by Julianne Haydel

Don’t Archive Your Agency


When the list of documentation required by AdvanceMed  for UPIC audits included a complete Medicare census, we were confused; or rather, we thought they were confused. Surely they can get their own lists based on any number of databases.
A report by the Office of the Inspector General reveals they are not confused. The OIG has noted that 9 of 28 agencies reviewed had discrepancies between Medicare data derived from claims and Casper and the list provided to surveyors at the time of state survey. It is this list that surveyors use to choose patient’s and they were not inclusive of all patients Medicare has on their lists.
Occasionally a difference of one or two patients can be explained. Many times a ‘missing’ patient is a typo -sloppy but not fraud. Changing out computer systems can be messy. Yet, when an agency presents a list to surveyors that is 150 patients light, equal to 90 percent of their patients, a very bad outcome is lurking on the horizon. Active patient lists that are incomplete ensure that absent patients are not visited by surveyors. In some cases, patients were omitted from the unduplicated census resulting in surveyors being unaware that the patient existed.
The OIG has arrived at the conclusion that while there are many possible reasons for these omissions, some agencies might be deliberately trying to avoid scrutiny for the omitted patients. Honestly, do you feel just a sorry for the OIG because they are only just now arriving at this conclusion?
The OIG also noted that patients were discharged from one agency on the day that the roster was requested by surveyors eliminating them from the ‘active patient’ list. These same patients were readmitted later in the year with no intervening events or claims from other providers such as hospitals, rehab facilities or other home health agencies. There are references a prior report that found frequent discharges and readmissions were often characteristic of fraudulent agencies.
The OIG suggests a couple of possible solutions to ensure that the list given surveyors has not been manipulated by the agency.
  • Instead of using an agency provided list, arm surveyors with a claims list provided by CMS
  • Spot check by asking an aide or a nurse about their patients and determine if all of those patients are on the agency provided lists.
  • Monitor the person in the agency who is running the list from the computer. Doesn’t this sound like fun for both the surveyor and the agency?
  • Conduct a retrospective review post survey using Medicare claims or Casper data.
Obviously you are not going to manipulate patient lists but it will instill confidence in surveyors if you are able to provide accurate information in a short period of time. Because surveys are unscheduled, multiple people should be trained to:
  • Run an active patient list
  • Run an unduplicated census (list of all patients regardless of the number of times they have been admitted. Each patient will be listed only once).
  • Run a duplicated census (the name of every admission regardless of whether the patient has been admitted more than once. This list is longer than the unduplicated census list.)
  • Speak intelligently about any potential flaws in your data and offer a work around. (Your biller should be able to provide a list of RAPs dropped or a referral log from the computer)
I know that agencies have rushed to ‘archive’ records of patients that who don’t have anything good to say about the agency and records that might be train wrecks due to documentation errors or poor care. Surveyors are very much aware that these patients exist. All agencies have at least one or two.
Unless care is egregious, state surveyors will allow the agency to provide a corrective action plan. If the deficiency is a repeat or widespread throughout the agency, you may be subject to financial sanctions and a hold on admissions until corrections are implemented and verified by the state agency.  It’s embarrassing to be certain but rarely fatal.
If you provide false information to the surveyors, you have crossed a line into a whole new level of non-compliance. Your Provider Agreement has been violated and you are at risk for losing your agency’s license or worse. And yes, there are consequences worse than being shut down because you have no license to operate.
Most agencies want to do the right thing. Knowing that the agency down the street with patients who do not need care or are not homebound and yet has a perfect survey while your agency has five or six deficiencies has been known to boil the blood of nurses but at least they know where to focus attention.
The agency that hides patients from surveyors now has a very real chance of being caught.  Depending on how patient lists are compared, it may take a while, too, contributing to insomnia.  If you have archived patients to avoid scrutiny, consider keeping a current passport handy. This could be fun.

 

by Julianne Haydel

Here We Go Again


A notification of the intent to re-implement the Pre-Claim Review process is being published today in the Federal Register.  The purpose, as stated in the notice, is to develop and improve methods to investigate and prosecute fraud in the home healthcare services.  In other words, Medicare wants you to send them evidence before you are even suspected of a crime. At its onset, agencies in Illinois, Ohio, Florida, North Carolina and Texas with the option to expand.

If there was even a chance that this burdensome, intrusive and expensive process would serve its stated process, my objections might not be so strong (but maybe they would).  Assuming that this process involves collecting the same information as the 2016/2017 demonstration, it is not likely identify or help in the prosecution of fraud. For those of you unfamiliar with the process, agencies had to gather and submit eligibility information for patients and submit it prior to billing the final claim.  (Palmetto GBA’s Guide to PCR submission) What’s even more amazing is that the United States Congress agrees with me.   

