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;
(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 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.
(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 patient, representative (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 firstname.lastname@example.org or call 800-332-0555.
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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On January 13th,
CoPs Breakdown on the New QAPI Regulations
the rules for CoP's Quality Assessment and Performance Improvement regulations changed. Section 484.65 QAPI has replaced sections 484.16 (Group of Professional Personnel) and 484.52 (Evaluation of the agency’s program). The new section does a great deal to highlight the responsibilities of the agency's executive team and expects the governing bodies to focus on technology concepts like data- driven indicators to identify, track, and measure quality initiatives for high risk, high volume or safety issues.
The program includes 5 standards:
• Program Scope 484.65 (a)
• Program Data 484.65 (b)
• Program Activities 484.65 (c)
• Performance Improvement Projects 484.65 (d)
• Executive Responsibilities 484.65 (e)
Agencies are required to develop a data-driven QAPI program with measurable improvement indicators. The organization must measure, analyze, and track quality indicators including a patient’s adverse events, as well as other signs of performance to assess processes, services, and operations. However, it is not enough to just create the indicators. Agencies must use data to provide evidence that the improvement has led to improved health outcomes (ex: reduced hospitalizations, ED visits), safety and quality of care for patients.
The QAPI program must utilize quality indicator data, including measures derived from OASIS that CMS has reported, to assess the quality of care provided to the patients and identify, prioritize, and manage opportunities for improvement. The QA efforts, including data collection, should focus on high-priority safety and health conditions. Like the program scope, data collected should support the quality measures and identify opportunities for improvement.
Agencies will need to focus on those areas of past performance which have proven problematic for the agency over time or areas where there was clear evidence of poor patient outcomes as well as high risk and high volume.
The QAPI activities should include incidence, prevalence, and severity of problems in those areas. So that preventative actions and mechanisms can be implemented, agencies must track and analyze activities over time to ensure sustained improvements. Management should immediately correct any issues identified that directly or potentially threaten the health and safety of patients.
Performance Improvement Projects
The QAPI program requires that agencies performance improvement projects be conducted annually, at a minimum. The plan should reflect each agencies unique scope, complexity, and past performance. There should be clear documentation of the QAPI projects including the reason for conducting these projects and the measurable progress achieved.
The agency’s governing body must define, implement, and maintain a program for quality improvement and patient safety that is ongoing and agency-wide.
The governing body for each agency is responsible for ensuring the QAPI reflects the complexity of the organization and its services, including contract and arrangement, are focused on indicators related to improved outcomes. They must also approve the frequency and level of detail in data collection. The governing body should establish clear expectations for patient safety and address issues in performance across the spectrum of care including the prevention and reduction of medical errors.
For more information on this topic or on our Document review and Coding Services or Revenue Cycle Management, please call Select Data at 1.800.332.0555.
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New CoPs and Your Agency: Patient-Specific, Individualized Care, and QAPI- Take a Deep Breath
An overview of the Conditions of Participation (CoP) revisions
It has been decades since the Conditions of Participation for Home Health have been significantly revised. The last time it was attempted, Bill Clinton was President.
The new rule expands patient rights, care planning, and care coordination standards. The changes require much education and planning. It requires the agency governing body to take responsibility for the new required QAPI program.
The theme throughout the rule and CMS response to comments is quality, individualized care and patient engagement. They stated they expect, “patient-centered, data-driven, outcome-oriented processes that promote high quality care at all times for all patients.”
An overview of the CoP revisions are highlighted below. For a full review see the 375 page final rule, effective as of July 13, 2017 or contact Select Data. A focus, per CMS, is to improve the quality of home health care services for patients and to strengthen patient rights.
CMS expects patients to be made aware of their rights in a form that can be understood by the patient and their representative (if they have one). The written patient rights forms must be given prior to any care being administered. If a patient does not wish their non-legally appointed representative to have a copy of the rights, the agency must note that fact in the clinical record.
If a patient has a legally appointed representative, they must receive a copy of the rights prior to the patient receiving any care. In addition, the patient is to be made aware of the name of the clinical manager and their business phone number so clinical questions may be directed to that person.
In addition, CMS is requiring that home health agencies be given the name and contact information of the agency administrator so complaints may be made directly to them.
