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Revised Conditions of Participation – Part 4

Two More Conditions of Participation

The next two conditions apply to the people who visit patients on behalf of your agency regardless of whether they are directly employed or contract personnel.

Skilled Professionals

Skilled professionals include nurses, therapists (Physical, Occupational and Speech) and Social workers.  The qualifications are expanded upon under another Condition of Participation, §484.115 Personnel qualifications.  So, this standard is as follows:

484.75 Condition of participation: Skilled professional services

Services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications.

Responsible for:

  • Ongoing interdisciplinary assessment of the patient;
  • Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s);
  • Providing services that are ordered by the physician as indicated in the plan of care;
  • Patient, caregiver, and family counseling;
  • Patient and caregiver education;
  • Preparing clinical notes;
  • Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care;
  • Participation in the HHA’s QAPI program; and
  • Participation in HHA-sponsored in-service training.


  • Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist
  • Medical social services are provided under the supervision of a social worker


  • Ensure that all employees are aware of responsibilities to QA program.
  • Begin involving entire agency now.
  • Clarify care coordination roles for nursing and therapists
  • Review recent charts for evidence of communication, patient teaching and collaboration. If unable to identify these elements, revise policies and educate staff.
  • When the above elements are identified, share the documentation with staff as examples of what is expected.

484.80 Condition of participation: Home health aide services

The requirements for home health aide services are  extensive.  The first section reviews what is to be included for agencies that train their home health aides.  Most agencies I work with hire home health aides who have a certificate from a trade school or hospital, etc.  Since the training requirements and competency requirements are very similar, I made you a short list of all the required elements.  home-health-aide-training.

This section is for the rest of you that hire qualified home health aides.  Your responsibility is to assess competency and supervise these valuable employees.

As an aside, you won’t find anything about criminal history background checks here.  This does not mean you do not have to run a background check that meets your state’s standards.  My go to guy for over 15 years Ernie of EF Research.  He pretty much knows everything about background checks and can run them faster than the state police in most cases.   If you know of any other resources, please post in comments.

Back to home health aide competency which is to be assessed before an aide is assigned patients.

Competency must include:

  • Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff.
  • Observation, reporting, and documentation of patient status and the care or service furnished.
  • Reading and recording temperature, pulse, and respiration.
  • Basic infection prevention and control procedures.
  • Basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor.
  • Maintenance of a clean, safe, and healthy environment.
  • Recognizing emergencies and the knowledge of instituting emergency procedures and their application.
  • The physical, emotional, and developmental needs of and ways to work with the populations served by the HHA, including the need for respect for the patient, his or her privacy, and his or her property.
  • Appropriate and safe techniques in performing personal hygiene and grooming tasks that include –
    • Bed bath;
    • Sponge, tub, and shower bath;
    • Hair shampooing in sink, tub, and bed;
    • Nail and skin care;
    • Oral hygiene;
    • Toileting and elimination;
    • Safe transfer techniques and ambulation;
    • Normal range of motion and positioning;
    • Adequate nutrition and fluid intake;
    • Recognizing and reporting changes in skin condition; and
  • Any other task that the HHA may choose to have an aide perform as permitted under state law.

Underlined tasks must be performed by observation of the aide with a patient.  The remaining tasks may be observed directly or competency may be assessed through oral or written exam.


If home health aide services are provided to a patient who is receiving skilled nursing or therapies, a registered nurse or other appropriate skilled professional makes a visit no less than every 14 days.  The supervision visit must be made by a skilled professional who is familiar with:

  • the patient,
  • the patient’s plan of care,
  • and the written patient care instructions

If an area of concern in aide services is noted by the supervising registered nurse or other appropriate skilled professional, then the supervising individual must make an on-site visit to the patient’s home in order to observe and assess the aide while he or she is performing care. (Present Supervisory Visit).

If the deficiency in aide services is verified during an on-site visit, then the agency must conduct, and the home health aide must complete a full competency evaluation.   That’s three things.  Here they are again.  I like lists.

  1. A deficiency is observed during a supervisory visit
  2. The Supervising nurse or other skilled professional will perform a present supervisory visit, and if a deficiency is observed;
  3. The aide’s competency is assessed again.

For agencies providing home health aide services paid for by Medicaid, (waived services), the aide’s competency may be abbreviated to include only those tasks that are specific to the patient.


