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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.

Face to Face Documentation Guidance

I have received several denials on face to face documents because the signature was not dated.  Would somebody please tell Palmetto GBA to lighten up a minute and read the regulations?   I would do it myself but I am busy trying to get y’all paid.

The Benefit Integrity Manual Section reads as follows:

For medical review purposes, if the relevant regulation, NCD, LCD and other CMS manuals are silent on whether the signature must be dated, the MACs, CERT and ZPICs shall ensure that the documentation contains enough information for the reviewer to determine the date on which the service was performed/ ordered.

If you read carefully the actual face-to-face guidance, it is, in fact, silent on the whether the signature must be dated.  Here is what I cut and pasted from the Benefit manual. 

The documentation must include the date when the physician or allowed NPP saw the patient, and a brief narrative composed by the certifying physician who describes how the patient’s clinical condition as seen during that encounter supports the patient’s homebound status and need for skilled services.

The certifying physician must document the encounter either on the certification, which the physician signs and dates, or a signed addendum to the certification. It may be written or typed.

It is acceptable for the certifying physician to dictate the documentation content to one of the physician’s support personnel to type. It is also acceptable for the documentation to be generated from a physician’s electronic health record.

It is unacceptable for the physician to verbally communicate the encounter to the HHA, where the HHA would then document the encounter as part of the certification for the physician to sign.

Not only is the regulation silent about dating the signature on the face-to-face document, it references the signed and dated certification which for most agencies is the 485.  I am unable to infer that the regulations imply that the signature on the face-to-face document must be dated because it is illogical for the guidance to reference one mandated date and not the other. 

Does anyone disagree with me?  If the face-to-face document is sent after the 485, it would be difficult to prove that it was received prior to billing if it was not dated.  That is not my problem.  My problem lies in trying to figure out why Palmetto is playing so dirty with providers and working around their attitude to get my clients paid.

Let’s move on, shall we?  If they can play dirty, so can I.  Louisiana is home to swamps and New Orleans.  I know dirty.

The following are some examples of what Palmetto GBA considers to be inadequate documentation.

  • Diagnosis alone, such as osteoarthritis
  • Recent procedures alone, such as total knee replacement
  • Recent injuries alone, such as hip fracture
  • Statement, ‘taxing effort to leave home’ without specific clinical findings to indicate what makes the beneficiary homebound
  • ‘Gait abnormality’ without specific clinical findings
  • ‘Weakness’ without specific clinical findings

In the first three bullets, note the word, ‘alone’.  I wholeheartedly concur with them.  But, what if the diagnosis is accompanied by the procedure and the injury.  Suddenly, they are not alone.

The Medicare Benefit Manual defines homebound status for us as such:

An individual does not have to be bedridden to be considered confined to the home. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort.

I am fairly certain many of you have read that before.  If the definition suits Medicare, why is Palmetto above accepting it.  I understand that I can cut and paste those words anywhere.  If I saw a face-to-face with a single diagnosis of hypertension and the Medicare language for homebound, I would think twice about the validity of the document but that’s not what is happening.

I just finished with an appeal for a patient who was admitted post discharge from the hospital for pneumonia, sepsis, COPD and CHF.  The physician wrote that it was a taxing effort for this 85 year old to leave the home.  Well, I guess so.  Evidently, Palmetto GBA needs more information to arrive at the same conclusion.

Would a reviewer who could not understand why a patient with Sepsis, pneumonia, COPD and CHF would be short of breath, could they possibly distinguish between the eight different types of gait abnormalities related to neurologic conditions alone.   See 5th bullet.  (hemiplegic, spastic diplegic, neuropathic, myopathic, Parkinsonian, choreiform, ataxic (cerebellar) and sensory.)

Weakness – last bullet – is a good reason to stay home.  I don’t see the issue here.  Obviously, there should be something wrong with the patient that causes weakness but what specific clinical findings go with weakness?  “Patient was unable to complete ten reps with 20 pound bar?”

