Bureau of Home Care & Rehabilitative Standards

1. Bureau of Home Care & Rehabilitative Standards Bureau Update Lisa Coots, RN Bureau Administrator

2. Objectives Describe the significant changes in the PROPOSED home health regulations (Federal Register dated October 9, 2014). Explain the new practices recently initiated for bureau surveyors when completing home health & hospice recertification surveys. Identify several trends of Missouri home health & hospices as evidenced by bureau statistics.

3. Background CMS’ History with Home Health Regulations March 1997 A proposed rule was initially published revising all the home health Conditions of Participation (CoPs) adding OASIS regulations; however, due to a large volume of public comments and the significant changes occurring in the home health industry during this time, this rule in its’ entirety was never finalized. January 1999 A portion of that rule, the OASIS regulations, were published (final rule).

4. Background Cont. December 2004 A rule was published in the Federal Register requiring any Medicare proposed regulation outstanding for three years to be ineffective, putting a halt to the remaining home health rule from 1997. May – August 2011 Comments were submitted by the home health industry and many other interested parties. These recommendations were then used for developing completely new home health regulations.

5. Background Cont. October 9, 2014 The new proposed home health regulations were published in the federal register. January 7, 2015 After an extension of thirty (30) extra days, the comment period was closed. April 2016 The home health industry still awaits finalization of the new home health regulations.

7. Overview of the PROPOSED Home Health Regulations The entire organizational structure of the regulations has been changed. Some requirements (CoPs) were consolidated. Two requirements (CoPs) were added. Several requirements (CoPs) were eliminated. Many of all remaining requirements were revised.

8. Overview cont. Divided into three Subparts: Subpart A – general provisions (basis, scope and definitions) Subpart B – patient care Subpart C – organizational environment

9. Overview Cont. Subpart B 3 Current CoPs were combined: Skilled Nursing Therapy Services Skilled Professional Services Medical Social Services

11. Overview Cont. Subpart B 3 Current CoPs were deleted: Group of Professional Personnel Qualifying to furnish outpatient physical therapy or speech pathology services Evaluation of the agency program

12. Overview Cont. Subpart B 2 CoPs were added: Quality Assessment and Performance Improvement (QAPI) Infection Prevention and Control

13. Quality Assessment & Performance Improvement (QAPI) Agency’s main objectives: Develop, implement, evaluateand maintain the program Be effective, ongoing, agency wide and data-driven

15. QAPI Cont. Specific Criteria Reflects the complexity of the organization. Involves all services (to include those under contract). Focuses on indicators related to improved outcomes (including hospital readmissions). Takes actions addressing across the board issues (including prevention & reduction of medical errors).

16. QAPI Cont. Five Components Scope Data Program Activities Performance Improvement Projects Executive Responsibilities

17. QAPI Cont. Scope Must show measurable improvements. Must use indicators that show improved health outcomes, patient rights are being observed, and quality of care is being given. Must demonstrate how the agency will measure, analyze and track quality indicators (including adverse patient events).

18. QAPI Cont. Data Utilize quality indicators, including measures from OASIS. Monitor effectiveness, safety of services and quality of care. Identify opportunities for improvement. Governing Body must approve detail of data and frequency of the collection.

19. QAPI Cont. Activities Focus on high risk, high volume, and problem areas. Consider incidence, prevalence, and severity of the problems. Lead to immediate corrective action if there is a threat to the health and safety of patient. Track adverse patient events, analyze the causes and implement action. Measure and track success and ensure improvement is sustained.

20. QAPI Cont. Performance Improvement Project (PIP) Number and scope needs to reflect the complexity, past performance, and incorporate the whole agency. Each performance improvement project (PIP) needs to be documented with agency’s reason for implementation and the measurable progress made.

21. QAPI Cont. Executive Responsibilities Ensure the agency has a program for Quality Improvement and patient safety and that it is maintained. Ensure the program is agency wide and addresses priorities, then evaluates for effectiveness for all actions undertaken. Communicate plan to establish, implement and maintain clear expectations for patient safety. Appropriately address any findings of fraud or waste.

