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More Conditions of Participation

484.55 Condition of participation: Comprehensive assessment of patients.

Most agencies will not find it difficult to comply with the requirements in the Comprehensive Assessment because they are already assessing these areas.  The fact that ‘Cognitive Status’ which is already included in the OASIS data set and ‘Patient Goals’ are now mentioned in the Conditions of Participation may be an indicator of exactly how serious Medicare is about changing their focus to a patient centered approach to care and outcomes as opposed to the more punitive approach of hunting for agencies that disregard regulations.

The biggest change regarding the Initial Assessment that I see is that the Occupational Therapist is now able to complete the initial visit if OT is the only service ordered by the MD and if the need for OT establishes Medicare Eligibility.  Welcome to the world of Admits, OT’s.

Content of Comprehensive Assessment

  • Current health; functional and cognitive status
  • strengths, goals and care preferences
  • Continuing need for home care
  • Review of all medications (Identify potential adverse reactions, ineffective drug therapy, side effects, significant drug reactions, duplication and noncompliance with meds.
  • Patients primary caregiver and other available support
    • Willingness to provide care
    • Availability and schedules
    • Patients representative if any
  • Incorporation of OASIS data

Recertification visits are still done within the same time frame (days 56 through 60 of episode).  Resumption of care visits are done within 48 hours of the patient’s return to home OR on physician ordered ROC date.

Plan of Care

Patients are accepted for treatment on the reasonable expectation that the agency can meet medical, nursing, rehab and social needs in the home.  Care plan must specify the care and services to meet specific needs identified in the comprehensive assessment.

Plan of Care contents

  • All pertinent diagnoses
  • Mental, psychosocial and cognitive status
  • Types of services, supplies and equipment required
  • Frequency and duration of visits to be made
  • Prognosis
  • Rehab potential
  • Functional limitations
  • Activities permitted
  • Nutritional requirements
  • All Medications and Treatments
  • Safety Measures
  • Risk for Emergency dept visits and rehospitalizations
  • Measures to mitigate risk of above
  • Patient and caregiver education
  • Specific interventions and education
  • Measurable outcomes and goals mutually identified by the patient and agency
  • Advance directives
  • All orders

Each patient must receive a copy of their plan of care.

Additionally, each patient is to receive written instructions that include:

  • Visit schedule
  • Med list with names, dosages and any meds to be administered by agency
  • Any treatments including those administered by agency or persons acting on behalf of agency including therapy.
  • Any other pertinent instructions specific to the patient’s care needs
  • Name and contact information of the agency clinical manager.

Revision of POC

There is nothing new here but something has been removed.  There is no requirement that a 60 day summary be sent to the physician.  It shouldn’t be needed if agencies abide by the following.

  • The plan of care must be reviewed and revised by the physician responsible for the home health plan of care at least every 60 days .
  • Agency MUST promptly alert relevant physicians to any changes in the patient condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered.
  • Revised plan must reflect current information from updated OASIS and contain information about progress to goals.
  • Revisions must be communicated to the patient, representative (if any), caregiver and all physicians issuing orders for the plan of care.
  • Revisions related to discharge planning must be communicated with all of the above plus the patient’s primary care practitioner or other healthcare professional who be providing care for the patient in the community.

Conformance with MD Orders

  • Drugs, services and treatments are administered only upon the order of a physician.
  • Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, and after assessing for contraindications.


  • Review the way your agency handles plans of care and ensure your process includes a mechanism for dissemination of information to all physicians writing orders for a patient.  Review or develop a vaccine policy that allows for administration of flu and pneumonia vaccines according to a well-written protocol developed in conjunction with a physician.
  • Most agencies will have to expand the collection of information related to caregivers and availability.
  • Begin now to audit admissions for the requirements set forth in the CoPs.
  • Begin reviewing admissions using a tool based on the new requirements.  admission-review-tool.pdf  Modify to fit the needs of your agency.
  • Educate your staff.

More Later.  And to think, we haven’t even looked at Quality Assurance, yet.

6 Comments Post a comment
  1. sahily #

    Good dissertation of this part of the CoP’s.
    I tried to click the link (see example) and it says not found.
    As always,
    Thank you.

    February 15, 2017

    • Sally,

      Try again. I think it has been fixed!

      More to come. These revisions are both extensive and scattered throughout the old regs.

      February 15, 2017
  2. Sharon Phillips BSN #

    What would your suggestion be for a hospital that will not say no to a referral that our home health agency cannot meet within the 48-hour discharge? If the doctor signs a verbal order that SOC is acceptable for a later day will it meet Medicare’s requirement?

    February 16, 2017

    • If a physician orders a specific start of care date, admission on that date meets the requirement but is in total disregard of the intent if the delay is because the agency cannot accept the patient earlier because of staffing issues. As an agency, you cannot override an MD order but delaying an admission for the sake of convenience is putting patients at risk. Furthermore, I wonder what a physician would say if interviewed – or deposed. Would he or she readily state that it was their practice to give orders to admit patients according to agency preference?

      Most hospitalizations happen within the first three weeks of admission and about half of those occur within the first week. Patients may not understand their meds or be able to have them picked up from a pharmacy. Wounds may become infected because of an unsafe home environment or a fall may occur, etc. Delaying admission is putting patients at risk and that is never acceptable regardless of whether you meet the CoPs.

      But all agencies have difficulties with staff at times. One option is to remember that you have five days to complete an initial assessment. A nurse can go out and begin an assessment focusing on the risk areas that present the greatest threat to the patient and later in the first five days, complete the assessment. Most patients admitted from an acute care hospital will benefit from more than one visit in the first week of services. If not, ask if they really need services. If the honestly do not need more than one visit, your agency can provide a non-billable visit once in a while.

      If that is not an option, refuse the admission regardless of your job. It would be highly unlikely that you would be fired for refusing to admit a patient you cannot care for assuming that there is another agency in the area that can care for the patient. Regardless of who signs your check or issues your license, your first responsibility is to the patients.

      February 16, 2017
  3. Miriam Blankenbiller #

    Hi, on a CMS conference call last week, they said that O.T.’s were still not allowed to admit patients…. I may have heard that wrong, but…

    February 16, 2017

    • Thank you so much for letting me know this. I don’t doubt that you heard this but I am confused as to whether the information given on the CMS call was correct. I have left a message with someone at CMS to clarify. It was our good fortune that there are three contact numbers on the expanded version of the regs.

      A variation of what is pasted below is written twice in Condition §484.55

      (3) When physical therapy, speech-language pathology, or occupational therapy is
      the only service ordered by the physician, a physical therapist, speech-language
      pathologist or occupational therapist may complete the comprehensive assessment, and
      for Medicare patients, determine eligibility for the Medicare home health benefit.

      One of the places I found that is under the standard of ‘Initial Visit’.

      I will verify this and keep everyone updated. Meanwhile, if someone else hears something, please update me.

      February 16, 2017

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