If I wrote a face to face, I would put something like:

Ms. Jane Deaux was seen by me on September 16, 2013 on the last day of her hospitalization for sepsis, pneumonia, COPD and CHF.  She spent 9 days in the ICU in a condition that is generally considered to be incompatible with life.   Without any regard to the rising cost of health care, the old woman refused to die.

She continues to complain about being short of breath and tired and refuses to accept that this is part of the aging process.    She has also called the office complaining of falls.  Reluctantly, I ordered physical therapy even though it is an expensive treatment modality for someone who might very well end up dying in less than a year.

She is confined to the home because she cannot breath very well when ambulating and getting to her car requires her to walk a short distance.  This ‘shortness of breath’ is caused by the inability oxygen to cross the alveolar membranes in the lung tissue resulting in a very low partial pressure of oxygen in her arterial blood.  The low PO2 manifests itself in a bluish cyanotic pallor which causes the patient to be self conscious as it draws unwanted attention from strangers.  Because carbon dioxide is not blown off in normal respiratory effort, her pH decreases causing her to become acidotic which leads to extreme electrolyte imbalances resulting in cardiac dysrhythmias expressed outwardly by symptoms of lightheadedness, falling, loss of consciousness, broken bones on impact and death.  As such I certify that it requires a considerable and taxing effort for this patient to leave the home.

I dare you.  I double dare you.  Find a doc and let him use this as a template.  Have the physician edit to fit the patient and see if it gets paid.  Just sayin…

Homebound Status

Last week, I posted about two patients who were driving but otherwise met the homebound criteria.  Your responses impressed me.  Above all, I was glad to see very few cut and dry answers and responses both sides of the fence were very convincing.   The best part was that it occurred to me that if you put that much thought into the answers, then maybe I wasn’t insane after all.

In order to be completely objective about it, I had to return to Chapter 7 of the Medicare Benefits Manual and review these patients compared to Medicare’s definition of Homebound.  Here’s the heart of the matter cut and pasted  from the manual but divided into two parts:

  1. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort.
  2. If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment.

So, both patients meet the first criterion.  It is a considerable and taxing effort to leave the home.  In fact, I meet that criterion.  I live on the third floor and at least twice I week I forget something upstairs.

One patient definitely does not meet the second criterion.  Parking at the lake does is not how the patient receives healthcare or treatment and apparently this occurs ‘regularly’.

Based on the information I posted which is all I have, we cannot tell how often patient number two leaves the home.

The regs specifically address non-medical absences later in the section.  Again, this is cut and pasted directly from the manual:

However, occasional absences from the home for nonmedical purposes, e.g., an occasional trip to the barber, a walk around the block or a drive, attendance at a family reunion, funeral, graduation, or other infrequent or unique event would not necessitate a finding that the patient is not homebound if the absences are undertaken on an infrequent basis or are of relatively short duration and do not indicate that the patient has the capacity to obtain the health care provided outside rather than in the home.

Now, go read it again.  How often is occasional?  What is meant by ‘relatively short duration’ and ‘infrequent’.  Steven Wright illustrates relativity even better than Einstein when he says that everywhere is within walking distance if you have the time.

Since Medicare offers no further clarification of these definitions, we have no choice but to use the most conservative definitions and therefore, neither of these patients are confined to the home.  I was so happy with my readers that none of you were happy with just stating that they weren’t homebound.  Neither am I.

My suggestion to my client with patient number 1 was that they go out and assess him and explain to him why he should not be cooped up in a car for hours at a time.  Homebound status is the least of my concerns at the point of referral.  That would come in later after I assessed his risk of blood clots, ulcers, etc. from immobility.  If he was willing, my client through diligent nursing care and therapy could restore his functionality to the point that it would be safe again in the future.  If he was willing to comply with a treatment plan that included diet and weight loss, he could improve his life to a level he had not experienced in years.  These things are not known prior to assessment.  In fact, it is often the non-verbal language that clues us into the sincerity of the patients’ desire to comply with a care plan.