Here’s what they wrote in the Final Rule for the 2015 PPS update:

Each year, the CMS’ Office of Financial Management (OFM), under the Comprehensive Error Rate Testing (CERT) program, calculates the Medicare Fee-for-Service (FFS) improper payment rate. For the FY 2013 report period (reflecting claims processed between July 2011 and June 2012), the national Medicare FFS improper payment rate was calculated to be 10.1 percent.  For that same report period, the improper payment rate for home health services was 17.3 percent, representing a projected improper payment amount of approximately $3 billion.  The improper payments identified by the CERT program represent instances in which a health care provider fails to comply with the Medicare coverage and billing requirements and are not necessarily a result of fraudulent activity.

Worse than being ineffective, the proposed PCR project does not state goals of prevention of fraud, improvement of patient outcomes, or identification of opportunities for innovative approaches to home healthcare.   The process focuses on Face-to-Face information, documentation of homebound status, signatures and dates, and care plans. Nothing written here is meant to dismiss the importance of these statutory requirements but agencies who are fraudulently bent are coached by the CMS in how to get paid whether or not visits are being made or if the ordered care is given. Numerous checklists and examples could serve as a Fraud 101 primer.    It befuddles me that an undated signature may result in a denial or delay in payment but Medicare doesn’t understand that a fraudulent agency may document homebound status perfectly even when the details are contrary to reality.

But you do have a choice.  You can opt out of the PCR process.  It’s a condescending choice like when a toddler is told he can eat his vegetables or be sent to bed early with no dessert. Most kids will hold their nose and get the Broccoli down.  

Similarly, Medicare is giving agencies a choice to participate in PCR or suffer a 25 percent reduction in payment IF they are paid after a mandatory request for additional records (ADR).  So agencies will hold their nose and participate in PCR.

Agencies can also opt for a post payment review. In this scenario, you would submit information after being paid which means any errors found occurred prior to billing.  Undated signature? Denied. Then you will have an overpayment which will be recouped. There are few things worse than having money you already earned taken back. But agencies have a choice.

Agencies will be removed from PCR after they reach an unannounced target goal. If the purpose of PCR is accurately stated, how could the goal be less than 100 percent?  If a 90 percent target is set, that means that 10 percent of claims meet the categories of fraud, abuse or waste.  

What has never happened to the best of my knowledge is anyone being notified by the person reviewing a patient in the pre-claim review process of errors that might cost Medicare money. Just once I would like to see advice to an agency to include therapy because even though it was received in a prior admission, it’s worth another shot because the patient is having pain difficult to manage without opiates increasing the risk of falls and subsequent injury.  

Luckily, you don’t have to sit back and wait for the curtain to fall.  You have been invited to comment on the PCR process. Before you do, take a look at the document which was to have been included in today’s Federal Register.  As of now, it does not appear to be there.

Note that there are multiple ways to submit your comments.  Use them all. Tell your co-workers, bosses, employees and mother to read the memo and draw their own conclusions.  There is an ethical dilemma if you tell them how to feel about a political matter but providing a stamp won’t draw the attention of anyone.

Also note the title of the gentleman who signed the memo; Director, Paperwork Reduction Staff.  I couldn’t make that up if I tried.

The Coders will prepare comments for submission and share them with you. Please feel free to share your comments for or against the reimplementation of the Pre-Claims Review Demonstration.  And remember, you have options.

 

by Julianne Haydel

Conditions of Participation 2018 Home Health Aide Requirements


The section of the 2018 Conditions of Participation pertaining to home health aides is lengthy and detailed and there are good reasons for that.  It is common to read reports of elderly patients who are victimized by their in-home caregivers.  Most of these reports concern Personal Care Services where an aide is in the home for hours each day.  In 2012 report, the Office of the Inspector General called for stringent background checks and greater oversight of these programs.  Since then, over 200 investigations have been opened to ferret out the fraudulent providers and their employees.

Expect that your home health aide services will be scrutinized during survey and should any irregularities be uncovered, it is not a stretch of the imagination to expect that other investigations may result if gross non-compliance or negligence is found.  So, the real question is how do you comply to the letter with the home health aide conditions of participation and the standards that support them?

Here is the Condition and the supporting standards.

Condition §484.80:

All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section.

  • 484.80(a) Standard: Home health aide qualifications.