CMS is seeking “a more holistic patient assessment.” The intent is to develop a more complete understanding of the patient that “will enable HHAs and physicians to develop a plan of care that is more comprehensive and more likely to achieve desired outcomes.” To achieve this goal, CMS has some new requirements that include:
- Adding a psychosocial, functional, and cognitive status assessment to the overall comprehensive assessment of the patient.
- Assessing and identifying the patient’s strengths, goals, and care preferences including progress toward goal achievement stated in the clinical record.
- Assess the patient’s primary caregivers
- Identify the patient’s representative
- Assess the patient’s risk for hospitalization/rehospitalization, require for ALL HHA admissions.
The individualized care plan must include “patient specific measureable outcomes which the HHA anticipates would result from its implementation.”
The agency must provide written instructions regarding care, tasks, or schedules so they have a tool to reference between visits. CMS did not restrict the agencies on the written instructions. Calendars for schedules could be used as well as checklists, or handwritten notes.
CMS wants agencies to use patient strengths and engage the patients so they are actively involved in their care. The belief is that the likelihood of positive outcomes is greater.
Care coordination is the driver toward quality with CMS stressing a focus on the patient as an active participant on the interdisciplinary team. It is obvious that the team is being encouraged to develop very patient-specific plans of care playing to each patient’s strengths and level of involvement.
CMS expects each visit note to identify what skill was completed, but what skilled service is needed for the patient. They also expect progress toward goal attainment to be well documented.
Quality Assessment and Performance Improvement
This new 484.65 CoP, Quality Assessment and QAPI will replace two CoPs, namely Group of Professional Personnel and Evaluation of the Agency Program.
CMS expects HHA to identify their own agency-specific risk areas with a focus on high risk, high volume problem areas. The program is to be agency wide and the Governing Body must approve details of areas chosen, dates/frequency of data collection, and review results. Because this program will take time to be fully operational, CMS is giving this CoP and extension of time, making it required January 13, 2018.
Agencies will be responsible for documenting the number of QI projects undertaken coupled with reasons chosen and results of each project.
Agencies must institute a strong surveillance, identity, prevention, and intervention infection control program. Education is expected to be seen throughout this program establishment.
Skilled Professional Services
Combining the CoPs Skilled Nursing Services, Therapy Services, and Medical Social Services, CMS is stressing an ongoing interdisciplinary assessment of the patient. They identify an expectation of development and evaluation of the POC in partnership with the patient, their representative (if any), their caregivers, and the HHA personnel. The professional services are expected to provide counseling, patient education, prepare clinical notes, communicate with the physician, participate in the QAPI program and participate in HHA sponsored inservice trainings.
Of course there remains specific direction regarding each service entity such as an RN supervising and LPN/LVN. Those types of items have not changed.
Home Health Aide
This new CoP has nine specific standards. A significant change allows an agency to accept a certified nurses aide for a home health aide position provided they completed their training and competency and remain in good standing on the state registry. Of course, any specific training necessary for the aide to perform safely in the home with a particular patient is the responsibility of the HHA.
It was stressed that the aide is a member of the interdisciplinary team. They are to have training as to how to document and communicate with/to patients, family members, and other members of the team.
There is also a new requirement that an annual onsite visit be performed at a location where a patient is receiving care to assess and observe care delivery. Also, under the new CoPs, home health aides may receive assignments by an RN or any other skilled professional also delivering care; PT, OT, or S/LP.
These new CoPs signal a shift from problem-focused care, that CMS acknowledged had “inherent limits” to quality focused care. The new CoPs actively involve the patient, capitalizing on their strengths, uses tools and communication methods the HHA identifies as best for the patient.
CMS is encouraging HHA to establish a meaningful QAPI program that identifies agency specific issues rather than mandating prescriptive dictated problems to address.
Though NAHC has sent a letter to CMS advising a delay until July, 2018 to institute the new CoPs, agencies should not delay in establishing a team to conduct a gap analysis, identify needs, and institute education programs for all CoPs mandated for July 13, 2017. They must also initiate planning for the indepth QAPI program that will take the extra time given by CMS to be fully functional.
For further information or consulting needs, contact Select Data at 1.800.332.0555