Tag / home health

by Julianne Haydel

Conditions of Participation 2018 Home Health Aide Requirements


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

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

Here is the Condition and the supporting standards.

Condition §484.80:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The new components are:

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

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

The competency consists of both oral and written examination.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

According to the Interpretative guidelines, documentation would include:

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

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

(d) Standard: In-service training.

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

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

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

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

standard have been met.

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

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

The Interpretative Guidelines list ‘others’ as follows:

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

 

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

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

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

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

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

 (i) Ordered by the physician;

(ii) Included in the plan of care;

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

(iv) Consistent with the home health aide training.

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

(i) The provision of hands on personal care;

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

(iii) Assistance in ambulation or exercises; and

(iv) Assistance in administering medications ordinarily self-administered

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

by Julianne Haydel

Conditions of Participation… Professional Requirements


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

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

484.75 Condition of Participation: Skilled professional services.

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

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

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

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

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

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

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

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

The first standard reads:

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

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

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

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

484.75(b) Standard: Responsibilities of skilled professionals.

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

  1. Ongoing interdisciplinary assessment of the patient;

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

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

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

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

Supervision

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

484.75(c) Standard: Supervision of skilled professional assistants

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

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

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

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

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

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

by Julianne Haydel

CoP’s Continued…. Infection Control


Clean Hands Count

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

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

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

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

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

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

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

Hand Hygiene

The Interpretive guidelines advise agencies that handwashing should occur:

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

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

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

Environmental Cleaning and Disinfecting

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

Safe Injection Practices

Safe injection practices include:

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

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

Appropriate Use of PPE

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

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

Minimizing Potential Exposures

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

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

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

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

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

The next standard is:

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

Surveillance

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

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

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

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

More specifically, we suggest:

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

If you have any other suggestions, please share them.

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

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

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

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

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

The last standard in Infection Control concerns training and education.

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

The interpretive guidelines are clear on what is expected:

HHA staff education should include as a minimum:

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

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

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

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

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

by Julianne Haydel

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.

by Julianne Haydel

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.