Draft Interpretive Guidance- HH CoPs

Members | November 10, 2017 | by Peter Notarstefano

The Centers for Medicare & Medicaid Service (CMS) has issued a draft version of the home health Conditions of Participation (CoPs) Interpretative Guidelines (IGs). The final rule delaying the new Home Health CoPs is scheduled to be posted in the July 10, 2017 Federal Register.  The rule delays the effective/compliance date for an additional six months until January 13, 2018

The Centers for Medicare & Medicaid Service (CMS) has issued a draft version of the home health Conditions of Participation (CoPs) Interpretative Guidelines (IGs). 

The final rule delaying the new Home Health CoPs was posted in the July 10, 2017 Federal Register. This final rule delays the July 13, 2017 effective date for the "Medicare and Medicaid Programs: Conditions of Participation for Home Health Agencies" originally published in the Federal Register on January 13, 2017.  The rule delays the effective/compliance date for an additional six months until January 13, 2018. Agencies will have until July 13, 2018 to implement one QAPI standard: Performance Improvement Projects. 

The Centers for Medicare & Medicaid Services (CMS) released its final rule on the Medicare and Medicaid Conditions of Participation (CoP) for home health agencies. A draft proposal was introduced in 2014. The rule was published in the Federal Register on January 13, 2017

The Centers for Medicare and Medicaid Programs (CMS) issued the proposed rule on March 31, 2017 that would delay the effective date of the final "Conditions of Participation for Home Health Agencies" for an additional six months.

Following publication of the January 2017 HHA CoPs final rule, CMS received inquiries that represented a large number of HHAs requesting that the agency delay the effective date for the new HHA CoPs. The inquiries asserted that HHAs were not able to effectively implement the new CoPs until CMS issued its revised Interpretive Guidelines (State Operations Manual, CMS Pub. 100 - 07, Appendix B) . In addition, one of the inquiries stated that HHAs were unable to effectively implement the new CoPs until CMS issued further sub-regulatory guidance related to converting subunits to branches or independent HHAs, which would impact 216 HHAs nationwide. One of the inquiries cited the estimated $300 million cost to implement the new requirements as a reason for delaying the effective date. CMS believes that the concerns expressed in the inquiries have merit, so in response to the concerns, CMS proposed to delay the effective date of the HHA CoPs final rule for an additional 6 months.

This proposed rule concerning the delay would also make two conforming changes to dates that appear in the regulations:

  • The phase-in date for the standard for Performance Improvement Projects will be revised to July 13, 2018
  • Grandfathering date for credentials of the Administrator of the Home Health Agency will be revised to January 13, 2018

CMS provided the following summary of the Final Rule:

