Expectations of the Skilled Professional in the New Conditions of Participation Environment

There are expectations of home health skilled professionals scattered throughout the updated home health Conditions of Participation, but specifically addressed in section §484.75. While agencies line out their expectations in the form of job descriptions, policies and procedures, the Centers for Medicare and Medicaid Services (CMS) now ties certain requirements to condition level standards. In this blog article, we will discuss these new CoP standards.

For Medicare-certified home health agencies, the skilled professional services are:

• Skilled nursing services
• Physical therapy
• Speech-language pathology services
• Occupational therapy
• Physician (as per 409.45)
• Medical social work services

The first expectation for these skilled professional services is noted at §484.75, where the last sentence of the introduction states “Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care.” According to §484.60(d), coordination of care includes the following elements:

1. Assuring communication with all physicians involved in the plan of care
2. Integration of orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient
3. Integrating services to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines
4. Coordinating care delivery to meet the patient’s needs and involve the patient/representative/caregivers in the coordination of care activities as appropriate
5. Ensuring that each patient (and caregiver(s)) receive ongoing education and training provided by the HHA regarding the care and services identified in the plan of care.
6. Ensuring training is given to facilitate a timely discharge

Since all skilled professionals, whether directly employed by the agency or contracted workers, must participate, each is responsible for coordinating care with the other disciplines, physicians, the patient, caregiver(s), and representative(s). This coordination of care should be well documented to avoid deficiencies upon survey. Level one and level two deficiencies may be cited when:

• the patient does not receive the services that are written in the patient-specific, individualized plan of care (G572, L1);
• the plan of care is missing one or more required elements (G574, L1);
• there is noted non-compliance with physician orders (G578, L1);
• medications, services, or treatments are administered improperly or without physician orders (G580, L1);
• agency policy is not followed when vaccines are administered by agency staff (G582, L1);
• the care plan is not reviewed and/or revised appropriately (G586, L2);
• the individualized plan of care is not reviewed and revised by the physician and the HHA as often as the patient’s needs require (no less frequently than once every 60 days beginning with the start of care date) (G586, L2);
• relevant physician(s) are not alerted to 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 (G590, L2);
• not assuming the responsibilities of the skilled professional per 484.75: (G704, L1);
• lack of ongoing interdisciplinary assessment of the patient (G706, L1);
• development and evaluation of the plan of care in partnership with the patient/representative/caregiver(s) (G708, L1);
• failure to provide services that are ordered by the physician as indicated in the plan of care (G710, L1);
• failure to provide patient, caregiver, and family counseling (G712, L1);
• failure to provide patient and caregiver education (G714, L1);
• failure to prepare clinical notes (G716, L1);
• failure to communicate with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care (G718, L1);
• professional assistants are not properly supervised: nursing services under RN supervision; rehab services under PT, OT, or ST; medical social services under supervision of social worker; (G724, G726, G728, G730, L2s)

While most skilled professionals are accustomed to providing these services as outlined, there are instances wherein contracted or part-time staff may have off-loaded some responsibilities to other professionals. Agency staff should be trained on the specific agency expectations and policies regarding professional expectations within the new CoP requirements. Agencies would be well advised to have these expectations added to the skilled professional job descriptions and contracts for professionals working under arrangement. Clear expectations and monitoring of productivity abilities should occur at least annually to ensure the skilled professional is able to perform the coordination of care activities as required.

For more information on the updated Medicare home health Conditions of Participation, view Axxess’ on-demand content here.