22. Infection Prevention & Control Three Components Prevention Control Education

24. Infection Prevention & Control Cont. Prevention Follow accepted standards of practice Use standard precautions Prevent transmission

25. Infection Prevention & Control Cont. Control and Education Coordinated agency-wide program forsurveillance, identification, prevention, control and investigation All needing to be incorporated into the QAPI program. Education provided to the staff, patients, and caregivers.

27. Conditions of Participation (CoPs) Revisions Patient Rights Comprehensive Assessment Care planning, Coordination and Quality Care Home Health Aide Organization and Administration Clinical Records Personnel Qualifications

28. Patient Rights Revisions Participate and be informed about comprehensive assessment to include assessment of goals and care preferences. Receive a copy of his/her individualized plan of care (POC) which is to be kept in their home (this is to include all updated POCs also). Access auxiliary aides and language services. Be informed about agency policies regarding admission, transfer, and discharge. Abide by list of criteria for transfer and discharge. Requires agency to investigate all allegations of abuse and neglect by anyone furnishing service on agency behalf.

29. Comprehensive Assessment Revisions Assessment of psychosocial, functional and cognitive status to be included. Documentation of primary caregiver, representatives, and any other support (if any) to be included. Content to be included in the assessment expanded. Allows physician to order a different timeframe (then that in the regulations) to resume care, if needed.

30. Care planning, Coordination & Quality Care Revisions Requires POC to include specific care and services necessary to meet the needs identified in the comprehensive assessment. POC must contain measurable outcomes. If HHA services initiated after hospital discharge, the POC must include a description of patient’s risk for emergency department visits and hospital re-admissions (needs to be rated as low, medium or high) and also needs to include all necessary interventions to address underlying risk factors.

31. Home Health Aide Revisions Elaborates on communication to include the ability to read, write and verbally report clinical information to patient, representative, caregiver and other HHA staff. Adds a new skill requirement of recognizing and reporting changes in skin condition, including pressure ulcers. Allows therapist to make aide supervisory visits even if the nurse is still seeing the patient. Specifies six elements needing to be assessed during aide supervisory visits.

32. Organization & Administration Revisions Describes role of administrator, and the need to have a pre-designated person to act in their absence (both needing to be authorized in writing by governing body and backup also needs authorized by the administrator). Adds a “clinical manager” role with specified duties and responsibilities. Adds a new standard describing parent branch relationship and changes the definition of a branch. Removes the requirement to send 60-day summary to the physician.

33. Clinical Records Revisions List more specific content Adds the standard of authentication Adds the standard of retrieval of clinical record Requires agency to make available upon request

34. Personnel Qualifications Revisions The administrator is required to be a physician, registered nurse, or someone who holds an undergraduate degree and has experience in health service administration, with at least one year of supervisory or administrative experience in home health care or a related health care program.

35. Changes in Survey Practices Only one surveyor at the agency the first day. Unable to do any consulting during the survey. Requesting all records to be copied; to be taken to hotel for review in the evenings. Any copied documents not needed for evidence will be given back to the agency to be shredded. Exit conference will be shortened with only one surveyor in attendance. No longer will surveyors be disclosing if the agency has a condition level deficiency, unless part of an IJ.

37. Missouri Home Health and Hospice TRENDS Administrator turnover rate continues to increase (for both home health and hospices). Medicare certification and licensure through deemed status continues at a steady pace with the majority through CHAP (currently Missouri has a total of 36 HHAs and 27 HOs deemed). Condition level deficiencies continue to rise. Number of complaints for both home health agencies and hospices were less in 2015 than in 2014 with fewer IJs cited.

48. Contacting the Bureau Phone - 573-751-6336 Email - HCRSINFO@health.mo.gov Website - www.health.mo.gov/safety/homecare Enjoy the rest of the conference!