHA is unable to identify and address the reason for the refusal, then the HHA must communicate with the patient’s responsible physician to discuss how to proceed with patient care.”

Consultant J’non Griffin, owner of Home Health Solutions in Carbon Hill, Alabama, says she is “disappointed that a physician has to tell an agency on a missed visit if they need to make up that visit.”

Surveyors have cited G572 182 times so far this year, according to CMS survey data updated through Sept. 3. That puts the tag at No. 4 on 2018’s citation list so far, with surveyors citing it in 8.1 percent of surveys. While it’s unclear how often the missed visit issue was the cause for the citation, it’s a dangerous risk area, observers say.

• RN med review for therapy-only cases. §484.55(c)(5) says The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information … a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.

The final IG, which remains essentially the same from the draft, specifies that “in rehabilitation therapy only cases, the patient’s therapist must submit a list of patient medications, which the therapist must collect during the comprehensive assessment, to an HHA nurse for review.”

Again, Griffin was disappointed CMS didn’t make a change to this guideline, she tells Eli.

The medication review requirement is one of the most commonly cited deficiencies thus far in 2018, according to CMS survey data on its website. Surveyors cited HHAs under tag G536 243 times — that’s in 11 percent of surveys, ranking as the No. 2 most commonly cited tag. The data doesn’t break out how many of the citations were due to the specific therapy-only case issue.

• EP. One place home health agencies have reported surveyor zeal in 2018’s surveys has been Emergency Preparedness. Perhaps that’s because EP “has been required for providers prior to the new Conditions,” notes consultant Kathy Roby with Qualidigm based in Wethersfield, Connecticut. Surveyors may be more lenient with new and drastically revamped CoPs, but HHAs have had more time to prepare for the EP requirements.

Surveyors have cited agencies 303 times under six different tags for EP thus far in 2018. Added together, that frequency is second only to citations for G574 §484.60(a)(2) The individualized plan of care must include the following at 363 citations.

HHAs may have had more familiarity with EP requirements than other new and revised CoPs. But under the new CoPs and IGs, which remain basically the same as the draft, “the requirements and potential citations are far more detailed and the requirements for interaction/documentation of education, testing, drills, coordination with state/local/federal groups more extensive,” Roby points out.

Result: The EP CoPs “will require significant investment in time, staffing, scheduling, development of training, research, etc.,” Roby says.

• Infection prevention/control/management. Surveyors have cited this area 58 times this year under tags G680, G684, and G686, the CMS survey data shows. This area may trip up agencies because “the section on Infection Prevention/Management is far more extensive and detailed than previously,” Roby warns. And it “impacts not only QAPI Adverse Event reporting and action, but also staff/patient education, the impact of the Infection types/rates at a local/state level, etc.”

This is another CoP area that requires “investment in time, staffing, scheduling, development of training, research, etc.,” Roby emphasizes.

• QAPI. Surveyors have cited agencies under three Quality Assessment and Performance Improvement tags 53 times so far in 2018 — G640, G660, and G720. QAPI requirements are challenging for HHAs because “the QAPI process is a radically different approach that has only newly been required as of July 1, 2018,” Roby says. “Providers are struggling with this now — gathering data, identifying concerns, establishing plans, and determining how to monitor/audit and document their progress,” she warns.

Note: View CASPER survey data at https://qcor.cms.gov — click on your provider type in the left column, then choose which type of report you’d like to run in the left column.