Showing posts tagged with: Compliance

CoP Interpretive Guidelines: Are You Compliant?

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Clinical Documentation Improvement, Clinical Practices, Compliance, Conditions of Participation (CoPs), HIPPA

CoP Interpretive Guidelines: Are You Compliant?

Are You Compliant With CoP §484.60?

 
Home Health Agency Condition of participation (CoP) went into effect January 13, 2018 (CMS, 2018). However, some agencies are still struggling when it comes to Condition of participation (CoP). According to the CoP Interpretive Guidelines, to be compliant with CoP §484.60, home health agencies must have established standards of practice issued by a nationally recognized organization with expertise in the field. If your organization fails to meet these minimum standards when audited, you may be assessed a monetary fine or lose your Medicare certification.

§ 484.60 Condition of participation: Care planning, coordination of services, and quality of care.

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.

(a)Standard: Plan of care.

Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan.

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

(i) All pertinent diagnoses;

(ii) The patient's mental, psychosocial, and cognitive status;

(iii) The types of services, supplies, and equipment required;

(iv) The frequency and duration of visits to be made;

(v) Prognosis;

(vi) Rehabilitation potential;

(vii) Functional limitations;

(viii) Activities permitted;

(ix) Nutritional requirements;

(x) All medications and treatments;

(xi) Safety measures to protect against injury;

(xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors.

(xiii) Patient and caregiver education and training to facilitate timely discharge;

(xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient;

(xv) Information related to any advanced directives; and

(xvi) Any additional items the HHA or physician may choose to include.

(3) All patient care orders, including verbal orders, must be recorded in the plan of care.

(b)Standard: Conformance with physician orders.

(1) Drugs, services, and treatments are administered only as ordered by a physician.

(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, and after an assessment of the patient to determine for contraindications.

(3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies.

(4) When services are provided on the basis of a physician's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician in accordance with applicable state laws and regulations, as well as the HHA's internal policies.

(c)Standard: Review and revision of the plan of care.

(1) The individualized plan of care must be reviewed and revised by the physician who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. The HHA 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) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care.

(3) Revisions to the plan of care must be communicated as follows:

(i) Any revision to the plan of care due to a change in patient health status must be communicated to the patientrepresentative (if any), caregiver, and all physicians issuing orders for the HHA plan of care.

(ii) Any revisions related to plans for the patient's discharge must be communicated to the patientrepresentative, caregiver, all physicians issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any).

(d)Standard: Coordination of care. The HHA must:

(1) Assure communication with all physicians involved in the plan of care.

(2) Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient.

(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines.

(4) Coordinate care delivery to meet the patient's needs, and involve the patientrepresentative (if any), and caregiver(s), as appropriate, in the coordination of care activities.

(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the u, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge.

(e)Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining:

(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA.

(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA.

(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services.

(4) Any other pertinent instruction related to the patient's care and treatments that the HHA will provide, specific to the patient's care needs.

(5) Name and contact information of the HHA clinical manager (Cornell Law School, 2018).

Need Help with your agency's Condition of participation (CoP) compliance?

For more information about how Select Data can ensure CoP Interpretive Guidelines have been met email info@selectdata.com or call 800-332-0555.

Resources Centers for Medicare & Medicaid Services (2018). Center for Clinical Standards and Quality /Quality, Safety & Oversight Group. Department of Human and Health Services. CMS.gov. Retrieved from: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO-18-13-HHA-.pdf Cornell Law School (2018). 42 CFR 484.60 - Condition of participation: Care planning, coordination of services, and quality of care. Legal Information Institute. Retrieved from: https://www.law.cornell.edu/cfr/text/42/484.60
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians Click here to read more.
Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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CoP Compliance – You Can’t Do It Without Your Clinicians!

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Clinical Documentation Improvement, Clinical Practices, Coding, Compliance, Conditions of Participation (CoPs), HIPPA, Uncategorized

CoP Compliance: You Can't Do It Without Your Clinicians!

CMS expects Conditions of Participation (CoPs) 100% Compliance on January 13th.