  • Verify competency now
  • Educate nurses and therapists regarding elements of competency defined by new CoPs.
  • Determine how your staff becomes familiar with the patient and commit it to policy.
  • Improve your hiring process to exclude candidates who do not have the dedication required to meet and exceed your standards.
  • Double up on education.  It will be less expensive to improve your home health aide services than investigating multiple complaints and your patients will appreciate excellent home health aide services as opposed to merely adequate.

None of this will be difficult for most agencies but when considering the patient rights condition which includes complaints together with the supervisory requirements in the home health aide services condition, a bad hire could be costly.  I’ve known agencies to skimp on competency because of a sudden need for a new aide.  This can’t happen anymore.  It shouldn’t have happened in the past.

Stay tuned.  The best is yet to come.

Condition of Participation Part 3

Quality Assessment Performance Improvement

Here’s some good news.  This provision replaces the former conditions at §484.16, “Group of professional personnel,” and §484.52, “Evaluation of an agency’s program.”  Those annual meeting minutes are now going to look suspiciously like QA reports.  I will miss being a community representative at all those dinners and want to point out that there is nothing in the CoP’s prohibiting agencies from taking their favorite consultant to dinner.

Agencies are free to design their own QA plans and formats as long as they include the following elements plus the infection control component below.

  1. Use of objective measures to demonstrate improved performance (Julianne’s note: Whenever possible, use data that is already being collected like OASIS or HHCAPS)
  2. Tracking performance to ensure that improvements are sustained over time
  3. Setting priorities considering prevalence, severity of identified problems; giving priority to activities affecting clinical outcomes
  4. Reflect the scope, complexity and past performance of the agency and documentation of projects.

Many agencies are already doing this and many are not.  Agencies that are accredited by the JCAHO, CHAP and ACHC and adhere to their standards are probably compliant but there are also agencies who choose to focus on dumb stuff that never actually happens to avoid looking bad.  Surveyors are not generally impressed when you show that 100 percent of your nurses now wear agency approved socks to match scrubs in the home environment.  The point is to make the focus of your work matter to your patients.

To determine what matters to your patients, have a meeting with all the visiting staff.  Where are the cracks and what is falling through them?  Examine all hospitalizations in the past quarter.  Ask patients and their caregivers.

Quality Assurance is not only about reading notes as they come into the agency.  It does not require an advanced degree and elaborate diagrams, either.  Somewhere in between these two extremes lies the sweet spot for an effective QA plan.  As you design or re-design your plan and implement it, avoid comparing it to someone else’s.  The only criteria are that it contains these elements and that it works to measure the improvements your agency make’s in patient care.


  • Determine if your agency’s plan incorporates all four requirements
  • Have meeting with a simple agenda so leadership knows what activities are currently being undertaken and determine how to expand upon them so that your plan meets these guidelines.
  • Use OASIS data or other assessment elements if appropriate to avoid additional data collection.
  • Chose projects that focus on patient care.
  • Call computer vendor to determine what reports may be used.
  • Learn to make pretty charts in Excel or Word and then post them for your staff to see.


Infection prevention and control

I was surprised to find that Infection control was a new addition to the Conditions of Participation.  There are state standards and OSHA standards that apply to home health.  The CDC does not have authority to ‘mandate’ actions but OASIS typically defers to the CDC’s extensive research to determine their course of actions.  But the conditions of participation have been silent all these years.  So, just in case you were not doing it right for other regulatory bodies, here’s some instructions on how to do right within the confines of the CoP’s.

The agency must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s QAPI program.

Infection Control must include:

  • The use of accepted standards of practice, including standard precautions, to prevent the transmission of infections and communicable diseases;
  • A method for identifying infectious and communicable disease problems;
  • A plan for the appropriate actions that are expected to result in improvement and provide infection control education to staff, patients, and caregivers.

That’s all for today.  Questions and comments may be posted below.

.  Stay tuned for more.

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.

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.


The Work Plan

The Office of the Inspector General (OIG) posted its work plan online in the fall of last year.   It describes the areas that are of interest to the OIG and where they expect to find problems with Medicare providers.  For those of you who are unfamiliar with the OIG, this is how the OIG describes its mission:

Office of Inspector General’s (OIG) mission is to protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries.

In short, the OIG is the Medicare police for our purposes.  Medicare and Medicaid, as well as other programs lie in the domain of the department of Health and Human Services.  When providers do not respond to gentle persuasion from a MAC or ZPIC to clean up their acts, they may be referred to the OIG.  Alternatively, when a provider blatantly commits fraud, they may become the subject of an OIG investigation.  The OIG does not call upon providers to congratulate them on a job well done; nor do they investigate half-baked conspiracy theories by a lone disgruntled employee who calls to report fraud.  The Office of the Inspector General has enormous resources available to identify potential fraud and they have credible information prior to initiating an investigation.

