Review of the New Home Health Conditions of Participation – Infection Control and Prevention; Skilled Professional Services; and Home Health Aide Services.

This is the third article in a series discussing CMS’s Final Revised Home Health Conditions of Participation (“Final CoPs”). With the release of the Final CoPs, CMS is finalizing the significant changes they proposed to make to the home health CoPs in October 2014. Although these major revisions are mostly adopted as proposed, CMS has introduced a number of “clarifying changes” in the final rule that are substantive.

Since the Final CoPs impose numerous requirements, Hall Render will issue a series of articles summarizing various components. Recently, Hall Render published an article that contained a brief analysis of the Final CoPs, as well as Parts 1 and 2 in the series: CMS Finalizes New Conditions of Participation for Home Health: Part 1 and CMS Finalizes New Conditions of Participation for Home Health: Part 2.

Infection Control and Prevention – Sec. 484.70

Executive Summary. CMS added this new CoP to provide a greater focus on infection control processes and improvements. The Home Health Agency (“HHA”) must follow accepted standards of practice, include the infection control and prevention efforts in its Quality Assessment and Performance Improvement (“QAPI”) program and ensure all patients, staff and caregivers are educated on the infection control and prevention program.

Detailed Summary. This new section details the following components of an acceptable infection control and prevention program.

  • The HHA will follow accepted standards of practice, including standard precautions, to prevent the transmission of infections. Sources of accepted standards of practice include the Centers for Disease Control and Prevention, state departments of health, accreditation organizations and national professional organizations.
  • The infection control and prevention program must be an integral component of the QAPI program. While a separate infection control committee is not required, all of the professionals necessary to create the infection control and prevention program should participate in its creation. An infectious disease specialist is not required for the development and implementation of the program.
  • The infection control and prevention program should include, at a minimum, a method for identifying infectious and communicable disease problems and a plan for the appropriate actions that are expected to result in improvement and disease prevention.
  • Although education of the patient, caregivers and staff is required, CMS did not specify the manner in which the education must be presented. CMS acknowledged that education may include written instructions, in-person demonstrations or video demonstrations. HHAs may format the education to best meet the needs of the patient, caregiver and staff.

Skilled Professional Services – Sec. 484.75.

Executive Summary. The requirements of three former sections were combined into this new section. Skilled professional services (skilled nursing, physical therapy, occupational therapy, speech-language pathology, medical social work and physician services) are held to responsibilities that aim to increase the interdisciplinary team function and focus on outcomes of patient care.

Detailed Summary. Skilled professional service providers are required to assume the following responsibilities:

  • 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 education and counseling;
  • 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.

This new CoP also includes the following supervision of skilled professional assistants:

  • Nursing services – supervision by a registered nurse;
  • Rehabilitation therapy services – supervision by an occupational therapist or physical therapist; and
  • Medical social services – supervision by a social worker.

Home Health Aide Services – Sec. 484.80

Executive Summary. The home health aide services CoP was moved from Section 484.36 to Section 484.80. There were several changes to the language of this CoP. Home health aide qualification criteria and required skills and training were added, and there were several changes to the requirements for home health aide assignments and duties. It is important to note that all home health aides must be appropriately trained on the new skills required of home health aides on by July 13, 2017.

Detailed Summary. The home health aide services CoP underwent several significant changes that require additional training and responsibility for all home health aides.

Content and Duration of Home Health Aide Classroom and Supervised Practical Training; Competency Evaluations

The components of a complete training program for home health aides have been updated to include the following new or revised skills:

  • 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;
  • Basic infection prevention and control procedures;
  • Recognizing emergencies and the knowledge of instituting emergency procedures and their application; and
  • Recognizing and reporting changes in skin condition.

The proposed rule required home health aides to recognize and report pressure ulcers. CMS agreed with comments that the skills involved in the reporting changes in the condition of pressure ulcers are beyond the scope of practice of home health aides and removed the requirement to train home health aides on the recognizing and reporting of pressure ulcers. Instead, home health aides must recognize and report changes in skin condition.

Home health aide qualifications must include successful completion of one of the following:

  • A training and competency program that includes specific subject areas expected to be known by a home health aide identified above as well as those that were previously required;
  • A competency evaluation that meets specific requirements and includes the subject areas identified in the training and competency identified above as well as those that were previously required;
  • A nurse aide training program approved by the HHA’s state and currently in good standing with the state; or
  • A state licensure program that includes training and competency in the specific areas identified above as well as those that were previously required.

The training and competency program must be supervised by a registered nurse that addresses specific subject areas over at least 75 total hours classroom and practical training (16 of the 75 hours must be classroom education). Prior to providing unsupervised care, the home health aide must be evaluated by a registered nurse. If the home health aide is determined by the registered nurse not to be competent in performing any task, the home health aide may not perform that task until their performance is deemed satisfactory by the registered nurse. If more than two tasks are considered unsatisfactory, the competency evaluation is not considered successful.

Important: All home health aides, including those currently employed, must undergo training and a competency evaluation on the new skills, including communication skills and recognizing skin changes no later than July 13, 2017.

Any home health aide who does not provide care for a period of 24 months or more must undergo a successful training and competency evaluation prior to providing services.

Home Health Aide Assignments and Duties

Home health aide assignments must be assigned by a registered nurse or other skilled professional (physical therapist, speech-language pathologist or occupational therapist) who provides written patient care instructions to the home health aide.

Home health aides must be members of the interdisciplinary team and report changes in a patient’s condition to the registered nurse or other skilled professional (for instance, physical therapist). In response to comments that the scope of practice of a home health aide may be limited by state licensure rules and therefore affect participation in the interdisciplinary team, CMS responded that HHAs are expected to determine the extent of involvement by home health aides in the interdisciplinary team.

CMS also indicated that the physician is not required to sign the home health aide’s written instructions. The home health aide’s written instructions or aide-specific plan of care must be established by a registered nurse or other professional who is involved in the patient’s care for the duration of their care. While therapists should contribute to the establishment and revision of this plan of care, the registered nurse is likely the appropriate individual to maintain responsibility for the plan of care in most cases.

Supervision

Supervision of the home health aide should be conducted by a registered nurse or other professional who is familiar with the patient. For patients receiving skilled nursing or therapy services, the supervising individual must make a visit to the patient’s home no less than every 14 days, but the home health aide does not have to be present during these visits. If the supervising individual notes an area of concern, he or she must make a return visit to observe the home health aide providing care. Even if no areas of concern are noted on these visits, the supervising individual must observe the home health aide providing care in the patient’s home at least annually.

If the patient is not receiving skilled nursing or therapy services, the supervising individual must observe the home health aide providing care in the patient’s home no less than every 60 days.

If an area of concern in the home health aide’s provision of care is noted during any visit, the home health aide must be reevaluated through a new competency evaluation.

CMS clarified that the written patient care instructions and the home health aide’s supervision do not have to be completed by the same individual, but the supervising individual must be familiar with the patient, the plan of care and the home health aide’s written instructions. CMS disagreed with comments that the supervisory visit should occur “every 2 weeks” as opposed to every 14 days, citing the potential for excessively long gaps between visits.

Practical Takeaways

  • HHAs need to update home health aide training to include the new elements regarding communication skills and recognizing and reporting skin care issues.
  • HHAs need to ensure all home health aides have been educated and their competency has been evaluated on these new requirements by July 13, 2017.
  • HHAs needs to review how home health aides participate in the interdisciplinary team.
  • HHAs should review their supervision of home health aides and ensure their policies and procedures complete with the new supervision and training requirements.