Home Health & Hospice Week

Verbal order clarification a boost.

You don’t have to worry about one troubling change Medicare had proposed for the Home Health Conditions of Participation, the CoP final rule shows.

Reminder: In the proposed CoPs the Centers for Medicare & Medicaid Services published in October 2014, CMS wanted to require home health agencies to provide the patient with a copy of the Plan of Care, recalls Judy Adams with Adams Home Care Consulting in Durham, N.C. Commenters on the proposed rule barraged CMS with many reasons why that requirement was a bad idea, ranging from the fact that patients and their families wouldn’t understand the medical jargon-filled technical document to the logistical difficulty of printing out a copy in the field.

Not to mention: Leaving a hard copy POC in the patient’s home would have been “a major PHI issue,” Adams adds.

In light of the many arguments against the practice, CMS has dropped the requirement (see box, p. 20).

Other bright spots in the CoP final rule include:

• Verbal orders. CMS had proposed that RNs must document verbal orders. But in the final rule, the agency allowed that “there is no health and safety-related reason to prohibit a LPN from receiving and documenting verbal orders because LPNs have the necessary training and skill to perform this function. Therefore, we agree that it is appropriate to allow LPNs to receive verbal orders as long as the LPN is acting within his or her state licensure requirements and permitted in accordance with state scope of practice.” Hospitals and hospice inpatient facilities already permit LPNs to receive verbal orders if the state and their own policies allow it. “We have revised the regulation text at §484.60(b )(4) to reflect this change,” CMS says.

“It is … a big deal that any nurse can take a verbal order — this will allow agencies to make better use of LPNs,” says Chicago-based regulatory consultant Rebecca Friedman Zuber, former home health survey director in Illinois.

• Changes from proposal. A number of changes between the proposed and final rule “resulted from input from home health agencies and other stakeholders offering suggestions and the responsiveness of CMS to listen,” Adams cheers. Those include removing the requirements: to provide contact information to the administrator for complaints and to provide a copy of admission policies. Other examples are clarifying that discharge is appropriate when the physician and agency agree that the patient has achieved the established goals in the individualized plan; clarifying agencies must report mistreatment, abuse, neglect, etc. in accordance with state law requirements (since these vary among states); and revising language that all of the written instructions, visit schedules, etc., apply to all patients without grading patient needs at low, medium and high, Adams adds (see specific provisions, p. 20).
• The underlying philosophy. The shift in focus from processes to outcomes and patients should result in better quality care, experts hope.
• Flexibility. The new CoPs’ “generalized flexibility on compliance” is one of the rule’s biggest benefits to HHAs, judges William Dombi with the National Association for Home Care & Hospice. One example is leaving HHAs to determine their own QAPI project topics (see story, p. 19).
• Patient rights form. CMS reassured commenters that they won’t have to achieve impossible goals with their new patient rights notices, language- wise. “We do not have the expectation that HHAs will be presenting a translated patient rights document to every single patient in their native language when they are admitted and before they begin receiving care,” CMS clarifies in the final rule. “We expect HHAs to utilize technology, such as telephonic interpreting services ... for oral communication in the patient’s primary or preferred language prior to the completion of the second skilled visit. The flexibility that is built into this requirement, allowing the use of technology, remote interpretation services, and patient-selected interpreters should accommodate most situations, alleviating potential concerns regarding an ‘unforeseen inability’ to communicate with patients in advance of furnishing services.”
• Multiple physicians. The new CoPs include “recognition that multiple physicians are likely to be providing orders for care,” Friedman Zuber says.

Note: For tips on CoP compliance preparation, see a future issue of Eli’s Home Care Week.