Understanding what the OIG has on its agenda for this year is a good place to start in your efforts to stay off their radar.  Here’s the part of the plan that addresses home health care and hospice providers


The OIG work plan restates that when a beneficiary elects hospice care, the hospice agency assumes the responsibility for medical care related to the beneficiary’s terminal illness and related conditions.  The OIG will review medical records and billing documentation to determine if billing was compliant.

Although this seems bland, consider that the hospice regulations for the past two years have clarified the definition of terminal illness, with good reason.  In recent years, some hospice providers have chosen a single diagnosis to represent the terminal diagnosis and have not covered medications or treatment for related conditions.  In some instances, the hospice providers did not cover pain medication if the pain was caused by a condition other than the terminal illness.  (Example:  pain meds for arthritis for a patient with terminal heart failure.)

The hospice Conditions of Participation (CoPs) at §418.56(c) require that the hospice must provide all reasonable and necessary services for the palliation and management of the terminal illness, related conditions, and interventions to manage pain and symptoms.

The regulations further state:

…we believe that the unique physical condition of each terminally ill individual makes it necessary for these decisions to be made on a case by case basis. It is our general view that hospices are required to provide virtually all the care that is needed by terminally ill patients.” Therefore, unless there is clear evidence that a condition is unrelated to the terminal prognosis, all conditions are considered to be related to the terminal prognosis and the responsibility of the hospice to address and treat.

The conditions of participation have been in effect since 1983 and the guidance regarding terminal illness has been restated in the federal regs for the last two years.  It would be no surprise if hospice clinical and billing records were reviewed to ensure that virtually all care was covered and those rare instances where care was not covered were explained in the clinical record.  But, we could be wrong.  Those hospice providers who insist that we are  will find out soon enough.

The OIG will also evaluate whether a hospice provider scheduled as visit by a registered nurse at least once every two weeks to oversee the Interdisciplinary Teams  adherence to the plan of care and determine if changes are needed.

This came up in ZPIC investigations last year when many claims were partially denied when the meeting notes for the IDT team meeting that occurred just prior to the claim dates under review, were omitted from the documentation.   If the IDT meeting was held on the 20th of the month and a claim beginning on the first of the following month is chosen for review, the IDT meeting documentation from the 20th of the prior month was to be included in the clinical records submitted for review.  When this did not happen, the days until the next IDT meeting were denied and the reason given was that the updated plan of care was not included.

2017 is not the year to relax your standards on documentation.

Home Health

The OIG work plan notes that in 2014, up to 51 percent of claims, as determined by Comprehensive Error Rate testing were not compliant with billing regulations.  Really?  Half of all claims?

The OIG work plan further goes on to say:

‘Improper payments identified in those OIG reports consisted primarily of beneficiaries who were not homebound or who did not require skilled services.’

But there’s more.  The OIG believes that fraudulent home healthcare agencies might intentionally omit some patients from the lists provided to state surveyors conducting recertification surveys to avoid scrutiny.  Because the state surveyors do not have access to claims data, they have no way of knowing if a patient has been ‘archived’ prior to running a patient report.  It will be interesting to see what happens to agencies who are deliberately withholding information from a surveyor.


When the OIG tells providers where they will be looking for fraud and abuse we question the decision to ignore it.   Yet, many providers are convinced that they are too small to warrant the attention of the OIG or other Medicare contractors.  Others reason that since they have operated in the dark for so many years and been paid, they will continue to be paid even when they demonstrate careless disregard for the regulations.  Of course, our favorite is the rationale that everyone else does it.  It simply is not true – thousands of profitable providers are making good money by doing the right thing and they get to keep it.  They may not drive high end luxury automobiles or live in an exclusive gated community if they have a small to mid-sized provider but they don’t have to worry about who will feed their cat while they are in a federal penitentiary.

There are any number of ways to improve documentation and compliance to payment regulations but there are even more rationales that providers use to justify shortcuts.   Absolutely nothing happens until senior leadership places compliance and education high on the priority list and understanding that compliance includes documentation.   The best care in the world will be denied under review if the documentation does not demonstrate patient eligibility and then it is often too late.

The OIG Work Plan for 2017 is easy to read and well organized.  Download it and share with your staff.  When the senior leadership in your agency buys into compliance on the front end, call us.  We can help.  We can also help defend your ADRs but our success depends on the quality of the documentation requested by your payor sources.  Just saying.

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