 
"January Funk" Shortly after ringing in the new year, people have been known to get the blues. Winters are cold, days are short, there’s not another holiday for months, and many people fall into what some call “The January Funk.” If you work in an industry that involves a lot of regulatory involvement, like healthcare, you may fall into a “January headache.” In healthcare, guidance, policy, and regulations are often updated, and new programs are launched at the beginning of the calendar year. For home health providers, saying “goodbye” to 2017 means saying “hello” to updated Conditions of Participation (CoPs) from CMS in 2018. After researching hundreds of pages of documentation, your head may be spinning as you lament over where to start. After all, just working in the home health business can keep your mind busy 24/7, never mind having more heaved onto your plate. With the new CoPs implementation quickly approaching, we’re in the warm up phase right now. If it hasn’t happened yet, it’s time for you to gather your team and start your pep talk. The success of any home health agency depends on teamwork. That’s now a new concept. Now is the time that your clinicians need to start wrapping their heads around how their life is going to be changing because of the updated regulations. Do you already have a plan in place for communicating to patients with limited English language skills? Do your clinicians know what the Patient’s Rights are? Since clinicians are just weeks away from having to give a verbal explanation of the Patient’s Rights to the patients, it’s time to start rehearsing. Clinician competency will be a key to your success, or the lack thereof will be the torpedo that sinks your battleship. Call your team together and let’s get the planning started. First, your team needs to know that these changes are coming, and that they are nothing to be afraid of. It seems that in healthcare when new policies (or regulatory changes) come around there is the feeling of impending doom. “What do we have to do now?” I recommend that you do an overview with your clinicians and let them know what exactly are the conditions of participation and why they are being updated. It’s time to discuss the paradigm shifts regarding CMS’s approach to patient care. It also may take a certain degree of convincing to get your long time veteran clinicians to buy into the idea of patient centered healthcare that is driven by the patient’s strengths and preferences. If your staff doesn’t buy into this new philosophy, there’s little chance that your patients are going to be convinced to shift their thinking. Eliminate Potential Anxiety For Your Clinicians After you get past the “why”, it’s time to get your paper out and start sketching out the “how.” Your clinicians need to clearly understand what part of their routine must change. What signatures do they need to get and when? What’s the phone number for the interpreter’s line? Are you going to publish your agency’s literature in different languages? How do you explain a patient’s right to people with different educational backgrounds and different cognitive ability? Your clinicians are much more likely to be compliant with the updated Conditions of Participation if you help eliminate some of the potential anxiety that accompanies change. Start talking about these things now. It’s not fair to throw clinicians into a new situation without the proper preparation. We’ve all been there, and we all know that it stinks to be there. Start coaching them now so they’re set up for success. Develop tools to get the job done right. Are there different fields that need to be custom added to your EMR so that the additional required information will have a home? If that’s not possible, you should work with your team to develop check lists (or worksheets) so that they are reminded of everything they need to ask or say during that home visit. Look at the tools you have now and decide what changes need to be made. When clinicians are forced to “do things on the fly” without the proper tools, they often find themselves jotting down random information in a disorganized and in a “non-HIPAA compliant” manner. Eventually, when this all of this becomes more familiar, your clinicians will probably develop their own system. While they’re just becoming accustomed to these new requirements, make sure they have the tools to be organized and efficient. Five-Day Window Coordination is a huge factor in the new Conditions of Participation. For coordination to be successful, good communication is a must. Unfortunately, communication is where many teams take shortcuts. The Clinical Manager role that is defined in the CoPs is immense. An agency’s Clinical Manager is only going to be successful if your team has a great communication plan. Communication about a patient’s care plan will be ongoing but it will be especially hectic at the time of admission. The communication plan among clinicians of different disciplines, multiple doctors’ offices, and the administrative staff, must be well thought out, organized and adhered to. Figure out how you’re going to manage all the information in the beginning five-day window, or your Clinical Manager may end up climbing out of the office window to escape. Practice, Practice, Practice! Finally, it’s time for your team to start practicing. There’s nothing that prevents you from implementing some of these changes before the beginning of the year. CMS expects you to be compliant with the updated Conditions of Participation 100% of the time on January 13th. Don’t wait until early one January morning to try and throw these ideas together. You’re not making a quick regulatory snack. You’re creating a huge feast of regulatory changes. Some of us know from experience that you shouldn’t be making your grocery list the day before Thanksgiving as your in-laws are in route to your home. Don’t wait until the beginning of January to bring in donuts for your clinical team so that you can “brainstorm this new thing.” Your clinicians are a key to your Conditions of Participation compliance. Invest in them. Train them. Listen to them. Invite them to join in on important conversations. Their success will lead to good patient outcomes. Isn’t that why we’re doing this after all? For more information about the implementation of the new Conditions of Participation please view our webinar from October. https://www.selectdata.com/clinicians-role-conditions-participation-cops-compliance-select-connect-clinicians/ For more information on this topic or on our USA based Document review and Coding Services or Revenue Cycle Management, please call Select Data at 1.800.332.0555.
Related Article - CoPs Breakdown On The QAPI Regulations
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians Click here to read more.

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Developing a Thorough and Compliant POC | Select Connects With Clinicians

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Clinical Practices, Compliance, Educational Videos

Developing a Thorough and Compliant Plan of Care (POC)

Live Recording from August's Select Connects With Clinicians

 
In this session, attendees will be able discuss the importance of developing a thorough and compliant Plan of Care (POC) and will develop a POC that CMS and their DON will be proud of.

Objectives:

  • What are Covered Services?
  • Visit Frequencies and Utilization
  • Plan of Care Development
To watch Developing a Thorough and Compliant Plan of Care live presentation fill out your name and email address

Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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HIPAA Compliance Checklist: Is Your Agency’s Documentation at Risk?

