Tag / Compliance

by Julianne Haydel

Ding!


A client just received their certification report and it was good but not deficiency free as they had been in the past.  The reason?  Although the risk factors for hospitalization were pulled from the OASIS assessment, they were not identified on the Plan of Care as risk factors for hospitalization.  The interventions were similarly not tied to the risk factors even though they did address them.  The DON reported that she talked to a friend at another agency and learned that the other agency had received the very same tag.  Coincidence or survey trend?  Time will tell.  For now, smart agencies will go with ‘survey trend’ as their final answer.

The Condition of Participation is §484.60(a)(2).  It reads:

(2) The individualized plan of care must include the following:

  1. All pertinent diagnoses;
  2. The patient’s mental, psychosocial, and cognitive status;
  3. The types of services, supplies, and equipment required;
  4. The frequency and duration of visits to be made;
  5. Prognosis;
  6. Rehabilitation potential;
  7. Functional limitations;
  8. Activities permitted;
  9. Nutritional requirements;
  10. All medications and treatments;
  11. Safety measures to protect against injury;
  12. A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors.
  13. Patient and caregiver education and training to facilitate timely discharge;
  14. Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient;
  15. Information related to any advanced directives; and
  16. Any additional items the HHA or physician may choose to include.

This is a new requirement included in the 2018 Conditions of Participation.  It’s something that (hopefully) has been done by agencies in the past but risk factors haven’t always been labeled.  The requirement is consistent with the CMS goal of avoiding unnecessary admissions.

There are no instructions on how to do this.  Prior to the final regulations, the proposed regs suggested stratifying patients as high, medium or low risk.  That was omitted from the final rule.  From the 2018 CoPs:

While there may be benefits to establishing more inter-HHA consistency in the application of this requirement, we do not believe that those benefits would outweigh the cost of reducing HHA flexibility and innovation to determine the best possible way to achieve the overall goal of reducing unnecessary emergent care visits and hospital admissions.

The OASIS question that examines risk factors for hospitalization is M1033 reads:

(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)

  •  History of falls (2 or more falls – or any fall with an injury – in the past 12 months)
  •  Unintentional weight loss of a total of 10 pounds or more in the past 12 months
  •  Multiple hospitalizations (2 or more) in the past 6 months
  •  Multiple emergency department visits (2 or more) in the past 6 months
  •  Decline in mental, emotional, or behavioral status in the past 3 months
  • Reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) in the past 3 months
  •  Currently taking 5 or more medications
  •  Currently reports exhaustion
  •  Other risk(s) not listed in 1–8
  •  None of the above

Additionally, M1036 looks at smoking, obesity, alcohol dependency and drug dependency.  There is a falls risk assessment which may score high in patients who have not fallen in the last 12 months such as those who had a recent hip replacement.  Depression is assessed and is known to impair recovery in most illnesses and conditions but is not included in the question specific for risk factors unless it has an onset within 3 months.

Some of the most dangerous risks to our patients are not captured by OASIS at all.

  • Elderly patients living alone in a rural area
  • Patients unable to afford or prepare food; may have frequent interruptions in utilities due to financial limitations.
  • Transportation or willing caregiver to pick up medications.
  • Functionally illiterate patients

It is possible that drawing in some information from OASIS might meet the condition, but it may not serve the patient.  On the other hand, it is highly unlikely that you would be hit with a survey deficiency if you included risk factors that were based on a full assessment even if they are not included in the OASIS assessment.

You won’t find many interventions to address isolation, depression and lower socioeconomic status in care pathways for other conditions, but they are equally as important for some patients as falls precautions which are ordered for pretty much everyone.  It may cost a little more but in the long run, lower hospitalization rates will correspond with higher margins.

The CoP’s mandate that care plans include patient risks for hospitalizations and Emergency Room visits and corresponding interventions to mitigate the risks.  Since you must do it, make it meaningful.

Contact us if you need help setting up a system for this or if you would have us review your careplans for you.

by Julianne Haydel

Home Health Denials


During January to March of this year, the top reasons for denial for Home Health Palmetto GBA claims were published on their website as listed below. They can be confusing in their meaning and so we have attempted to clarify as we understand them.  Without further ado:

56900—Medical Records not received
This has been the number one reason for denials for years. This occurs most often when an ADR is not seen in the system.  Alternatively, it is noticed too late to get records together and sent. To avoid this denial:

CGS encourages providers to use the Fiscal Intermediary Standard System (FISS) to check for MR ADRs at least once per week. To check for MR ADRs,
in the FISS system:

  1. Use Option 12
  2. Enter your NPI number and status/location of ‘S B60001’
  3. ADRs will appear as reason code 39700
  4. The ADR date is in the upper left corner.  45 days from the date of the ADR
    date the claim will auto cancel.

In addition to the above, we suggest:

  1. Uploading the documents when you are able.
  2. Mail the documents with proof of delivery requested.
  3. Track delivery.
  4. Retain copies of everything including the completed ADR.  If you sent by overnight mail five days before the due date and the records are not there two days later, you will have the opportunity to resend.
  5. Use the address and mail code on the ADR.  This is on the last page of the printed document and may differ from the return address on the first page.
  6. Print the ADR from the computer and include a copy with Your submitted documentation.

5FF2F Face to Face Requirements not Met

This should be easy by now but it’s still confusing. Our favorite cheat sheet is the PDF on CGS’s website. Additionally, we see denials that can be prevented by being mindful of the following:

  1. Regardless of the episode within the sequence of multiple episodes, the Face-to-Face document must be included even if it occurred six or more months ago.
  2.  The physician clinic visit or hospital documentation will be used to establish eligibility.
  3. If the information sent by the doctor does not clearly indicate that the patient is confined to the home or the need for skilled services, the agency can supplement the information.  Here’s how.  Send you Admission OASIS to the physician with a request to sign and date it, make a copy, file one in his records and return the copy to you.
  4. Teach everyone in the agency how to evaluate Face-to-Face documents.  You should never come into contact with one without reviewing it.

5F023 No Plan of Care

It is a rare event that an agency omits the plan of care from an ADR.  When an ADR is denied for not having the plan of care, agencies often assume that the mistake is on the part of the reviewer. Look again.  Often this means:

  1. The plan of care was not signed.
  2. The plan of care was signed by a Nurse Practitioner or Physician Assistant
  3. A different physician than the one listed on the plan of care signed it.
  4. The signature was not dated although there is a seperate code for this.
  5. The date of the signature was after the date of billing.

5CHG3 Partial Denial of Therapy

A reviewer will often deny visits based upon an arbitrary number of feet that a patient can walk or problems with individual notes. Because therapy adds significantly to the dollar amount of a claim, these services are an opportunity for Medicare contractors to save a few Medicare dollars at your expense. To avoid these denials:

  1. Document not only how far the patient ambulated but how they tolerated the ambulation.
  2. Take pre and post vital signs.  Document balance and gait disturbances.
  3. Always document pain and discomfort in quantitative measures.
  4. Document any complaints or new orders not related to therapy and report them to the case manager.  Follow up in writing.
  5. Most importantly, request a case conference and schedule discharge when the patient no longer needs therapy.

5FNOA – Appropriate OASIS not submitted

This code means that the OASIS was not found in the repository when the claim was billed.  Palmetto GBA explains this denial code as follows:

Under the HHPPS, an OASIS is a regulatory requirement. If the home health agency does not submit the OASIS, the medical reviewer cannot determine the medical necessity of the level of care billed and no Medicare payment can be made for those services.

Since this list was generated from 2018 claims, it is unlikely that agencies would receive this denial code in response to an ADR because they are auto-rejected upon dropping the claim.  Yet, this reason for denial is ranked fifth.  If you have received a denial for reason code 5FNOA in response to records submitted in response to an ADR, please let us know.

5T072 – No physician Orders for Services

This denial refers to services provided in excess of what the MD ordered, or services provided before an order was obtained.  This is frequently seen when a physician orders PT to evaluate the patient but there are no subsequent orders. It may also be related to the date next to the nurse’s signature on the plan of care.  Nurses new to reviewing and signing plans of care will often date their signature with the date that the document was signed instead of the verbal SOC date.

To prevent this denial:

  1. If possible (and it should be possible), include therapy frequency on the plan of care.
  2. Consider amending your standard therapy contract to state that the agency will not pay for unauthorized visits.
  3. If the therapist includes the frequency and goals on the evaluation and that is signed by the MD, make a second copy to include with orders when an ADR is received.
  4. Educate and spot check the POCs of new case managers.  If a plan of care is not complete by the first day of the episode and the nurse contemporaneously dates his signature, all days prior to the date indicated are not billable as there are no signed orders.
  5. The same signature and dating rules apply to MD signatures on interim orders.
  6. The correct way to write an order that was received earlier is:
    1. Date the document on the day it was written
    2. Begin the order with, ‘Effective on (the date you received the order)
    3. Date your signature when you signed the document.

5F041-Information does not support medical necessity

This denial is listed twice with the same code.  It is also the easiest one to avoid when clinicians understand and appreciate the importance of their documentation. To avoid this denial:

  1. Read and distribute chapter 7 of the Medicare Beneficiary Coverage Manual.  Review specific topics at case conference.
  2. As much as possible document in the home.  Some patients complain that the nurse spends too much time focusing on the computer.  To prevent that, as you are finishing up, ask the patient if you can sit and document before you leave.  That way, you are not taking your attention away from the patient and if you forgot anything, you are still in the home.
  3. Display some clinical notes that are truly impressive as examples.
  4. Turn off the ability to cut and paste if duplicate notes by a nurse are found.
  5. Read The Z-Factor on the Haydel Consulting Services blog.
  6. If your job is to review notes, focus on what is important. Medicare does not pay for spelling and grammar and there is little virtue in embarrassing your nurses.  Focus on the contents of chapter 7.

Remember that the best reason to document is to communicate the condition of the patient to other clinicians.  You don’t have the luxury of shift change report.

5T070 – Visits/Supplies/DME Billed Not Documented/Not Documented As Used

Although this code includes visits, supplies and DME, Palmetto GBA’s explanation of this denial appears to be limited to visits.

The services(s) billed (was/were) not documented in the medical records submitted in response to the Additional Development Request (ADR). As a result, medical necessity for these services could not be determined.

It looks very similar to a denial for medical necessity.  Palmetto GBA advises:

To avoid unnecessary denials for this reason, the provider should ensure that adequate documentation is submitted to substantiate the medical necessity for all the services billed when responding to an ADR. The provider may submit discipline visit notes and/or a summary of the services rendered for the billing period. If a summary is submitted, it should include the following: (1) the information for the dates of service billed, (2) documentation of the services that “were rendered” by each discipline billed, (3) documentation of the patient’s condition, and (4) documentation of the patient’s progress/response to the treatments/services rendered.

This information appears to be outdated as visit notes are specified in the list of documentation required for ADRs. Our advice is to:

  1. Ensure that the recert and therapy evaluation are included if they were performed prior to the starting date of the episode.
  2. Include lab and other diagnostic tests that substantiate a diagnosis even if is not included in the episode.

5A301 Info Provided Does Not Support the M/N for Therapy Services

The same information that applied to the partial denial for therapy services also applies here so we won’t be redundant and repeat it here.

We hope you don’t need help with appealing denials but we are here for you if you do and to answer any questions about denials you might have received.  We would also appreciate any input if you have anything to add, especially about the denial for OASIS and the denial for Visits/Supplies/DME Billed Not Documented/Not Documented As Used.  Email us at TheCoders@hhcoding.com.

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.