NAHC Submits Comments to CMS on the Proposed Rule for the Home Health Conditions of Participation
January 15, 2015 03:37 PM
The National Association for Home Care & Hospice recently submitted comments to the Centers for Medicare & Medicaid Services (CMS) on the proposed rule for the home health conditions of participation (HHCOPs). CMS issued the proposed rule on October 8, 2014 with a 60-day comment period. The comment period was extended by an additional 30 days, to January 7, in response to requests from NAHC and others within the industry.
The proposed revisions to the HHCOPs focuses on a patient-centered, data driven, outcome-oriented process that promotes high quality of care, while at the same time eliminating unnecessary procedural burdens on HHAs. While NAHC agrees that many of the proposed changes will result in improved patient care by allowing agencies to focus their efforts on processes and initiatives that have a direct impact on high-quality care, there were several areas that raised concerns. NAHC recommended for following in the comments that it submitted:
As a general comment, NAHC requested that CMS clearly indicate in the rule what actions are required of home health actions that must be communicated in writing. While there are a number of standards that specifically reference written or verbal notice, there are others that leave it open to interpretation.
Establishing and revising the plan of care (POC), including receiving a copy of it:
CMS proposed to require that the agency provide the patient with a copy of the POC and any revisions to the POC. NAHC urged CMS to review the requirement in terms of the magnitude and complexity it will be to implement. As an alternative, NAHC proposes permitting the agency to inform the patient of the plan of care and revisions verbally in a manner the patient understands, and require that the agency document in the medical record that the information was provided. The written POC could be provided when requested by the patient.
Plan of care to include patient-identified goals, and anticipated risks and benefits:
CMS should clarify what is required for compliance with meeting patient identified goals when those goals are unclear or unrealistic.
Be advised of the names, addresses, and telephone numbers of pertinent, Federally-funded and State funded, State and local consumer information, consumer protection, and advocacy agencies:
CMS proposes to require that agencies provide information for a broad number of consumer and advocacy agencies. Agencies should have the flexibility to determine, based on their patient population, which organizations are appropriate to be included in order meet this requirement. Additionally, CMS should require that state surveyors develop a comprehensive list and make it available to patients and their families online.
Transfer and discharge:
CMS proposes to set out the conditions for permitted patient discharges. NAHC commented on two areas for discharge/transfer reasons: discharge/transfer related to acuity of the patient, and discharge/transfer related to cause.
NAHC recommended that the rule be revised to require that an HHA inform the patient’s physician that it cannot adequately meet the patient’s needs, not that it secure the physician’s agreement, and delete the restricting phrase “based on the patient’s acuity.”
Additionally, NAHC believes reasons for cause should not be limited to disruptive, abusive, or uncooperative behavior. Rather, the rule used these as examples for when it would be appropriate for an agency to transfer or discharge a patient, but not represent a complete list of causes justifying discharge or transfer.
NAHC also strongly recommend that the rule provide the flexibility in terms of the HHA’s actions to initiate a discharge immediately, prior to the steps set out in (5)(1) through (iv). For example, where staff are at imminent risk of harm, the HHA should not need to first advise the patient that a discharge for cause is being considered followed by efforts to resolve the problems presented.
Investigation of complaints:
The provision requires definitive action from HHA staff or contractors that may be beyond the control of the HHA. Also, it sets a standard that needs to be integrated with potentially conflicting state law requirements.
Finally, it provides no protection to the HHA staff from reprisal, nor does it permit anonymous reports. The proposed rule should be revised to require that HHAs establish policies and procedures for staff reporting of incidents in a manner and means consistent with state laws. In the absence of such state law, the HHA policies should permit an anonymous report
Comprehensive assessment of the patients:
CMS, in the propose rule maintained, the requirement that the registered nurse conduct the initial and comprehensive assessment when both nursing and therapy are ordered. NAHC requests that CMS permit either the RN or the therapist to conduct the initial and comprehensive assessment, as required by the POC, when both disciplines are ordered at the initiation of care.