The report I received on the second patient is that he had dementia.  Dementia as a diagnosis used on home health plans of care is very poorly defined in my opinion.  Patients with early memory loss who end up on Namenda with no diagnosis of Alzheimer’s are often put into the broad category of ‘dementia’.  Dementia can mean mild confusion at times or flat out psychosis.  Furthermore, patients will often come out of the hospital with a diagnosis of Dementia that is carried over to the home health chart.  Often times, quite sane people lose it considerably in the hospital due to drugs, illness, unfamiliar environment, etc.  and get right in the head again once home. (I am re-reading this before posting.  My first inclination was to find clinical terms to replace ‘lose it considerably’ and ‘get right in the head’ but those of you who live in other states will need to know these terms should you ever decide to work in the South.)

Pretty much everyone was on target with their responses.   If the patient only has mild memory loss, he may be able to drive but will get lost and end up on Crack Alley negotiating deals for those pretty little rocks.  If he is beyond mild dementia, the police or elderly protective need to be contacted immediately.  My experience with Elderly Protective Services or whatever they are called in your community is that their scope of usefulness varies widely between communities so choose carefully.

Sadly, sometimes we are best suited to be the bad guy.  The kindest thing to do may involve being the one who is willing to go toe to toe with a patient until they surrender their car keys.  I mean that figuratively, by the way.  There are laws against assaulting patients.  We cannot take keys from patients or steal them but we can be the ones who tell the patient that we are by law obligated to report dangerous situations.  We can notify the physician and even help him draft a letter to the Department of Motor Vehicles.  Remember, the life you save may be your child’s.  And even though it is no fun, it really is okay if the occasional patient doesn’t like you because truly caring for them means making them angry.

This is what upset me and why I asked the question of you.  These two patients were referred to two separate clients in two different communities 200 miles apart.  In both instances, other agencies had refused these patients due to the fact that they were driving.

I am not at all impressed with those agencies.  Either they are much better than us in their assessment skills because they were able to make that determination without seeing the patient or they were not able to think critically and assess patients as individuals.  In nursing, there are very few black and white decisions.  Our patients are people and they are all unique and deserve consideration in these grey areas.  Even if an admit isn’t forthcoming after the initial assessment, as nurses we should look at all the assessment data and determine what is best for the patient.   If they turn out not to qualify for Medicare home health, perhaps we could find an alternative.  And no.  Medicare doesn’t pay for that but that doesn’t mean we don’t benefit from taking care of our elderly.

And so on……

Medicare 101

We have a lot of challenges in Home Health next year.   No savior came to our rescue.  Congress has absolutely no reason whatsoever to overlook home health when cutting the budget.  They also  have every reason in the world to come after home health for fraud and abuse and they have with a vengeance.  They show no signs of stopping now and if you have been paying attention, nobody is safe.  I have clients with as few as 100 patients undergoing a ZPIC audit and we know that the larger companies are not excused from scrutiny, either.

So before you get serious about implementing new programs and creating new ways to improve care while reducing costs, spend a little to make sure that you as a nurse or you as agency are building upon a sound foundation that protects you if you find yourself under scrutiny.

Take the Medicare Quiz and when you are through, you will see your results immediately.  Let me know what you think of it.

Good Luck.


You In?

I received an email from somebody last week who made the first valid points about The Alliance and associated groups that I have read.  Respectfully I do not agree with most of his points, but it did give me pause to consider some of my positions.  I remain firm on my position that the exclusivity of these groups and the ulterior motive of some members are reprehensible and contemptible.

That was my disclaimer.  Let me share with you one or two of his opinions that hit home.

First of all, CMS is not going to listen to any providers from any sector of the industry ‘whine’ about payment.  That much is certain whether you are the Alliance or Joe Bleaux on the street.  Fair, according to CMS is determined by the numbers.

I took the time to read the trustees report to Medicare over the weekend so you wouldn’t face that burden.  Say, Thank You, Julianne.  Most of the information was fairly useless to us as home health providers.   Some of it was so boring that I came close to tears a couple of times.  But within the report there were one or two things that are important to us as clinicians.

Here are some numbers from the report.  Stay with me.  Your only alternative is to read it yourself.