  • Revised the definition of “representative” at §484.2 for additional clarity.
  • Revised §484.50(a)(1) to clarify that it is the patient’s legal representative that must be informed of the patient rights information prior to the start of care.
  • Revised §484.50(a)(1)(i) to require that an HHA must provide each patient with written notice regarding the HHA’s transfer and discharge policies. This requirement was originally proposed at 484.50(d).
  • Re-designated proposed §484.50(a)(1)(ii) as §484.50(a)(3).
  • Re-designated proposed §484.50(a)(2) as §484.50(a)(1)(ii) and removed the requirement that HHA administrators are expected to receive patient questions.
  • Re-designated proposed §484.50(a)(3) as §484.50(a)(1)(iii).
  • Re-designated proposed §484.50(a)(4) as §484.50(a)(2), and clarified that a signature confirming receipt of the notice of patient rights is only required from a patient or a patient’s legal representative.
  • Revised §484.50(a)(3), requiring that the HHA must provide verbal notice of the patient’s rights no later than the completion of the second visit from a skilled professional.
  • Added new §484.50(a)(4), requiring that the HHA provide written notice of the patient’s rights and the HHA’s discharge and transfer policies to a patient-selected representative within 4 business days after the initial evaluation visit.
  • Revised 484.50(b) to replace the term “incompetence” wherever it appears with the more precise term “lack legal capacity to make health care decisions.”
  • Revised §484.50(c)(4)(i) to clarify that patients have the right to participate in and be informed about all assessments, rather than just the comprehensive assessment.
  • Removed the requirement at §484.50(c)(4)(iii) regarding providing a copy of the plan of care to each patient.
  • Revised §484.50(c)(10) to require HHAs to provide contact information for a defined group of federally-funded and state-funded entities.
  • Revised §484.50(d) to remove the requirement for HHAs to provide patients with information regarding HHA admission policies and clarified that the “transfer and discharge policies” are those set forth in paragraphs (1) through (7) of this standard.
  • Revised §484.50(d)(1) to clarify that HHAs are responsible for making arrangements for a safe and appropriate transfer.
  • Revised §484.50(d)(3) to clarify that discharge is appropriate when the physician and the HHA both agree that the patient has achieved the measurable outcomes and goals established in the individualized plan of care.
  • Revised §484.50(e)(1)(i) to clarify that the subject matter about which patients may make complaints is not limited to those subjects specified in the regulation. HHAs must investigate all such complaints.
  • Revised §484.50(e)(1)(iii) to specify that HHAs must take action to prevent retaliation while a patient complaint is being investigated.
  • Revised §484.50(e)(2) to specify that circumstances of mistreatment, neglect, abuse, or misappropriation of patient property must be reported in accordance with the requirements of state law.
  • Added a requirement at §484.55(c)(6)(i) and (ii) that the comprehensive assessment must include information about caregiver willingness and ability to provide care, and availability and schedules.
  • Added a requirement at §484.60 that patient and caregiver receive education and training including written instructions outlining medication schedule/instructions, visit schedule and any other pertinent instruction related to the patients care and treatments that the HHA will provide, specific to the patient’s care needs.
  • Moved proposed §484.60(a)(3) to §484.60(a)(2)(xii), making it applicable to all patients, and removed the terms “low,” “medium,” and “high.”
  • Revised §484.60(b)(1) to permit drugs, services and treatment to be ordered by any physician, not just the one responsible for the patient’s plan of care.
  • Revised §484.60(b)(4) to permit any nurse acting in accordance with state licensure requirements to receive verbal orders from a physician.
  • Added requirements at §484.60(d)(1) and (2) that HHAs must assure communication with all physicians involved in the plan of care, and integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient.
  • Re-designated proposed §484.60(d)(1) through (3) as §484.60(d)(3) through (5).
  • Added a requirement at §484.60(e), Written information to the patient.
  • Revised §484.65 to require that QAPI program indicators include the use of emergent care services.
  • Revised §484.75(b)(7) to require skilled professionals to communicate with all physicians involved in the plan of care.
  • Revised §484.80(b)(3)(xiii) by withdrawing part of the provision under home health aide training requirements for aides to recognize and report changes in pressure ulcers.

An administrator of a Home Health Agency  who begins working for an HHA after the effective date of this final rule, even if he or she was previously employed as an administrator for a different HHA, is required to be a licensed physician, a registered nurse, or hold an undergraduate degree. A registered nurse would include a Nurse Practitioner or other advance practice nurse. Additionally, an administrator who begins working for an HHA after the effective date of this final rule is required to have experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program.

LeadingAge had submitted comments to the Centers for Medicare and Medicaid Services (CMS) on the CMS-3819 -Proposed Rule Medicare and Medicaid Program: Conditions of Participation for Home Health Agencies.

LeadingAge is pleased that CMS has incorporated the principles of patient-centered plans of care that are outcome oriented and data driven. To reflect that we no longer can work in silos of care based on our specific provider licensing and regulations, the rule emphasizes integration and interdisciplinary care planning. We are also pleased that the rule eliminates the 60-day summary to physician, professional advisory committee (PAC), and quarterly record review. These three requirements would be a duplication of processes and documentation that were proposed in other sections of the rule. We support that the rule significantly expands patient rights, especially the right to participate in the care planning process. This change correlates with final rules for Medicaid that were released by CMS that also stresses the need for a person centered plan of care and the patient’s participation in the care plan process.

LeadingAge developed for members a set of Checklists that delineate the requirements of the new home health Conditions of Participation (HHCoPs) published in the final rule and the actions needed to be in compliance.