CMS Home Health Conditions of Participation – Care Planning

PUBLISHED: Mar 22, 2017

The Centers for Medicare & Medicaid Services (CMS) issued a final rule governing home health agencies earlier this year. See the StayAlert! Notice published on January 12, 2017 for an overview of that final rule. Today’s notice reviews the CMS Conditions of Participation (CoPs) related to care planning, which are effective July 13, 2017.

Patients accepted for treatment by a Home Health Agency (HHA) have the reasonable expectation that the HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. According to CoPs for Care Planning, Coordination of Services, and Quality of Care (§ 484.60) the HHA must ensure the following:

  • Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration.
  • The individualized plan of care must include:
    • All pertinent diagnoses
    • The patient's mental, psychosocial, and cognitive status
    • The types of services, supplies, and equipment required
    • The frequency and duration of visits to be made
    • Prognosis
    • Rehabilitation potential
    • Functional limitations
    • Activities permitted
    • Nutritional requirements
    • All medications and treatments
    • Safety measures to protect against injury
    • A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors.
    • Patient and caregiver education and training to facilitate timely discharge;
    • Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient
    • Information related to any advanced directives
    • Any additional items the HHA or physician may choose to include.
  • All patient care orders, including verbal orders, must be recorded in the plan of care.
  • Drugs, services, and treatments are administered only as ordered by a physician.
  • Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, and after an assessment of the patient to determine for contraindications.
  • Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies.
  • The individualized plan of care must be reviewed and revised by the physician who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date.
  • The HHA must promptly alert the relevant physician(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered.

Included with today’s notice are example policies related to Home Health care planning.

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