(1) A qualified home health aide is a person who has successfully completed:

(i) A training and competency evaluation program as specified in paragraphs (b) and (c)    respectively of this section; or

(ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or

(iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or

(iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section.

So there are four ways that an aide can be recognized as competent.  Number 2, according to the Interpretative Guidelines ‘assumes that candidate has had training in the past that addresses all or some of the topics in paragraph (b) of this section. The competency test must address all requirements in 484.80 (c).

Be aware that some states have more stringent requirements for home health aide qualifications.  When comparing federal and state requirements, the most stringent regulation is the one to which agencies will be held accountable.

(2) A home health aide or nurse aide is not considered to have completed a program, as specified in paragraph (a)(1) of this section, if, since the individual’s most recent completion of the program(s), there has been a continuous period of 24 consecutive months during which none of the services furnished by the individual as described in §409.40 of this chapter were for compensation. If there has been a 24-month lapse in furnishing services for compensation, the individual must complete another program, as specified in paragraph (a)(1) of this section, before providing services.

  • 484.80(b) Standard: Content and duration of home health aide classroom and supervised practical training.

(1) Home health aide training must include classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. Classroom and supervised practical training must total at least 75 hours.

(2) A minimum of 16 hours of classroom training must precede a minimum of l6 hours of supervised practical training as part of the 75 hours.

If you don’t provide a program for training, you will want something in writing that verifies that a training program followed these guidelines.

(3) A home health aide training program must address each of the following subject areas:

The following are paraphrased for brevity.  Please check the official guidance before making any changes to your policies and procedures.

  1. Communication skills including reading, writing and verbal skills
  2. Observation, reporting and documentation of patient condition and services provided
  3. Reading and recording temperature, pulse and respiration
  4. Infection prevention and control
  5. Elements of body functioning and changes that must be reported to the supervisor
  6. Maintenance of a clean, safe and healthy environment
  7. Recognition of emergencies and knowing emergency procedures and their application
  8. Understanding physical, emotional and developmental needs of patient population and how to work to address those needs including need for respect, patient privacy and patient property
  9. Appropriate, safe techniques in performing personal hygiene and grooming tasks including:
    1. Bed bath
    2. Sponge, tub, and shower bath
    3. Hair shampooing in sink, tub and bed
    4. Nail and skin care
    5. Oral hygiene
  10. Safe transfers and ambulation
  11. Normal range of motion and positioning
  12. Adequate nutrition and fluid intake
  13. Recognition and reporting of changes in skin condition, including pressure ulcers
  14. Any other task that the Home Health Agency assigns as permitted under state law
  15. The HHA is responsible for training home health aides, as needed, for skills not covered in the basic checklist, as described in paragraph (b)(3)(ix) of this section.

The new components are:

  1. Communication, including the ability to read and write
  2. Recognizing and reporting changes in skin condition
  3. Ensuring that the aide is trained before doing anything for which competency has not been assessed; example shaving a male patient (or even female)
  • 484.80(c) Standard: Competency evaluation.

An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section.

The competency consists of both oral and written examination.

  • 484.80(c)(1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (b)(3)(iii), (b)(3)(ix), (b)(3)(x), and (b)(3)(xi) of this section must be evaluated by observing an aide’s performance of the task with a patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient. The following skills must be evaluated by observing the aide’s performance while carrying out the task with a patient.

For your convenience, those tasks which must be observed directly during patient care (Subject areas specified under paragraphs (b)(3)(i), (b)(3)(iii), (b)(3)(ix), (b)(3)(x), and (b)(3)(xi)) are:

  • Communication skills including reading, writing and verbal skills
  • Reading and recording temperature, pulse and respiration
  • Appropriate and safe techniques in performing personal hygiene and grooming tasks that
  • include
    • (A) Bed bath;
    • (B) Sponge, tub, and shower bath;
    • (C) Hair shampooing in sink, tub, and bed;
    • (D) Nail and skin care;
    • (E) Oral hygiene;
    • (F) Toileting and elimination;
  • Safe transfer techniques and ambulation;
  • Normal range of motion and positioning

These tasks must be observed in their entirety to verify competency of the home health aide.  The use of mannequins or simulated activity is prohibited.

The Interpretative Guidelines state that the Competency for the remaining tasks may be demonstrated via written or verbal testing or during performance of the task.

(2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section.

To comply with this standard, you must also know what paragraph (f) says.  For your convenience, it is stated almost verbatim below:

 (f) Standard: Eligible training and competency evaluation organizations.