NAHC also requests that CMS delete the requirement that the clinical professional who responsible for the comprehensive clinical assessment is also responsible for a Medicare eligibility assessment.
In the past, CMS had stated that they would reconsider restrictions on conducting the initial and comprehensive assessments. NAHC was surprised to see that CMS had not altered their policy.
Conformance with physician orders:
CMS proposed to require that the RN or qualified therapist time and date verbal orders. NAHC request that CMS maintain the current standard that verbal orders be signed and dated with the date of receipt by the RN and or qualified therapist, and eliminate the word “time”.
Methods to maximize physician involvement in the patient’s care:
CMS is seeking recommendation to increase physician involvement in home health patients.
NAHC urges CMS to use their demonstration authority to develop a care delivery model that would test the use of Nurse Practitioners (NPs) as primary care practitioners for home health patients.
Quality Assessment and Performance Improvement and Infection prevention and control program:
Both the QAPI and infection control programs are new Conditions of Participation. Given the time, effort, and investment required to implement the new CoP, NAHC urges CMS to provide ample time for all agencies to comply with the new CoP – and to consider phasing in the requirements of the proposed QAPI Program.
Content and duration of home health aide classroom and supervised practical training:
CMS proposes to add several new subjects to the home health aide training program. NAHC urges CMS to allow the effective date for compliance to be phased in to accommodate those aides currently employed by the agency, and to permit the agency to provide the training through in-service training.
CMS proposes to prohibit the agency from using its equipment for patient self-testing, except in limited circumstances. CMS should allow the agency the flexibility to use their own equipment as determined by the patient’s needs and choice when assisting with self-testing.
It is unclear the extent to which - or even if - the administrator may be shared among agencies. NAHC recommends that CMS permit the administrator to be shared among commonly owned organizations if they can demonstrate that the administrator is able to fulfill all the proposed requirements.
The clinical manager position is a new designation. NAHC requests CMS to clarify how the agency can best meet the requirements. This might require delegating tasks to others, including therapists or non-skilled personnel, for a large agency or combining the duties with the administrator in a small agency.
CMS maintains the requirement that at least one service be provided in its entirety by an employee of the agency. NAHC argues that HHAs should be permitted to provide unlimited services under arrangements both by individuals or other agencies or organizations.
CMS should enforce the home health regulations that require oversight and control of services by the certified providers regardless of whether the persons providing care are employees or contractors. This requirement does not fit within the current health care service economy and workforce market. The “service directly requirement” is a proxy for establishing quality assurance in the provision of care.
Medicare maintains an outdated and unfounded belief that an employed caregiver is more capable of providing high quality services to patients than a contracted caregiver. Arbitrary staffing/contractor ratios do not ensure quality of care. Existing and proposed quality, coordination, and supervision of regulations and guidelines, if enforced, can serve to ensure quality of care to Medicare beneficiaries.
Discharge or transfer summary:
CMS proposes that a discharge/transfer summary contain elements that go beyond what is necessary for a typical summary. Additionally, it is unclear when the transfer summary would be required. Further, the agency would need to provide the summary to the receiving medical professional within seven calendar days, and to a facility receiving the patient within two calendar days.
NAHC recommends CMS allow professional standards of practice to dictate what should be communicated in a discharge/transfer summary to health care professionals assuming care of the patient. NAHC further urges CMS to replace “calendar days” with “business days,” and to require that a transfer summary be required only if the agency is discharging a patient to a facility.
Elimination of subunit designation:
NAHC urges CMS to provide ample time for agencies to convert a subunit to either a parent or a branch. CMS should require the Medicare state survey agencies to reprioritize to Tier 1 any approvals related to a subunit transitioning to a parent or a branch.
Also, efforts must be coordinated among all affected departments within CMS to ensure that claim processing related to a subunit transition is uninterrupted.
To view the NAHC’s full comments, please click here.