Home Health & Hospice Week

But not every new frequently asked question is as helpful.

Home health agencies are welcoming some of the new guidance released in a frequently asked question set about the Home Health Conditions of Participation that took effect a year ago.

A few FAQs on verbal orders and plan of care requirements are a good reiteration to keep agencies out of survey trouble.

Question: If an additional service is added after the initial plan of care has been approved by the responsible physician (e.g. therapy only then adds nursing), what documentation must be completed to add the additional service? Would a separate plan of care be developed for the new service?

Answer: “Patients receive services under a single plan of care that includes all services,” the Centers for Medicare & Medicaid Services says in the FAQs released in a Jan. 23 letter to State Survey Agency directors. “The initial plan of care would need to be updated adding the new service and be signed by the responsible physician. This may be completed using a verbal order with the plan of care being signed by the physician at the time of recertification. See §484.60.”

A second FAQ addresses the point as well.

Question: Is the expectation that a new plan of care (or CMS-485) is sent to the physician responsible for the HHA plan of care each time a verbal order is received in order to meet compliance with §484.60(a)(3)?

Answer: “No. The plan of care does not need to be re-issued and signed by the responsible physician with every verbal order,” CMS says. “The HHA must authenticate and incorporate the order into the plan of care but [the] plan does not need to be resigned by the responsible physician until the patient is recertified to continue care or is discharged. See §484.60(a)(3).”

Attorney Robert Markette Jr. with Hall Render in Indianapolis appreciates the emphasis of this important point. The “provider does not need to reissue a POC with each verbal order,” Markette notes. “The POC document is updated and signed by the physician at the time of recertification. In the period between cert and recert, properly documented verbal orders are sufficient.”

The final Interpretive Guidelines for the new CoPs released last August contained a new clarification, compared to the draft IGs, that also made this point. Under tag G576, CMS said that “all patient care orders, including verbal orders are part of the plan of care. The plan should be revised to reflect any verbal order received during the 60 day certification period so that all HHA staff are working from a current plan. It is not necessary for the physician to sign an updated plan of care until the patient is recertified to continue care and the plan of care is updated to reflect all current ongoing orders including any verbal orders received during the 60 day period.”

“I think we were all clear on that from the IGs,” Markette tells Eli. “But it is nice to have this reiterated in several answers” in the FAQs, to head off any surveyor confusion.

HHAs Still Figuring Out Missed Assessments

Not all the FAQs are as beneficial as those about verbal orders and POCs, however. A number of questions confirm additional challenges for HHAs (see details on aide competency testing, Eli’s HCW, Vol. XXVIII, No. 5), or are just confusing.

For example, a FAQ about missing the initial assessment timeframe is not particularly helpful, judges Julianne Haydel with Haydel Consulting Services and The Coders in Baton Rouge, Louisiana.

Question: What should an HHA do if it cannot meet the timeframe for the initial assessment?

Answer: “If the HHA anticipates that it cannot meet this timeframe, it should not accept the patient for services,” CMS responds. “In instances where the patient requests a delay in the start of care date, the HHA would need to contact the physician to request a change in the start of care date and such change would need to be documented in the medical record. See §484.55(a)(1).”

That is all true, Haydel allows. But HHAs really need guidance on what to do when they don’t know they are going to miss the timeframe, but do, she contends.

“Most of the time, the 48-hour deadline is missed because of unforeseen circumstances,” Haydel explains. “Maybe nurse is on her way and gets a call about an emergency at home late in the afternoon of the second day, for example. Because she is distraught, she doesn’t notify the agency until the next morning.”

Agencies often aren’t sure what to do regarding CoP compliance in that scenario. “Getting an order from the physician is inappropriate because there was no MD order,” Haydel says.

“The agency could choose to admit the patient the next morning,” she offers. “The physician should be notified that the agency failed to follow orders and if this is a regular occurrence, the agency can expect it to show in their outcomes. The first three weeks are critical and the agency can address the possibility of unforeseen misadventures in their staffing, scheduling, etc.”

How a surveyor will view such instances is still unclear — and could result in negative survey results.

Note: See the FAQs online at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/AdminInfo19-07-HHA.pdf.