A home health aide training program and competency evaluation program may be offered by any organization except by an HHA that, within the previous 2 years:

(1) Was out of compliance with the requirements of paragraphs (b), (c), (d), or (e) of this section; (these are the standards and guidance about training, qualifications of the trainers and inservice training).

(2) Permitted an individual who does not meet the definition of a “qualified home health aide” as specified in paragraph (a) of this section to furnish home health aide services (with the exception of licensed health professionals and volunteers); or

(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or

(4) Was assessed a civil monetary penalty of $5,000 or more as an intermediate sanction; or

(5) Was found to have compliance deficiencies that endangered the health and safety of the HHA’s patients, and had temporary management appointed to oversee the management of the HHA; or

(6) Had all or part of its Medicare payments suspended; or

(7) Was found under any federal or state law to have:

  • Had its participation in the Medicare program terminated; or
  • (ii) Been assessed a penalty of $5,000 or more for deficiencies in federal or state standards for HHAs; or
  • (iii) Been subjected to a suspension of Medicare payments to which it otherwise would have been entitled; or
  • (iv) Operated under temporary management that was appointed to oversee the operation of the HHA and to ensure the health and safety of the HHA’s patients; or
  • (v) Been closed, or had its patients transferred by the state; or
  • (vi) Been excluded from participating in federal health care programs or debarred from participating in any government program.

(3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate.

Although other professionals such as therapists may assist in the competency evaluation of an aide, the ultimate responsibility defaults to the Registered Nurse.

(4) A home health aide is not considered competent in any task for which he or she is evaluated as unsatisfactory. An aide must not perform that task without direct supervision by a registered nurse until after he or she has received training in the task for which he or she was evaluated as “unsatisfactory,” and has successfully completed a subsequent evaluation. A home health aide is not considered to have successfully passed a competency evaluation if the aide has an “unsatisfactory” rating in more than one of the required areas.

(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met.

According to the Interpretative guidelines, documentation would include:

  • A description of the competency evaluation program, including the qualifications of the instructors;
  • Documentation that confirms that competency was determined by direct observation and the results of those observations.
  • Documentation that distinguishes between skills evaluated during patient care, and those taught in a laboratory, i.e. using a volunteer or combination of evaluation techniques including direct observation of patient care, skills lab demonstration, written and oral examinations.
  • How additional skills (beyond the basic skills listed in the regulation) are taught and tested if the admission policies and case-mix of HHA patients require aides to assist medically complex patients.

Question:  How many agencies have a ‘competency evaluation program’?

(d) Standard: In-service training.

A home health aide must receive at least l2 hours of in-service training during each 12-month period. In service training may occur while an aide is furnishing care to a patient.  Notice that the standard does not mandate one hour each month.

(1) In-service training may be offered by any organization and must be supervised by a registered nurse.

According to the Interpretative Guidelines, RN supervision means RN approval of the content and attendance at the presentation to ensure that the material is appropriate and consistent with the agency’s policies and procedures.

(2) The HHA must maintain documentation that demonstrates the requirements of this

standard have been met.

(e) Standard: Qualifications for instructors conducting classroom and supervised practical training.

 Classroom and supervised practical training must be performed by a registered nurse who possesses a minimum of 2 years nursing experience, at least 1 year of which must be in home health care, or by other individuals under the general supervision of the registered nurse. 

The Interpretative Guidelines list ‘others’ as follows:

  • Physical therapists;
  • Occupational therapists;
  • Speech and language pathologists;
  • Medical social workers,
  • LPN/LVNs; and
  • Nutritionists

 

The next standard is §484.80(f) Eligible training and competency evaluation organizations.  This standard was referenced above and the content was moved up so you wouldn’t be waiting with baited breath to find out who was and was not able to train and evaluate the competency of aides.

  • 484.80(g) Standard: Home health aide assignments and duties.

 (l) Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist).

 Patients are assigned a specific home health aide by design by considers the skills of the aide and, when possible, the preferences of the patient.  A nurse generally identifies the need for home health need services, but a therapist may determine a need for home health aide services in therapy only cases.  In therapy-only cases the therapist may create the plan of care for the home health aide and perform the supervisory visits.

  (2) A home health aide provides services that are:

 (i) Ordered by the physician;

(ii) Included in the plan of care;

(iii) Permitted to be performed under state law; and

(iv) Consistent with the home health aide training.

(3) The duties of a home health aide include:

(i) The provision of hands on personal care;

(ii) The performance of simple procedures as an extension of therapy or nursing services;

(iii) Assistance in ambulation or exercises; and

(iv) Assistance in administering medications ordinarily self-administered

The Interpretative Guidelines state (at this time) that Assistance in administering medications in this requirement means that the HH Aide may take only a passive role in this activity. This assistance is limited to getting water or fluids for the patient to take their medication.