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Clinical Practices, Compliance, HIPPA

HIPAA Compliance Checklist: Is Your Agency's Documentation at Risk?

HIPAA Compliant Documentation Supports Your Agency's Services. Read this to find out.

 

Supporting HIPAA Compliant Documentation

HIPAA can be complex. As HIPAA compliance experts, Select Data has created a checklist to help you self-assess the status of your organization's compliance. With OCR/HHS HIPAA audits on the rise, there's never been a better time to understand what needs to be done to become HIPAA compliant and how far along in the process you already are. Select Data provides professional coding services to Home Health and Hospice agencies and are industry experts in the language of CMS. We assist agencies with the accurate representation of their patient. To find out how Select Data can help you improve coding accuracy check out our OASIS review and coding services. To download the HIPAA Compliance Checklist fill out the information below

Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians webinar on December 14, 2016. Click here to read more.
 
Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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The Surveillance and Utilization Review Subsystem (SURS)

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Audits

Predictive Analytics or Provider Profiling? Call it what you want, is your agency being monitored by CMS and/or state Medicaid etal? And, have you directly triggered an alert? Or, are physicians that sign orders for your agency patients being investigated? Should you be aware that your agency could trigger a PPS RAC, MAC, or Z-PIC audit and that a related party or a referral source under review could trigger an audit of your agency? Yes, that could be a reality. CMS and related agencies are using predictive analytics to identify aberrant care delivery and utilization patterns for PPS. At the time the claim is dropped, an assessment of multiple patient factors is conducted. These factors may include diagnoses, frequency, and disciplines involved in care. Your agency practice patterns are now being compared to peer groups and may include a comparison to validated benchmarks. Physicians who refer to your agency may be having their practice patterns monitored also, especially if the payor source is Medicaid. The Surveillance and Utilization Review Subsystem (SURS) is responsible for monitoring claims process for Medicaid, seeking indicators of fraud.  They look for duplicate, inconsistent, or excessive visits in relation to diagnoses and visits provided in State systems. Section 456.25 of Title 42, Code of Federal Regulations writes that "States are required to have a post-payment review process that allows State personnel to develop and review: (1) recipient utilization profiles, (2) provider service profiles, (3) exception criteria; and (4) identifies exceptions so that the agency can correct misutilization practices of recipients and providers." No two state Medicaid systems are the same, thus, there are a variety of post- payment review SUR systems. Some state systems are routinely using tools that can statistically use random sampling with extrapolation for provider reviews. This allows the auditor to identify a current trend and apply the findings retrospectively for a specific past time point. Recoupment dollars can add up quickly using this methodology. The SURS are also using tools that flag inconsistencies and over-utilization of visits in relation to care delivered at those visits. At times, they may be focusing on specific discipline practices. States have different practices.  Personnel in the New Hampshire Surveillance and Utilization Review Subsystem (SURS) monitor financial claims for the NH Medicaid plan. SURS review provider claims for fraud, waste or abuse and may refer cases under suspicion to the Medicaid Fraud Unit of the State Attorney General. The unit also recovers overpayments by using predictive analysis algorithms that search its data warehouse for aberrant claim information. "In addition, SURS in New Hampshire also conducts reviews to determine if recipients are inappropriately using certain types of medications." This can trigger other areas of investigative need. Some states are querying relational databases which provide flexible and easy access to years of paid claims and the ability to query real time data along with trending patterns and profiles. The SURS also use exception profiling as a starting point for case development. Ranked reports can quickly identify outliers. A sample profile might include the following elements: -Average patients per agency -Average reimbursement per agency -Average disciplines per patient -Average diagnoses per patient -Average number of patients with labs -Average number of patients with injections -Evidence of upcoding -Evidence of downcoding Medicaid is monitoring payment for care and now closely monitoring physician practices. Agencies need to be certain that they strictly adhere to the regulations for care provision. A physician who is being monitored now can bring review and audits to those for whom he or she may provide referrals. Compliance risks have always existed. But now, agencies need to expand those risk mitigation practices to their referral sources as well as their marketing departments. Be certain you and your referral source philosophies are similar. Quality oriented physicians are also seeking agencies with like philosophies. They too want to improve the patient transition of care.  The bad press regarding 78 Texas home health agencies and the linked Texas physician has raised some physicians concerns nationally re this industry. Showcase your agency quality programs and excellent outcomes.

  • Work to improve bi-directional communication flow.
  • Establish points of accountability for sending and receiving patient information.
  • Increase the use of case management and professional care coordination.
  • Develop performance measures that encourage better transitions of care that are well documented.
  • Let it be known that your agency supports a strong regulatory culture that offers accountability and effort toward solid patient outcomes.
That well-stated philosophy and agency culture exhibited through employee conversation, patient care, and marketing materials tells all stakeholders involved that your agency strives to be a quality-oriented care delivery provider.

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