Medicare Expenditures for 2010 in Billions


Part A Part B Part D Total
Benefits 244.5 209.7 61.7 515.8

By Provider Type

Hospital 136 31.9l 168
Skilled nursing facility 26.9 26.9
Home health care 7.0 12.1 19.1
Physician fee schedule services 64.5 64.5
Private health plans (Part C) 60.7 55.2 115.9
Prescription drugs 61.7 61.7
Other 13.8 46.1 59.9

The report also said:

It is possible that healthcare providers could improve their productivity, reduce wasteful expenditures, and take other steps to keep their cost growth within the bounds imposed by the Medicare price limitations. For such efforts to be successful in the long range, however, providers would have to generate and sustain unprecedented levels of productivity gains—a very challenging and uncertain prospect.

The last sentence is worthy of repeating.  “For such efforts to be successful in the long range, however, providers would have to generate and sustain unprecedented levels of productivity gains – a very challenging and uncertain prospect.”

For the home health care industry, I think it is challenge we will meet.

The next argument posed by the anonymous emailer is that the researchers and brain power in these groups was very high level.   I will begrudgingly concede that there is room for this kind of academic and intellectual examination of our industry.  But, I am a nurse and I know nurses and we are just as smart, as a whole, as any other group on the planet.  Plus we have an edge.  Nurses answer to a higher authority than any shareholders, state licensing board, policy maker organization, or even Congress.  We answer to the patient first, and then to each other.

So, down to business and I do mean business.  We sell health care for a living.  In particular, we sell nursing care and to a lesser degree, ancillary therapies.  I have used the analogy that home health agencies are like brothels in the past to illustrate that all the payor sources care about is the end product.  I was advised that some people may find my analogy offensive.  I can’t imagine why the sex industry workers would be offended but just to show my sensitive side, I will not expound on my analogy.  The point I was trying to make is that our end product is our clinical care.

In other words, CMS and Medicare HMO groups do not care who has the best accountant or even the most paid lobbyists.  They judge us by how well we perform as determined by our cost vs benefit ratio to the overall Medicare budget.

Looking at the budget numbers, the first thing you see is that the bulk of the budget goes towards hospitalizations.  Over 168 billion dollars last year was paid to hospitals from Medicare alone and I assume approximately equal percentage was paid by the Managed Care Plans in Part C. If we are competent and keep hospital rates down, we will survive.  If we are excellent and reduce overall costs to the Medicare trust, we will be golden.  They will turn to us for answers and be eager to give us the budget to care for patients.

Next number to look at is Physician costs.  Every time we provide appropriate contact to a physician for a patient already on service we reduce the total payment to physicians.  Obviously, physicians are our colleagues and we are not out to eat into their income.  But, I think even the doctors appreciate a nurse who recognizes the need for intervention and arranges for it with his assistance as opposed to interrupting his day with an unplanned patient visit.  If you keep their patient out of the hospital, you have proven your worth to them more than any expensive dinner or cute little sticky notes.

Look at the part D drug expenses.  We like drugs.  Patients like drugs.  Drugs are good things.  Nurses, in particular, are fond of drugs.  How many of you have ever wished for a Xanax or Prozac salt lick in the office.  By making a concerted effort to truly examine our patients’ medications and identify duplicate and ineffective therapy, we both improve care and reduce the risks of hospitalizations.  When we identify medications that are ‘left overs’ from an illness the patient no longer has, we save money.  We don’t do that.  I know it says that we do in the OASIS, but as an industry, there is vast amount of room for improvement.  We do not need policies or pathways to check medications.  We just need to remember to do it and address all inconsistencies.

Nursing home care is expensive.  The part of nursing home care that Medicare pays for is ‘skilled’ needs much like the skills we can and do provide in the home.  Ask yourself; is it better for the patient to be in the home or in a nursing home?   If you can provide those same skills at a lower level of expense than a skilled nursing facility or rehab hospital, you can save the Medicare system money.  Better than saving money is that you may be able to keep the patient in his or her home where life is much friendlier.

So, there is your challenge. You in?

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