(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient’s condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA’s policies and procedures.

 When an aide is assigned to a patient, it is likely they know a lot about the patient.  Much of this information is not written down due to the formatting of the home health aide documentation tools in your software or the hard copy notes.  Furthermore, home health aides may have limited ability to communicate in writing.  Although they must have the skills to document vital signs, etc., expressing a complex thought in writing is often difficult.  Nurses and therapists should speak often with the home health aides caring for their patients and encourage an open line of communication.  And, home health aides should always be present at team conferences.

  • 484.80(h) Standard: Supervision of home health aides. 
  • If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient’s home no less frequently than every 14 days. The home health aide does not have to be present during this visit.
  • If an area of concern in aide services is noted by the supervising registered nurse or other appropriate skilled professional, then the supervising individual must make an on-site visit to the location where the patient is receiving care in order to observe and assess the aide while he or she is performing care.
  • A registered nurse or other appropriate skilled professional must make an annual onsite visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care.

This is new.  It can be condensed as saying that if a problem is found during a supervisory visit, the supervising nurse must return when the aide is performing services to assess the situation.

In the absence of any problems where the supervising nurse accompanies the aide to the house, an onsite visit must be made annually.   Neither the CoP’s or the Interpretative Guidelines specify whether this is per patient or per home health aide.  An annual onsite visit with each aide is a good idea and can be combined with competency testing should you keep no patients on service longer than one year.

(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care.

(3) If a deficiency in aide services is verified by the registered nurse or other appropriate skilled professional during an on-site visit, then the agency must conduct, and the home health aide must complete a competency evaluation in accordance with paragraph (c) of this section.

(4) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements:

 Following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional;

  • Maintaining an open communication process with the patient, representative (if any), caregivers, and family;
  • Demonstrating competency with assigned tasks;
  • Complying with infection prevention and control policies and procedures;
  • Reporting changes in the patient’s condition; and
  • Honoring patient rights.

This is considerably different from the check off boxes used in most forms that document that the aide is dressed appropriately and shows up on time.   The person making the supervisory visit is expected to document how these elements were evaluated.  During the routine supervisory visits without the aide present, the six factors listed above must be evaluated.  When the aide is present for the visit, only one through four are documented.

The Interpretative Guidelines further describe ‘maintaining an open communication’ process.  The aide should be able to explain what he or she is doing to the patient, ask the patient open ended questions, seek feedback from the patient and representative (if any), caregivers and family.

(5) If the home health agency chooses to provide home health aide services under arrangements, as defined in §1861(w)(1) of the Act, the HHA’s responsibilities also include, but are not limited to:

  • Ensuring the overall quality of care provided by an aide;
  • Supervising aide services as described in paragraphs (h)(l) and (2) of this section; and
  • Ensuring that home health aides who provide services under arrangement have met the training or competency evaluation requirements, or both, of this part.

This standard does not apply to most of you but if you only have sporadic needs for aide services, it might be a future consideration.  Alternatively, if you have a large agency, it may be an idea to offer aide services under arrangement to smaller agencies.

484.80(i) Standard: Individuals furnishing Medicaid personal care aide-only services under a Medicaid personal care benefit.

An individual may furnish personal care services, as defined in §440.167 of this chapter, on behalf of an HHA. Before the individual may furnish personal care services, the individual must meet all qualification standards established by the state. The individual only needs to demonstrate competency in the services the individual is required to furnish.

That’s it, folks and it is more than enough.  Medicare has raised the bar for home health aide services and your aide services will be at risk unless you raise the bar in your agency.

I wish the changes were not so lengthy and I wish they were more interesting, but they are important.  Read them.  Call us for help, if needed.  If you step up to the plate, your patient care will improve.

by Julianne Haydel

Conditions of Participation… Professional Requirements


This week’s Condition of Participation involves Professional Services.  These are common practice and similar to what is in place in your agency anyway.   There are new requirements for the Administrator and a new position called ‘Clinical Manager’.  The requirements are linked in the post.  Adjust your job descriptions and a review of the Medicare Benefit Policy Manual, chapter 7 would be a good idea.

The Condition is pasted below followed by the standards that will be surveyed to verify compliance.

484.75 Condition of Participation: Skilled professional services.

Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician and medical social work services as specified in §409.45 of this chapter.

Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care.

This Condition is written as though you know all about subsections 409.44 and 409.45 but in case you do not, you can click the links.

