For the first time since 1997, CMS has updated the Conditions of Participation (CoPs) for home health agencies (HHAs). The CoPs focus on standards that HHAs must meet to participate in Medicare and Medicaid programs, while current regulations specify that HHAs participating in the Medicaid program must also meet the Medicare CoPs. These are used as the basis for which survey activities establish initial compliance and ongoing re-assessment during surveys by state, federal entitites and organizations with deeming authority.
The CoPs focus on the organizational structure and oversight of staff to ensure patients are safely and effectively receiving healthcare services. The new requirements, which go into effect July 13, 2017, focus on an interdisciplinary approach to patient care delivery, as well as HHA self-assessment, monitoring and improvement in the quality of delivered care. This enhanced focus ties directly to the Triple Aim: Population Health, Patient/Caregiver Experience and Per Capita Cost.
The revised CoPs have been completely restructured, where some parts of the regulations have significant rewording and others have only been relocated. There are also several new regulations added to the updated CoPs.
Reorganization of CoPs
One of the most significant changes is the reorganization of the CoPs, which is outlined in the table below:
| Previous CoP Organization | Revised CoP Organization |
| Subpart A: General Provisions | Subpart A: General Provisions |
| Subpart B: Administration | Subpart B: Patient Care |
| Subpart C: Furnishing of Services | Subpart C: Organizational Environment |
Regulations directly related to patient care and the OASIS are now in the beginning of part 484 at Subpart B followed by the regulations concerning organization and administration of the HHA in Subpart C. Subpart A is primarily the basis and scope, and is followed by definitions of terms used throughout the rule.
A major change in Subpart A concerns the parent, branch and subunits structure of home health agencies. Beginning July 13, 2017, any existing “subunits”, which already operate under their own provider number, will be considered distinct HHAs and will be required to independently meet all CoPs, including having an independent governing body and administrator.
Subject to state-specific laws and regulation, this federal regulatory change will permit a subunit to apply to become a branch of its existing HHA if the parent provides “direct support and administrative control” of the branch. The state survey agency and CMS regional office will continue to be responsible for approving a HHA’s application for a branch office. New “subunits” will not be approved, rather only branch offices will be approved. Furthermore, a CoP violation in one branch office will apply to the entire HHA, under the new revisions.
The new CoPs focus on patient-centered, interdisciplinary care. Multiple examples of this perspective are apparent throughout the 2017 Final Rule in which CoPs were published. Part A also contains new definitions for in advance, quality indicator, representative, supervised practical training and verbal order. Representatives are defined as a patient’s legal and/or patient-selected representative, who participates in making decisions related to a patient’s care or wellbeing. This could be a family member, friend or other advocate.
HHAs will need to know the legal scope of patient representatives to ensure compliance with the intentions of the new CoPs. For example, they may have a representative for financial decision-making, but not healthcare decision-making. HHAs are expected to act in accordance with specific patient decisions. The key will be to distinguish between a representative and legally appointed person and understanding the scope of responsibilities.
Patient Rights
We also see an expanded patient rights section in the new CoPs. Notification of patient rights will become a focal point in preparation for compliance by July, as notification of patients and representatives will be mandated differently. The new standards include notification of the patient rights to both the patient and representatives in a language and manner in which the individuals can easily understand during the evaluation visit, in advance of furnishing care. This is to be followed with written notice of patient rights, which must be understandable by those with limited English proficiency (LEP), by the second visit and free of charge to the recipients.
Meeting these standards will require HHAs to find interpreter services and create easy-to-understand notification statements, geared toward LEP individuals. New policies and processes will need to be created, and staff education will be required to ensure compliance.
Quality Assessment Performance Improvement Programs
The Quality Assessment Performance Improvement (QAPI) Programs requirements have been revised to focus on a patient-centered, data-driven, outcome-oriented process that promotes high-quality patient care. Agencies will need to develop a more integrated care process across all aspects of home health services, beginning with a true patient-centered assessment, care-planning and service-delivery model, on a continuous basis.
This will be enhanced by an agency-focused, data-driven and outcomes-apparent QAPI program. Agencies must use a patient-centered, interdisciplinary approach to care delivery; and records should show the contributions of different skilled professionals and evidence of peer interaction to meet patient needs. New to the CoPs are specific details included in the comprehensive assessment, including:
- The patient’s current health, psychosocial (new), functional (new) and cognitive (new) status;
- The patient’s strengths, goals, and care preferences, including the patient’s progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA (new);
- The patient’s continuing need for home care;
- The patient’s medical, nursing, rehabilitative, social and discharge-planning needs;
- A review of all medications the patient is currently using;
- The patient’s primary caregivers, if any and other available supports (new); and
- The patient’s representative, if any (new).
Some HHAs may already meet these guidelines, depending on their level of accreditation. However, failure to meet these requirements will be condition-level issues that will, at a minimum, result in costly fines and can escalate to suspension of participation in Medicare- and Medicaid-funded programs since these requirements are now part of the CoPs.
Future blog posts and on-demand video content will further highlight CoP changes.
