Home Health & Hospice Week

CMS updates State Operations Manual

If your policies state that you must secure a physician's order before discharging a patient, you could be setting yourself up for unnecessary survey trouble.
 
Home health agencies often can't figure out whether they need the physician's order if they discharge a patient earlier than expected. For example, if the plan of care is set up for six weeks but the patient meets the goals in five weeks, "do we have to have a discharge order?" asks Bev Kelley, administrator with Guardian Home Care in Roswell, GA.
 
Now HHAs can look to the Centers for Medicare & Medicaid Services official State Operations Manual for a concrete answer. "In the situation where the patient progresses to the point where it is no longer reasonable and necessary to continue services, because the patient's medical, nursing, and rehabilitative needs have been met adequately by the HHA, the HHA may notify the physician and discharge the patient, even though the certification period has not ended," CMS explains in the newly revised manual. "The clinical record should maintain documentation that the physician was notified of the discharge, but it does not need to contain a physician's order for discharge."
 
Dodge this pitfall: But one major problem may keep agencies from availing themselves of this provision - their own policies. "If, however, an HHA has a policy ... to obtain a physician's order before discharging a patient, the agency would be expected to abide by their policy," CMS says in its new transmittal detailing the revisions. State law could also require the order, CMS allows.
 
"Many home health agencies trip themselves up by having an agency-specific policy that does require an order from the MD to discharge," notes consultant Judy Adams with Charlotte, NC-based LarsonAllen Health Care Group. "Surveyors have always used the most stringent rule in evaluating," meaning they look to the Medicare conditions of participation, state regulations or individual agency policy to see what is the highest standard to hold the agency to, she explains.
 
But some agencies will be loath to give up their requirement for a physician discharge order, notes Chicago, IL-based regulatory consultant Rebecca Friedman Zuber. "Lots of [HHAs] feel that, as nurses, they need that order to discontinue care," Zuber says.

Online Manual Led Agencies Astray

Confusion about discharge orders may have increased because when CMS transferred its SOM from paper to the Internet, it inadvertently included a requirement to secure physicians' orders when discharging early or reducing services (see Eli's HCW, Vol. XIII, No. 35, p. 277).
 
In addition to the discharge order language, CMS adds many other provisions that were accidentally left out of the manual during the transfer to online, or that CMS has issued in guidance since the online manual took effect two years ago.
 
"The best thing about this transmittal is that it re-establishes CMS' position on these topics that were inadvertently left off the last update to the online manual," Adams notes. "HHAs now have an official written resource to use as reference."

Beware Payment Info Citations

Under Tag G115, CMS adds a lengthy section instructing surveyors how to check whether HHAs are informing patients of payment information. For example, one question surveyors should ask is, "What documentation in the clinical record indicates that the HHA informed the patient of Federally-funded or aided covered and non-covered services?" the manual states.
 
Survey hot spot: "They are going overboard on the issue of informing folks about charges," judges Zuber, a former regulator in Illinois. But "lots of agencies don't even give this info out - and they are required to." The new interpretive guidelines show CMS is "trying to give the surveyors some backbone to pursue this."
 
And "now we are supposed to explain consolidated billing," laments Bob Wardwell with the Visiting Nurse Associations of America (see Eli's HCW, Vol. XIV, No. 30, p. 235). "There are professionals in the field who barely understand it, but now we can teach it to a sick 80-year-old?" grouses Wardwell, a former top CMS official.
 
Other additions to the manual address: