Conditions of Participation – Quality Improvement


Maybe the most frustrating element of Quality Improvement for us has always been that there is not a clear definition.  One agency may ‘QA’ notes as they come in but never go any further.  Another may collect data on countless areas of concern but never put into place a plan for improving those areas.  There are those agencies with a program that is great but so complex and time consuming that it never gets done.

All of that is changing.  Effective January 18, 2018, agencies must meet specific criteria in their Quality Assurance as written into the new Conditions of Participation.  The Condition reads as follows:

(484.65) The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data driven QAPI program.  The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS.

The short version:

  1. Your agency must have a QA program that is based on data
  2. It must reflect the complexity of the agency and include all services provided.
  3. Focus on indicators related to improved outcomes including:
    1. Adverse Events
    2. Use of emergent care services
    3. Hospital admissions and readmissions
  4. Takes action to address performance across the spectrum of the agency
  5. The agency must document its program and be able to show compliance to CMS.

This is not hard.  It does require time and buy in from employees in every department of the agency.  Agencies who invest the resources to make this happen will find themselves at the top of the list for star ratings and be every referral source’s darling.  But, it will not happen unless and until senior leadership in the agency buys into the process. With Gusto.

The standards that will be surveyed to determine compliance are similarly easy, but they are comprehensive.  Here they are  (paraphrased):

The agency must be capable of showing improvement in indicators for which there is evidence that health outcomes, care and patient safety will improve when action is taken to address those indicators  In other words, the indicators chosen by your agency must be useful.

And agencies must measure, analyze and track indicators, including adverse events and other aspects of performance that enable the agency to assess processes of care, services and operations.  Simply put, agencies will review data related to their chosen indicators to determine if their plans are working and the plan must include the frequency at which data is collected.  The governing body must approve the frequency of data collection.

Standard – Program Data

The agency must use data from OASIS when applicable as well as other relevant data in the design of its program to:

  1. Monitor effectiveness of service and quality of care
  2. Identify opportunities for improvement

The governing body is the person or group of persons who assume full legal authority and responsibility for the agency’s overall operations.  Ultimately, the buck stops at the governing body.  They write checks and approve budgets.  They can veto decisions.  It may be the owner of a small agency or a group of executives appointed by the boards of publicly traded companies.  Think CEOs, CFO’s and any other person with a job title beginning with a capital C.

So, the Governing body approves the data that will be collected as well as the frequency.  That means that if the data is not collected or is useless or does not result in improvement; ignorance on the part of the governing body will not be an acceptable excuse.  Truly, it never was acceptable but now it is in writing.

Medicare has already given agencies three indicators they expect to see written into the Quality Assurance plan; hospitalizations, emergent care and adverse events.  You’re halfway there but to be effective means determining why patients are visiting the hospital and receiving emergent care.  You already have much of that information in your transfer assessments.  You should know what percentage of your patients are hospitalized because of falls, wounds, medication errors, etc.  If more than a quarter of your patients are going to the hospital for unknown reasons, it could be that the clinicians completing the assessment aren’t taking the time to find out.  Now is the time to instill the importance of taking the effort to get the information required to complete a transfer assessment.

Potentially Adverse Events must be investigated, and action must be taken to prevent future occurrences.  This is not new but is overlooked with an alarming frequency.  Adverse Events retrieved in OASIS reports often have diminished value due to of the age of the data, but you can investigate Adverse Events as they happen while all staff involved with care are still employed and memories are still fresh.  The names of the Potentially Avoidable Events are self-explanatory, and a list provided to staff who complete discharge assessments or billing audits may be useful for identification prior to generating an outdated report.

Monitored Measures to Demonstrate and Track Sustained Improvement

For all activities undertaken to improve quality of care by the agency, there must be measures that are monitored to demonstrate improvement and track sustained improvements. It is a common occurrence for education to yield immediate results for a brief period of time with a return to baseline after a few weeks.

Performance Improvement Projects

Agencies must conduct performance improvement projects. The number and scope of distinct projects must reflect the scope, complexity and past performance of the agency.  Documentation will include a description of the project, the underlying reason for undertaking the project and measurable achievement.  The nature of the project is up to the agency but it must be related to data that has been and will be collected.

Governing Body Responsibilities

Finally, the governing body is responsible for ensuring that:

  • An ongoing program is defined, implemented and maintained
  • The Quality Assurance activities address priorities for improved care and patient safety and that all actions are evaluated for effectiveness.
  • Clear expectations for patient safety are established, implemented and maintained
  • That any findings of fraud or waste are appropriately addressed.

Regarding fraud and waste, the interpretive guidelines go on to say:

In the event that the HHA identifies a possibly illegal action by its employees, contractors or responsible/relevant physicians, it is the responsibility of the HHA to report the actions to the appropriate authorities according to the individual State laws and the nature of the action(s).

I have taken liberties with the actual language.  The full text of the new Conditions of Participation can be found here.  Ultimately it is the responsibility of each agency to understand the CoP’s and we hope we are able to help you.  But we are not now and never will be a substitute for any regulatory body or document.

Next up in the new Conditions of Participation is Infection Control which will be discussed in detail next week.  For now, agencies will do well to pull all relevant OASIS reports and outcomes so that a plan can be put in place.

As always, if you need help implementing the new Conditions of Participation, you know who to contact.

Two More New Conditions of Participation


Assessment and Plan of Care

The current Conditions of Participation are not specific about the scope of the assessment or the plan of care, but most agencies are already meeting the CoP’s due out in January.  In the current CoP’s, the scope of practice for each discipline is defined, followed by a section on clinical records.  It reads:

A clinical record containing pertinent past and current findings in accordance with accepted professional standards is maintained for every patient receiving home health services. In addition to the plan of care, the record contains appropriate identifying information; name of physician; drug, dietary, treatment, and activity orders; signed and dated clinical and progress notes; copies of summary reports sent to the attending physician; and a discharge summary. The HHA must inform the attending physician of the availability of a discharge summary. The discharge summary must be sent to the attending physician upon request and must include the patient’s medical and health status at discharge.

The new Conditions of Participation have details about what is expected to be in your assessment and plan of care.

Assessment:

The condition reads: Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment

The standards that fall under this condition are as follows as I understand them.  They are not verbatim.

  1. The RN must conduct an initial assessment to determine the immediate care and support needs of the patient and for Medicare patients, determine eligibility, including homebound status. This visit must occur within 48 hours of referral or return to the home or on the specific date ordered by the MD.
  2. When nursing isn’t ordered, Physical Therapy, Speech Therapy or Occupational Therapy can perform the initial assessment. This is later clarified to read that Occupational Therapy can perform the assessment if the need for OT services establishes the need for services.
  3. The initial assessment must be completed in a manner consistent with the immediate needs of the patient but no later than five days after the start of care.
  4. Content of the plan of care is expected to include:
    1. Patient strengths, goals and care preferences – including information that may be used to demonstrate patient progress to the patient’s goals and measurable outcomes identified by the agency.
    2. The patient’s continuing need for home care
    3. Medical, nursing, rehab, social and discharge planning needs
    4. Medication review of all drugs the patient is using to include
      1. Potentially adverse effects
      2. Drug reactions
  • Ineffective drug therapy
  1. Significant side effects
  2. Significant drug interactions
  3. Duplicate drug therapy
  4. Non-compliance with therapy
  1. The patient’s primary caregiver(s) and other support including their willingness and ability to provide care, their availability and schedules and the patient’s representatives, if any.
  2. Incorporation of the OASIS dataset into the comprehensive assessment.
  1. The assessment must be updated at least every 60 days and also at the time of a significant change in condition, beneficiary elected transfer, transfer and discharge to the same agency within the same 60-day period, within 48 hours of return to home after a hospitalization and discharge.

Surely you have realized by now that most of these criteria are already written into the OASIS regulations, prior Conditions of Participation and sound clinical principles.   Now they are Conditions of Participation and while similar to what we already do, note that Occupational Therapy can now perform OASIS assessments.  Also, it’s worth noting that whenever the comprehensive assessment is mentioned, it is followed by the assessment of Medicare eligibility for Medicare patients including homebound status.

Careplanning, Coordination of Care and Quality of Care

 This is a new condition and while many agencies already do most of this, there are some standards that some agency’s haven’t done in the past.

The actual condition is:

Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice.

The standards that agency’s will follow to ensure and demonstrate compliance are as follows:

  1. Each patient must receive services that are written in a patient specific plan of care identifying patient goals and outcomes, established and reviewed periodically and signed by a doctor of medicine, osteopathy or podiatry acting within his or her scope of practice.
  2. If the physician refers a patient and the plan of care cannot be completed until after an evaluation visit, the physician is consulted to approve additional orders.

Contents of the Plan of Care

  1. The individualized plan of care must include the following:
  • All pertinent diagnoses;
  • (mental, psychosocial, and cognitive status;
  • The types of services, supplies, and equipment required;
  • The frequency and duration of visits to be made;
  • Prognosis;
  • Rehabilitation potential;
  • Functional limitations;
  • Activities permitted;
  • Nutritional requirements;
  • All medications and treatments;
  • Safety measures to protect against injury;
  • Risk assessment for emergency room visits and rehospitalizations and all necessary interventions to address the risk factors.
  • Patient and caregiver education and training to facilitate timely discharge;
  • Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient;
  • Information related to any advanced directives; and
  • Orders, including verbal orders
  1. Drugs, services and treatments are administered only as ordered by a physician
  2. Flu and pneumonia vaccines may be administered per agency policy developed in consultation with a physician and after the assessment of a patient to determine contraindications.
  3. Verbal orders must be accepted only in accordance with state laws pertaining to verbal orders. When a verbal order is obtained, services are to be carried out as ordered without waiting on the signed order. Verbal orders must include the signature, date and time that the order was received and be placed in the clinical record.  They are to be authenticated and dated by the physician who gave the orders in accordance with state laws and regulations as well as agency policies.

Review and Revision of the Plan of Care

  1. The plan of care is reviewed and revised by the physician who is responsible for the for the home health plan of care as often as indicated by the patient’s condition but at least every 60 days. The agency  must promptly alert the relevant physician(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered.
  2. The revised plan of care must reflect current information from the patient’s updated comprehensive assessment and contain information concerning progress towards goals identified by the agency and patient in the plan of care.
  3. Any revisions to the pan of care due to a change in health status must be communicated to the patient, representative (if any) and all physicians writing orders for the patient.
  4. Any revisions to discharge plans must be communicated to the patient, representative (if any) and all physicians ordering care, the patient’s primary care practitioner or other health care professional who will provide care to the patient after discharge from the agency.

Ensuring Care Coordination involves:

  1. Communication with all physicians involved in the plan of care.
  2. Integration of orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient.
  3. Integration of services provided by the agency or under arrangement to assure the identification of patient needs and factors that affect patient safety and treatment and coordination of care.
  4. Involvement of the patient, representative (if any), and caregivers as appropriate in coordination of care activities.
  5. Ensure that education is provided by the agency to the patient and caregivers regarding care and services in the Plan of Care and to ensure a timely discharge.

The agency must provide written information to the patient that includes:

  1. Visit schedule of all agency and contracted personnel
  2. Patient Medications and instructions on how to take meds including medication name, dosage and frequency and which meds will be administered by the agency or contracted personnel.
  3. Al pertinent instructions related to the patient’s care and treatments that the agency will provide specific to the patient needs.
  4. The name and contact information of the agency’s clinical manager.

So that’s a lot.  Agencies who choose to wait will be working weekends and holidays to be in compliance by mid-January.  The first thing I might do is call my software vendor.  The plan of care requirements haven’t changed but the information that is required to be given to the patient has.  Could a patient friendly medication sheet containing frequency as well as the name and strength of the med be generated?  Depending on your patient population, there may be questions about whether or not you want to leave the entire plan of care in the home.  Will the computer generate a separate form?

Notice that teaching must be specific to the patient.  This may seem self-evident but I have seen nurses teach that Neurontin is for seizures when the patient never had a seizure in their life but was taking Neurontin for neuropathy.  Still, the patient verbalized understanding.

Care coordination and communication is an ongoing Condition and an ongoing problem.  I thought that software messaging would reduce the problem but sadly it has not.  The software accounts I have for clients have so many emails in the inboxes and the vast majority of them do not concern me. One of you has a better idea.  Care to share?

Look for more next week.  Meanwhile, get through these Conditions before moving on to the next.

The Countdown Begins


Here’s a rundown of the first section of the new Home Health Conditions of Participation.  Check back for additional information.  We’ll be adding more later.  Let us know if you have anything to add.

Patient Rights and Responsibilities

The Condition of Participation concerning patient rights and responsibilities will require that:

  1. The agency must provide information about rights and responsibilities verbally and in writing in a manner the patient can understand. There must be documentation that the agency has complied in the chart.
  2. There must be a complaint log that documents the existence and resolution of complaints about care furnished made by the patient or their representative and family.
  3. The agency must let the patient know in advance of the disciplines that will furnish care, the plan of care, the anticipated outcomes of care and changes in the care to be furnished.
  4. The agency must advise the patient of agency policies regarding disclosure of patient records.
  5. The agency must advise the patient of any financial liability.
  6. The agency must advise the patient of the home health hotline number and explain its purpose, hours of operation.
  7. The names and telephone numbers of specified state and federally funded entities. (See Below)
  8. The right to access auxiliary aids and language services and how to access these services.

Specified numbers

  1. Agency on Aging
  2. Center for Independent Living
  3. Protection and Advocacy Agency
  4. Agency and disability resource center
  5. Quality Improvement Organization

These new and revised rights are in addition to other patient rights that are currently being used so you will have to edit your current forms before January 1.  We expect that most forms will patient rights 2 taken from the regulations and edited slightly for clarity.

We suggest that when the forms are replaced that old forms be removed from the office and archived on your computers so they are not accidentally used in 2018.

Complaints

Another thing you can do immediately is prepare your complaint binder for 2018.  Remember that the complaints that you must record and address are those having to do with patient care and mistreatment, neglect, or verbal, mental, sexual and physical abuse including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the agency.

Anyone employed by the agency in any capacity who identifies, notices or recognizes anything suggestive of mistreatment, neglect, or verbal, mental, sexual and physical abuse including injuries of unknown source, MUST report the findings to the agency immediately and other appropriate authorities in accordance with state law.  Notice that it states the employee who identifies mistreatment must report it.  Be supportive of your staff but keep in mind that the person who suspects any neglect or abuse must report it.

Communication

Every agency who is Medicare Certified has completed a Section 504 packet for submission to the Office of Civil Rights.  The penalty for not doing so is having payment withheld so it’s a The Office of Civil Rights investigates claims of discrimination and assures that healthcare providers and others understand and attest to their non-discrimination policies.

Now the section on limited English proficiency has become a standard in the Conditions of Participation.

If your agency is very old, you may not be aware of what is in the packet but you can obtain sample policies and explanations on the Office of Civil Rights webpage.  If you scroll down to the third section  of the linked page, you can find the tools that The Office of Civil Rights has for Medicare Certified Healthcare Providers.

The available resources that you must plug in such as translators, etc. will vary according to your location.  Now is the time to task somebody with identifying these resources if you haven’t already.

So, here are three new requirements that your agency can address in a week.  Instead of being overwhelmed by all the changes, complete a few to the best of your ability and move on to the next.  Keep checking back for more advice on how to get in a position to be compliant by January and send to us any ideas that you have on how to best comply with the new Conditions of Participation.

30-Day Episodes and More…


To be certain, I would have not written the 2018 proposed regulations in the manner in which they were posted earlier in the week.  The document which is technically not published because it hasn’t been certified, starts with the basic rate changes that are proposed beginning January 2018 and some important changes to the scoring system.  The most significant of these involves therapy.  Then it jumps into a couple of hundred pages (not including charts and attachments) describing a new system proposed for 2019.  By the time you finish reading about the 2019 changes and are wondering if you would look good in a Taco Bell uniform, the document once again returns to the changes for 2018.

There’s a lot of material to digest, folks.   Shall we begin?

2019 Payment System

Unlike Medicare, we are going to start with the 2019 payment system.  To call this an update or refinement is taking liberty with the concepts.  It barely stops short of introducing an entirely new payment system.  Even though the proposed implementation date isn’t until 2019, it is important that you become familiar with the payment system now so that your comments can be considered.

The document, posted here, gives the following contact information.  Whether you agree with our views or not, everyone’s voice should be heard if they have an opinion on the proposed regs.  The last day for comments is September 25, 2017.  Mark your calendars.   Here’s where comments should be submitted.

Electronically. You may submit electronic comments on this regulation to http://www.regulations.gov. Follow the instructions under the “More Search Options” tab.

By regular mail. You may mail written comments to the following address ONLY:

Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
Attention: CMS-1672-P,
P.O. Box 8016,
Baltimore, MD 21244-8016.

There are additional addresses for overnight and in person delivery in the document.

Home Health Grouping Model

If all goes according to plan (doubtful but let’s pretend that it will), we will see the advent of Home Health Grouping Models.   Patients will fall into one of six groups depending on their primary diagnosis.  If there is a problem with an assessment falling into one these groups, the claim will likely be sent back to the provider who will have to produce coding with improved accuracy.

These groups are:

  1. MMTA                                            Medication Management and Teaching
  2. MS                                                  Musculoskeletal Rehabilitation
  3. Wound                                          Includes ulcers, surgical incisions, skin lesions, etc.
  4. Complex Nursing:                     Determined by diagnosis code
  5. Neuro, Stroke, Rehab              Self Explanatory
  6. Behavioral                                  Usually called psych

Therapy

Here’s a change that might interest you.  There will be no adjustment for therapy in this system.  The payment is built into the grouping models.   Please feel free to leave your comments below.  We want to know what you think.

Admission Source

Then there’s the Admission Source component of payment in 2019.   You will have four choices:

  1. Institutional Early
  2. Institutional Late
  3. Community Early
  4. Community Late

The rationale for these admission source criteria is that patients admitted from the hospital generally require more resources than those admitted from the community.

Comorbidities

There are 841 diagnoses that will bump up payment if they entered as a comorbid condition.   Here’s how you find them.  Go to https://www.cms.gov/center/provider-Type/home-Health-Agency-HHA-Center.html.

The first section is called, ‘Spotlights’.  There are three paragraphs followed by four links.  The link called, HHGM Grouping Tool has a nifty little spreadsheet where you can calculate payment according to the proposed rules.  Download it and extract all the files.  The very last extracted Excel file (above the Help file which I didn’t bother to read) is a ‘toy’ grouper.   That’s a very fun tool and I’m sure you’ll be using it a lot.  However, to find the significant comorbidities mentioned above, look at the tabs on the bottom of your screen.  One is called, ‘ICD-10 DXs’.  Click it.  There you will find almost 70,000 diagnosis codes.  Do not be alarmed.  Click Ctrl and the letter F at the same time.  A search box will appear on your screen.  Type ‘yes’ in the search box and ‘Find All’ at the bottom of the search box.  The comorbid conditions will be presented to you.

If anyone can tell me how to extract only those codes, feel free to let me know.

Functional Level

 This is the last step of the proposed payment system is similar to the current system with two notable additions.  M1033 –  Risk for Hospitalization and M1800 – Grooming have been added as contributors to the functional level.   The rest of the questions are the same:

  • M1810: Dressing Upper Body.
  • M1820: Dressing Lower Body.
  • M1830: Bathing.
  • M1840: Toileting.
  • M1850: Transferring.
  • M1860: Ambulation/Locomotion

Using the Medicare Grouper tool, you can enter data for your patients and see how they compare to your current case mix weights.  Alternatively, you can call us for assistance and for a very reasonable price, we will come up with a comparison of your case mix weights as they stand now to how they would fall out in 2019.  No dollar value has been assigned.

Questions

  1.  Medical Boards across the country are monitoring prescriptions of narcotics. According to the National Clearinghouse for Alcohol and Drug Information, as many as 17% of adults age 60 and over abuse prescription drugs. Narcotic pain killers, sleeping pills and tranquillizers are common medications of abuse.  An increase in the use of therapy, often ordered for pain management, can reduce the need for these meds.  Has anyone tried to determine with a large amount of data if this is the case?
  2. More to the point, does this payment system create an environment where agencies are given incentive to reduce therapy to the detriment of patient care?
  3. Billing for home health is a complex process. 30-day episodes will result in almost double the amount of work for the office staff increasing expenses without contributing to patient outcomes.  Will billing requirements be lessened?
  4. With 60-day episodes, there is occasionally a situation when an agency admits a patient who is a patient of another agency because the prior agency did not drop a RAP timely. The likelihood of this happening will greatly increase in a 30-day episode.  Will there be any protection for agencies who admit a patient of another agency unknowingly?
  5. In the early years of PPS, points were only awarded for the primary diagnosis resulting in widespread upcoding. Many nurses were upcoding in good faith because their supervisors had told them to put Ortho, Diabetes, Neuro or Trauma codes first.  Is the 6-clinical group method creating a similar situation?

 The current political environment casts doubt on whether any of this will be implemented and raises the chances that it will be postponed.  This does not cancel our obligation to make our opinions known because there are changes on the way.

Do not hesitate to contact us if you have any questions or comments.  The Coders will be submitting comments about the 2019 payment system and we hope that you do, too.

2018 Changes

Our Cliff Notes version of the 2018 payment updates is coming soon.  We promise.  We find it easier to understand one year at a time and think you will, too.  And because your deadline for comments is only a few weeks away for 2019 payment system, we tackled that first.  So, for today, that’s all, Folks.  Keep us posted with any news that you hear.

Medicare’s Pre-Claim Review Demonstration Project


Imagine if every one of your Face-to-Face documents and plans of care were scrutinized prior to payment.  Would 90 percent of them be found compliant with existent rules?  If a non-clinical person determined that your documentation did not meet Medicare coverage guidelines, would you take their word over your nurses’?  How would you feel about submitting a perfectly valid claim for eligible services and being paid 25% less than your peers?

Agencies in Illinois do not have to use their imagination.  It is already happening through the Pre-Claim Review process.  This process involves submitting plans of care, face to face documents, physician and hospital notes and sometimes more to Palmetto prior to dropping a claim for ‘affirmation’.  Once affirmed, a secret code is given to the agency which is placed on the claim. Without the code, final claims are reduced by 25 percent.

And while Medicare is reporting a 90 percent ‘affirmation’ rate, it does not report that there were over 80,000 RAPs submitted compared to 23,000 final claims.  Agencies are apparently reluctant to submit their pre-claim review documentation.

Because a RaP will be taken back after 120 days if not answered by a final claim, I expect that many agencies are going to drop an enormous number of claims in the coming weeks which means the number of pre-claim reviews will far exceed that ever imagined by Palmetto, GBA.  Maybe Palmetto really can process an additional 60k reviews without any interruption in services to the rest of us.  Maybe; but I doubt it.

In April, Florida will come on board.  Texas, Michigan and Massachusetts will follow at undetermined dates.

Agencies in states other than Illinois might not be impressed with all this stuff and nothing.  They are busy with the changes to the OASIS data set, the impending Conditions of Participation and perhaps their own audits or surveys.  Hopefully they will take pause and consider the magnitude of this demonstration project to understand the egregious nature of this intrusive and burdensome little project taken on by Medicare.

The new conditions of participation expected in July of this year explain that the prior Conditions focused on identifying agencies with poor performance.  The updated Conditions of Participation take a much-needed step away from this punitive approach.  As written in the new regulations:

Ensuring quality through the enforcement of prescriptive health and safety standards, rather than improving the quality of care for all patients, has resulted in expending much of our resources on dealing with marginal providers, rather than on stimulating broad-based improvements in the quality of care delivered to all patients.  

There is nothing about the Pre-Claim Review process that stimulates broad-based improvements in healthcare.   How could the Pre-Claim Review Project be so far removed from the intent of the home health Conditions of Participation?

Consider that the demonstration project is resulting in difficulty meeting the educational demands in Illinois and that resources have already been relocated from Florida to Illinois.  Do agencies in other states have the same access to education as the agencies under pre-pay review?

According to the Medicare Pre-Claim Review Q & A:

The demonstration establishes a pre-claim review process for home health services to assist in developing improved procedures for the investigation and prosecution of Medicare fraud occurring among Home Health Agencies providing services to Medicare beneficiaries.

Nobody can deny that a small number of agencies operate without any regard to Medicare rules and only a passing acquaintance with ethics.  This inconvenient acknowledgment of fraud amongst the ranks does not justify excessive scrutiny on 100 percent of providers.  Somehow it does not seem fair to involve home care agencies in a demonstration project designed to enhance their prosecution.

And yet, agencies who fail to submit documentation for a Pre-Claim Review are put on a 100 percent review – a level of scrutiny previously reserved for agencies operating far outside of Medicare rules for an extended period.

The documentation required for a pre-claim review is reviewed for clerical errors and dare I say, elements that cannot be established with limited documentation by reviewers who are not nurses.  The reason for denial given most often per Palmetto GBA is lack of medical necessity.  We see care plans daily that are very poorly crafted supported by excellent nursing and therapy notes.  Conversely, we see plans of care worthy of a Pulitzer prize supported by 9 visit notes at weekly intervals documenting that a skilled nurse taught meds – presumably meds ordered for the patient but who knows?  Nobody asked us if it was possible to determine Medical Necessity without a complete review of the chart.

In the same vein, we see homebound status documented on visit notes that is contradictory to plans of care.  In one recent chart, we found that a patient was shopping weekly.  On another, a therapist documented the patient was driving.  Sufficient documentation on a plan of care that a patient meets the homebound criteria does not make it so.

But, the reviewers are also quick to note when a signature is not dated or the date of encounter is omitted from the Face-to-Face encounter document.  I agree that dates are an important step towards compliance but lack of a date is often nothing more than an oversight; not a tell-tale sign of fraud on behalf of the agency, especially since it is the physician who responsible for the dates.  If this keeps up, the federal prisons will be filled with healthcare providers who forgot to date a couple of documents.

The burden to the agency is extensive.  On a recent CMS conference call, many agencies reported that the PCR process was costing them $25,000.00 per month.  Another agency stated it was taking them about an hour per claim.  Even if these estimates are overstated, they are still far above Medicare’s estimation that it would take minimal time and expense to get the pre-claim reviews submitted.

If Tom Price is confirmed as the new secretary of HHS, there may be some relief but the Georgia representative will oversee 13 different agencies including CMS, the CDC, the FDA, National Institutes of Health and more.  While he has been outspoken against the Pre-Claim Review Process as a senator it is hard to imagine that the Pre-Claim Review process will find its way to the top of his priority list upon confirmation.

So, who benefits from this circus?  Is Palmetto being honest when they say the project is going well?  Are our patients happier and healthier because of frantic efforts to assemble and transmit paperwork?  Could the resources being consumed by The Pre-Claim Review project be put to better use?  What can you do?

I can only provide an answer for the last question.  The first thing you should do is to contact your elected officials in Washington.  After that, get your care plans and Face-to-Face documents in order because there is now an abundance of reviewers at Palmetto who are fluent at reviewing (and finding cause to deny) them.  If you are in Illinois and have claims that you believe are non-affirmed due to incompetent reviewers at Palmetto, contact NAHC.  Under no circumstances do we recommend ignoring the Pre-Claim Review Process because your state is not in the demonstration project.

Many Thanks to Tim Rowan, founder of the Home Care Technology Report. who has extensively and  investigated the Pre-Claim Review process and its effect on providers.  His articles are linked within the content of this post and you can find additional information on his website.

And of course we want your comments and questions.  You can leave a comment here or email us with questions.  We particularly want to hear from Illinois agencies (after you contact your elected officials).

Survey Readiness


Because you are bright and shiny home health employees with enthusiasm to spare, it goes without saying that you are ready for survey all day, every day.  But just in case you fell behind, here’s a few tips on being ready when those cheerful surveyors come calling.

  1. Make sure your annual advisory meeting is held timely. There is nothing you can do when it’s time survey and your PAC meeting is six months late.
  2. Get your CLIA waiver updated if it within three months of expiration. If it is current, put the expiration date on your calendar with a reminder three months from the date.
  3. Plans of care for all patients should be current and updated and reflect the actual needs of your patients – not just what the computer thinks.
  4. Medication lists should be current. Obviously, you and your colleagues are checking meds on every visit but just in case it never hurts for the DON or QA nurse to spend an afternoon doing supervisory visits and checking medications.  If meds are okay, relax.  If you find errors, implement an agency wide plan to have the meds of all patients reconciled within a week.   After the initial medication campaign, follow up.
  5. Do the QA thing. At a recent Home Care of Louisiana meeting, the state agency responsible for whipping home health agencies in line gave a presentation about what they were finding on surveys.  Although tags were not frequently issued for Quality Assurance plans, almost every other tag could have been prevented by reading notes as they came into the agency against the plan of care.  Consider the difference between seeing a missed visit cross your desk compared to a chart with numerous missed visits.  You must read your charts if you want to know what is in them.
  6. Most importantly, call the physician.   Almost every survey with deficiencies includes at least one tag resulting from a change in the patient’s condition that was not communicated to the physician.  I have spoken with nurses who are unwilling to call physicians because they have been chastised in the past for ‘bothering’ physicians.  Communication is not the same as harassment.  If you reserve phone calls for emergent situations and fax or secured email for updates, everyone can be on the same page without overwhelming the physician.
  7. Consider a coding company. Although the primary purpose of The Coders is to ensure correct ICD-10 codes and OASIS responses, a registered nurse reviews the clinical records to determine what those codes and responses should be.  So, while we don’t specifically look for QA indicators, we notice the more serious omissions and make note of them for the agency.  Another side effect of a Coders contract is that our coders notice when assessments are incomplete or late.  Getting caught up can make an enormous difference for agencies with a backlog.

Notice what is not on the list.  There is no minimum standard for face-to-face encounters.  Surveyors may comment about excessive lengths of stay but rarely is a tag issued for redundant teaching or failure to provide reasonable and necessary services.  The state agencies do not pay your bills.  The hoops you must jump through for payment are in addition to the minimum standards for your state.

Some of you may know some people at an agency that is utterly unprepared for state survey.  If this is a long-standing problem, there is probably not much they can do in a short period.  On the upside, in the absence of patient harm and extreme irresponsibility on the part of the agency, the state will allow for an opportunity to clean up any messes in the form of an action plan.  Or they can pay a consultant to come in and have them write an action plan.  We prefer the latter but you won’t receive an invoice from the state surveyors.  Just saying.

Here’s what you don’t do.  Don’t call a consultant in the weeks before survey is due and expect them to make the changes required for a flawless survey.

Three Little Questions


Because the OASIS C database has become easier for you, Medicare has taken measures to ensure that 2017 offers some challenges in the way of OASIS C2.  In turn, we have taken measure to ensure that you understand at the very minimum the three new questions.  They come complete with their own conundrums, confusion and lots of reformatting and subtle shifts in definition.  It’s not as simple as it seems but it certainly isn’t out of your range of capabilities.

New Questions

Written by someone who is comforted by redundancy, MO1028 assesses (again) whether a patient has diabetes or peripheral vascular disease.

(M1028) Active Diagnoses– Comorbidities and Co-existing Conditions—Check all that apply

See the OASIS Guidance Manual or click here for a list of relevant ICD-10 codes.

  • Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
  • Diabetes Mellitus (DM)

Additional guidance is not much different from coding conventions.  The diagnoses must be documented in the medical records produced by the physician or NP.

Having the condition is not enough to win a checked box.  The C2 manual states that the diagnosis must be active and the manual infers that ‘active’ means that there are orders written or monitoring of the disease process ongoing.

So, that’s two criteria –

  1. Does the patient have the condition and
  2. Is anyone watching it or writing orders for it.

Worth noting, if only for a laugh, the OASIS Guidance manual for the C2 dataset provides the following rationale for this question.  We are not kidding.

Disease processes can have a significant adverse effect on an individual’s health status and quality of life.

Section GG

Another new question is (GG0170C) Mobility.  The question occupies an entire page in the manual and if you are like me, it may take you a while to understand what they are truly asking.  Look the column in the body of the table to the very most right where it says something about the patient moving from a completely supine position to sitting on the side of the bed, feet flat on the floor with no backrest.   Everything else on the page refers to that single activity.

The answer reflecting the greatest impairment is 01 and a patient who can complete the tasks independently gets a 06 score.  Note that this is a new opportunity to make a careless error as the level of severity for every other question is reversed with 00 being the least impaired and the last possible response being the worst level of severity.

But there’s more.  The dataset asks for a goal.  If your patient is able to do this task at admission, it is not a problem.  Your initial response and your goal will be the same.  However, if some improvement is expected by the grace of your carefully crafted careplan, there will be a second response describing your patient’s expected ability upon discharge.  Take your best shot and don’t fret about not being able to predict the future.  It is true that all kinds of things can happen between admit/resumption of care and discharge but it is not reasonable to downgrade your goal in the event of a zombie attack.  On the other hand, remember that you are not so good that you can take a person who is totally dependent following a cerebral vascular accident and have them independent at discharge.

Getting Personal

Medicare wants to know the patient’s height and weight in M1060.

(M1060) Height and Weight—While measuring, if the number is X.1 – X.4 round down; X.5 or greater round up.

The Coders assume that you know how to round off numbers but Medicare does not and includes explicit instructions within the question.

Guidance for this question includes a helpful tip to measure your patient’s height and weight in accordance with the agency’s policies and procedures, which should reflect current standards of practice.  So, how many of you have a policy addressing how to measure the height and weight of a patient?

Assuming that such a policy exists in your agency, is it based upon sound clinical practice standards?  On your behalf, we have scoured the internet for practice standards for measuring height and weight and like the CDC Antropometry Procedures Manual.  Sadly, the manual refers to the Integrated Survey Information System anthropometry computer application (ISIS).   Do not be alarmed when you see this.

Also, when determining how height will be measured, plan on buying a stadiometer.  This is the apparatus seen in Physician offices that measures height.  Most of the affordable ones are wall mounted and we suggest that wall mounting is not recommended in your patient’s home environment.  Also, note that anything with brightly colored giraffes and ruler-like markings cheering on big boys and girls is not likely to be received well by adult patients or meet the practice standards. Call your medical supply company and plan to spend about $150.00 per portable stadiometer.

The Dash

There’s more – so much more but you have patients to see and notes to write.  We are going to leave you with information about The Dash.  This is not a simple dash as found in other places like a date or a social security number.  According to Medicare,

a dash (–) value indicates that no information is available, and/or an item could not be assessed. This most often occurs when the patient is unexpectedly transferred, discharged or dies before assessment of the item could be completed. CMS expects dash use to be a rare occurrence.

This definition is consistent throughout the manual.  When a dash value is an available option for questions, OASIS guidance generally indicates if the dash is a valid response.

For your convenience, we have uploaded some of these documents.  Hopefully, you will read them and then fill us in.  As always, we welcome your questions.  Maybe we’ll even answer a couple.