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Revised Conditions of Participation

Do you remember when you were new to home health and you really wished someone would tell you what the CoP’s were and why they mattered?  Let’s spend a minute with our newer colleagues so they won’t feel lost as our industry turns its attention to the revised Conditions of Participation in the next few months.

The Conditions of Participation are a set of Medicare guidelines that every home health agency must follow if they bill and get paid by Medicare.  These guidelines apply to every patient in an agency regardless of who is paying for care.  Therefore, certain elements common to our practice such as assessing homebound status are not present in the CoPs because a private payor source may elect to pay for care without regard homebound status.  But all patients have rights and all clinical records must include certain elements, etc.  Failure to meet one or more CoP’s usually results in a survey deficiency but continued non-compliance is grounds for civil monetary penalties or revocation of a provider number.  When the term ‘compliance’ is used, it includes compliance to the CoP’s.

Got it?  Let’s move on.  If you are still confused, email us for more boring details.

The 2017 update, effective in July of this year, to the Medicare Home Health Conditions of Participation are extensive.  As I read them, I made my own ‘cheat sheet’ adding questions and courses of action that might be followed to comply with the new CoP’s.  It Is important to note that I am sharing them as I interpreted them.  I have also posted the CoP’s with all the public comments as well as the pared down version.

Click Here for the full version with comments

Click Here for just the CoP’s without the discussion.

The Conditions of Participation are being revised in part because:

Ensuring quality through the enforcement of prescriptive health and safety standards, rather than improving the quality of care for all patients, has resulted in our expending much of our resources on dealing with marginal providers, rather than on stimulating broad-based improvements in the quality of care delivered to all patients.

A new condition – QAPI – is designed to ensure that agencies look at data and design activities to improve outcomes agency-wide.  Other conditions have been changed to expand the focus to all patients and improve outcomes.

It is rare that I heartily agree with Medicare rule makers but I am on board.  I hope you jump on board as well.

484.45 Reporting and transmission of OASIS data

No significant changes were made to this condition except the requirement that agencies have a dedicated phone line for OASIS transmission was removed since agencies are already transferring electronically over the internet.

§484.50 Condition of participation: Patient rights.

New rights.

  • Verbal notification of rights in a language and manner that the individual understands is required for patients who are unable to read.
  • The names, addresses, and telephone numbers of specified State-funded and federally-funded entities.
    • Agency on Aging
    • Center for Independent Living
    • Protection and Advocacy Agency,
    • Aging and Disability Resource Center; and
    • Quality Improvement Organization.
  • The right to access auxiliary aids and language services, and how to access these services.

Retained Rights

You should recognize these.

  • An HHA must provide the patient and representative (legal or patient-selected) with an oral and a written notice of the patient’s rights in a manner that the individual can understand. The HHA must also document that it has complied with the requirements of this section.
  • An HHA must document the existence and resolution of complaints about the care furnished by the HHA that were made by the patient, representative, and family.
  • An HHA must advise the patient in advance of the disciplines that will furnish care, the plan of care, expected outcomes, factors that could affect treatment, and any changes in the care to be furnished.
  • An HHA must advise the patient of the HHA’s policies and procedures regarding the disclosure of patient records. (HIPAA Privacy Notice?)
  • An HHA must advise the patient of his or her liability for payment.
  • An HHA must advise the patient of the number, purpose, and hours of operation of the state home health hotline.


Transfer and Discharge Rights

Seven conditions allow for a patient transfer or discharge:

  • MD and agency agree that agency can no longer meet patient’s needs due to acuity (This does not include patients for which payment will be made but care will be expensive)
  • Patient or payer will no longer pay for services
  • MD and agency agree goals met
  • Patient refuses care or requests transfer/discharge
  • Disruptive behavior after remediation has been attempted (Documented disruption and Documented Remediation attempt)
  • Patient death
  • Agency death

Investigation of Complaints

Very specific requirements are written into the CoP’s regarding patient complaints.  Agencies must:

Investigate complaints by patient or patient representatives, caregivers or family regarding care received (or not received), care furnished inconsistently or inappropriate care.

Mistreatment, neglect or verbal, mental, sexual and physical abuse including injuries of unknown source and or misappropriation of patient property by anyone caring for the patient on behalf of the agency.  Additionally, if an employee (or contracted employee) sees signs of the mistreatment described above, they must report it immediately to the agency and to other appropriate authorities in accordance with state law.

Complaints must be documented and the agency must take measures to prevent recurrence.

Actions to get ready now:

  • Revise forms to include required new elements.
  • Determine if there is a state or federally funded Agency on Aging, Center for Independent Living, Protection and Advocacy, Aging and Disability resource center or a QIO who serves your area. Gather contact information to include on forms.
  • Provide additional training on elderly abuse.
  • Schedule an inservice with each of these agencies so that visiting staff will be able to make appropriate referrals and answer patient questions.
  • Review complaint policy and implement now. Agencies accredited through JCAHO, CHAP and ACHC must already do this.  Many states have state requirements
  • Review documentation to determine if the new forms are being used and documentation supports that the patient received their rights.
  • Review every discharge to determine if the reason for discharge included on the seven acceptable elements. Revise Discharge form if possible to ensure compliance.  Add an ‘Other’ option and do not bill on these claims until the Clinical Director has approved the discharge.
  • To minimize problems with the discharge requirements, re-educate staff on the use of the Advance Beneficiary Notice.
  • Educate staff six ways to Sunday.

Not every agency must complete every action to comply.  Many agencies are already doing the majority of the work required to meet the Revised Conditions of Participation.  These are ideas that came to me as I was making notes and I am certain that my list of proposed actions is far from complete.  If you have other suggestions, please post in comments below or email me.  With six months left, there is a chance we could actually do this right.


3 Comments Post a comment
  1. Bonita Gillenwater #

    Under Discharge/Transfer section I have a question. Many agencies will refuse to take a patient back when hospitalized – mainly due to complexity/too expensive. Is there some protection for the patient to grieve this decision, as well as the physician? We give the NONMC to prepare a patient.

    February 25, 2017

    • I had the same thought. The agency must adhere to its admission policies and act without regard to individual patients. If an agency will accept most wound care patients but not those that require very expensive wound dressings or a high frequency of visits, there may very well be grounds for a complaint. Agencies will always welcome with open arms those patients who are expected to be discharged after a few visits that do not cost very much. For example, many knee replacement patients are no longer homebound after a couple of weeks. If five or more visits are complete, the agency is paid the full amount of the HHRG. There will also be the occasional high dollar patient that costs the agency money. Everything else aside, (and there’s a lot being put aside), it is a very poor business decision to focus so much attention on the details of individual patients instead of managing the entire agency as a single entity. A single patient does not make or break an agency.

      If the agency is found to be cherry picking patients, the best consequence would be that it loses respect within the nursing community, physician referral base and state regulatory bodies. It would likely be a survey deficiency to deny admission to a patient that meets admission criteria. The state hotline would be a good place for the patient to start.

      February 27, 2017

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