Not to be confused with official guidance from Medicare, here’s an abbreviated summary of what you already know:

Skilled nursing services are those skills which can only be performed by a nurse.  Coverage is determined by the complexity of the skill as well as the condition of the patient.  If the skill could be performed by the average Joe, it would not be considered skilled.  The Medicare Benefit Policy Manual is our favorite source for researching skilled nursing services.

Physical Therapy skills must be of a nature that they can only be performed safely by a skilled therapist.  In determining if therapy is skilled, determine if the Jimmo ruling of 2013 applies.

Medical Social Workers provide services ordered by the physician to address emotional and social needs that may interfere with the patient’s ability to respond to the plan of care or the agency’s ability to carry out the plan of care.  According to the Interpretative Guidelines, they are furnished ‘on a short-term basis and it can be demonstrated that the service is necessary to resolve a clear and direct impediment to the effective treatment of the beneficiary’s medical condition or to his or her rate of recovery’.

The standards that demonstrate compliance should be familiar to you even if you did not know they were a part of the Conditions of Participations.

The first standard reads:

484.75(a) Standard: Provision of services by skilled professionals.

Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures.

The appropriate qualifications are in another section, so we made a quick cheat sheet.  The information is straight forward except for physical and occupational therapists.  Each of these therapists have provisions for states that do not have licensing laws.  A quick search of the web revealed that all states require licensing so if you stick with licensed therapists in your state, you should be okay.

There is also a provision in this condition that professional services are provided according to the agency’s policies and procedures.  This includes contracted therapists so be sure to share relevant policies with contractors and include them in compliance training.

484.75(b) Standard: Responsibilities of skilled professionals.

Skilled professionals must assume responsibility for, but not be restricted to, the following:

  1. Ongoing interdisciplinary assessment of the patient;

The interpretative guidelines define ‘interdisciplinary’ as an approach to healthcare that includes a range of health service workers, both professionals and non-professionals, with the majority being from professional groups. Ongoing interdisciplinary assessment is the continual involvement of all skilled professional staff involved in the plan of care from the initial assessment through discharge and periodic interactive, discussions regarding the status and recommendations for the plan of care. The interdisciplinary approach recognizes the contributions of the disciplines (MDs, RNs, LPN/LVN, PT, OT, SLP, MSW, HH aides) and their interactions with each other to meet the patient’s needs.

The Coders recommend weekly or bi-weekly case conferences where patients approaching the end of their episodes are discussed in a meaningful way by all involved disciplines.  Any patients who have significant changes in their condition or treatment plans can be added to the list.  It also means documentation of any casual discussions you may have with other agency employees or physicians.

  1. Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); 
  1. Providing services that are ordered by the physician as indicated in the plan of care; 
  1. Patient, caregiver, and family counseling; 
  1. Patient and caregiver education; 
  1. Preparing clinical notes;
  1. Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; 
  1. Participation in the HHA’s QAPI program; 
  1. Participation in HHA-sponsored in-service training 

Some of these criteria will be discussed in subsequent parts of the Conditions of Participation so don’t worry if one or more confuses you.

Supervision

Supervision is the focus of the next standard supporting the condition involving Skilled Services.  There are numerous references made to §484.115; our little cheat sheet referenced above with personnel qualifications. 

484.75(c) Standard: Supervision of skilled professional assistants

This is a generic supervision standard that applies to therapy assistants, LPN, etc.  As such, it does not include a time frame or the criteria for supervision.  Oversight is usually guided by the practice standards for each discipline.  Additionally, there must be written instructions for these assistants and you can expect that they will be surveyed.

484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k).

484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(e, f) or (g, h), respectively. 

Please note that therapists can only supervise assistants within their disciplines.  Occupational Therapy must supervise Occupational Therapy assistants, etc.

484.75(c)(3) Medical social services are provided under the supervision of a social worker that meets the requirements of §484.115(m).

Home Health Aide services, training and competency are soon to follow.  Meanwhile if you have any problems with the Professional Services information, feel free to drop us a line.

by Julianne Haydel

CoP’s Continued…. Infection Control


Clean Hands Count

Historically, there have been very few studies concerning infection control and home Visits.  The work environment is the patient’s home and there is only so much we can do to control it.   We don’t have a housekeeping department to mop up our messes with industrial strength cleaning agents like hospital nurses.  We cannot fire other family members if they don’t wash their hands and what about those pets who jump on the bed after being outside?

One idea is to simply give up.  A better idea is to recognize that without a clean-up crew and a controlled environment, Infection Control is more important than ever.  And, since the new Conditions of Participation you must implement a program by mid January 2018,  the latter option might be best.

