CoP Interpretive Guidelines: Are You Compliant?
§ 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;
(vi) Rehabilitation potential;
(vii) Functional limitations;
(viii) Activities permitted;
(ix) Nutritional requirements;
(x) All medications and treatments;
(xi) Safety measures to protect against injury;
(xiii) Patient and caregiver education and training to facilitate timely discharge;
(xv) Information related to any advanced directives; and
(xvi) Any additional items the HHA or physician may choose to include.
(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.
(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 patient, representative (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 patient, representative, 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.
(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.
(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:
(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 firstname.lastname@example.org 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
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HIPAA Compliant Documentation Supports Your Agency's Services. Read this to find out.
Supporting HIPAA Compliant DocumentationHIPAA 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
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.