The condition is straight forward.  Here it is for reference.

The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases.

The reason Infection Control is getting an entire blog post to itself even though technically it is part of the QA Condition is because the Interpretive Guidelines list specific components that your surveyors will be assessing.  They include six components identified by the CDC as being relevant in the home.

  1. Hand Hygiene;
  2. Environmental Cleaning and Disinfection;
  3. Injection and Medication Safety;
  4. Appropriate Use of Personal Protective Equipment;
  5. Minimizing Potential Exposures; and
  6. Reprocessing of reusable medical equipment between each patient and when soiled.

Not only should your plan address all six of these issues, but they should be evident in practice.

Hand Hygiene

The Interpretive guidelines advise agencies that handwashing should occur:

  1. Before contact with a patient;
  2. Before performing an aseptic task (e.g., insertion of IV, preparing an injection, performing wound care);
  3. After contact with the patient or objects in the immediate vicinity of the patient;
  4. After contact with blood, body fluids or contaminated surfaces;
  5. Moving from a contaminated-body site to a clean body site during patient care; and
  6. After removal of personal protective equipment (PPE);

Alcohol based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers most of the time. Antiseptic soaps and detergents are the next most effective and non-antimicrobial soaps are the least effective.  Bars of soap are so retro that they really don’t deserve much attention except that you might still find them in patient homes.

When hands are not visibly dirty, alcohol based hand sanitizers are the preferred method for hand hygiene. The agency must ensure that supplies necessary for adherence to hand hygiene are provided.  However, be careful if you have a patient diagnosed with Clostridium Difficile as hand sanitizers are not effective.  Gloves must be worn.

Environmental Cleaning and Disinfecting

The interpretive guidelines recognize that you have little control over the tidiness and disinfection in another person’s home.  However, they do state that the home health personnel ‘must maintain their equipment and supplies clean, during the home visit, during transport of reusable patient care items in a carrying case in the staff vehicle and for use of the items in multiple patients’ homes.’  Thus, your primary focus is on your supplies and equipment.

Safe Injection Practices

Safe injection practices include:

  1. Use aseptic technique when preparing and administering medications;
  2. Do not reuse needles, lancets, or syringes for more than one use on one patient; Use single-dose vials for parenteral medications whenever possible;
  3. Do not administer medications from a single-dose vial or ampule to multiple patients;
  4. Use fluid infusion and administration sets (i.e intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use;
  5. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to patient’s intravenous infusion bag or administration set;
  6. Enter medication containers with a new needle and a new syringe even when obtaining additional doses for the same patient;
  7. Insulin pens must be dedicated for a single patient and never shared even if the needle is changed;
  8. Sharps disposal should be in compliance with applicable state and local laws and regulations.

Since none of you would dream of reusing or sharing equipment, your attention is needed at number 8.  Know your state and local laws and regulations about disposal of sharps.  Frankly, it is a little insulting that someone thought they had to tell home health nurses that they shouldn’t use insulin pens or IV sets on more than one patient.

Appropriate Use of PPE

This refers to the gear used as a barrier against infection.  The idea is that any contaminants thrown your way will hit your PPE and be disposed of as you leave the patient room.  Examples include gloves, gowns, masks, and eye protection depending on the nature of the potential threat.

Although it is not clearly spelled out, it is in inherent in any regulation about PPE that the staff understand how to use it.  It is not as easy as it looks and taking it off is even more difficult.  Do you remember the nurse, Nina Pham who contracted Ebola in a Dallas Hospital?   She might tell you to take every advantage to learn about PPE.

Minimizing Potential Exposures

This focuses on the protection of the family members, other caregivers and visitors and the transmission of pathogens while transporting specimens and medical waste such as sharps.  There isn’t much written on it in the interpretive guidelines or Conditions of Participation probably because each patient and family are in a different situation.  Nobody catches arthritis by breathing the same air as a patient but patients with contagious diseases need to be assessed and plan put into place that is specific to the nature of the patient’s contagious condition.

Reprocessing (cleaning and disinfecting) of Reusable Medical Equipment is essential.

Reusable medical equipment (e.g., glucose meters, INR machines and other devices such as, blood pressure cuffs, oximeter probes) must be cleaned/disinfected prior to use on another patient and when soiled. The HHA must ensure that staff are trained to:

  • Maintain separation between clean and soiled equipment to prevent cross contamination; and
  • To follow the manufacturer’s instructions for use and current standards of practice for patient care equipment transport, storage, and cleaning/disinfecting.

There must be documentation that the staff has been trained.  To minimize the resources spent on training, an agency might limit the purchase of machines such as INRs and blood glucose machines to one or two brands so the instructions don’t change.  If, like many agencies, you opt to use the patient’s equipment whenever possible, be sure that patients know how to use and maintain their equipment.

The next standard is:

The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include:

Surveillance

According the Interpretative guidelines, The HHA infection control program should ‘use observation and evaluation of services from all disciplines to identify sources or causative factors of infection, track patterns and trends of infections, establish a corrective plan, and monitor effectiveness of the corrective plan.’

In other words, you should task all disciplines with looking for infections, their underlying cause and any trends.  A plan should be established to address any trends or patterns and the agency will monitor effectiveness.

The Interpretative Guidelines suggest the following activities be used in your surveillance:

  • Clinical record review;
  • Staff reporting procedures;
  • Review of laboratory results;
  • Data analysis for physician and emergency room visits for symptoms of infection; and
  • Identification of root cause of infection through evaluation of HHA personnel technique and selfcare technique by patients or caregivers.

More specifically, we suggest:

  • New orders for antibiotics
  • Hospitalizations for suspected infection
  • Deteriorating wounds
  • Fever – most computer systems have a trendline for temperature over time. Look for spikes.

If you have any other suggestions, please share them.

Now that you know who has been infected, an analysis should occur.  The easiest way to do this is to enter your numbers on a spreadsheet and then make a graph out of them.  If you are not friends with MS Excel, you can do the same thing manually.  Depending on the type of graph, you may see spikes, clusters or other indicators that ‘one of these things is not like the other’.

Put a plan into place that will address any variations in data or infections that might have arisen from your care or have been prevented by your care.  Instead of asking what your agency did wrong, consider what could have been done better.

Write down the steps that are needed to address any areas that could be approved.  Assign them to appropriate staff.  The agency does not have to break new ground in the science of infection control.  The tools and knowledge are there.  Use them.

Monitoring results is the missing step in many infection control programs.  When you write your plan that includes specific activities, include the frequency and method of monitoring results.  This will allow the agency to rapidly respond to any increase in infections that occur despite your well executed plan.  This is not failure, by the way.  Recognizing that a plan isn’t working and calling an impromptu meeting to make changes before your regular meetings is how good Infection Control Programs are managed.

When positive results are noted, they should be shared.  You have asked your nurses to participate in your Infection Control Program.  Let them know when their hard work has netted results.

The last standard in Infection Control concerns training and education.

The HHA must provide infection control education to staff, patients, and caregiver(s).

The interpretive guidelines are clear on what is expected:

HHA staff education should include as a minimum:

  • Appropriate use, transport, storage, and cleaning methods of patient care equipment according to manufacturer’s guidelines and receive the following provide the following for staff education:
  • Job-specific, infection prevention education and training to all healthcare personnel for all of their respective tasks;
  • Processes to ensure that all healthcare personnel understand and are competent to adhere to infection prevention requirements as they perform their roles and responsibilities;
  • Written infection prevention policies and procedures that are widely available, current, and based on current standards of practice;
  • Training before individuals are allowed to perform their duties and periodic refresher training as designated by HHA policy;
  • Additional training in response to recognized lapses in adherence and to address newly recognized infection transmission threats (e.g., introduction of new equipment or procedures);
  • Provide in-service infection control education for staff at periodic intervals (minimally annually) consistent with accepted standards of practice, such as: at orientation, annually, and as needed to meet the staffs learning needs to provide adequate care, identify infection signs and symptoms, identify routes of infection transmission, appropriately disinfect/sanitize/transport equipment and devices used for the patient’s care, medical waste disposal, including instructions on how to implement current infection prevention/treatment practices in the home setting.

It might be that Medicare is serious about Infection Control.  What do you think?

There is a plethora of tools on the internet to help with Infection Control.  As time allows, we will post links to some of them.  Many agencies have Infection Control programs that are outdated or not implemented and some of them are frankly too confusing to follow.   Simplify instead of complicate what is in place.  Put your real efforts into preventing and monitoring infections and let your computer do the data collection.

One approach that has a 100 percent chance of failure is writing or buying a pretty binder and keeping on the shelf between surveys.  The plan should be available and have clear instructions for anyone with a question.  The number of pages your plan has irrelevant.  The effectiveness of the program is where you should focus your efforts.

If you need any help designing and implementing an infection control program or any or all of the Conditions of Participation, you know who to contact.  We’re ready and willing to help.