HHA – Citations and Description

2180 - HHA – Citations and Description (Rev. 1, 05-21-04) 2180A - Citations (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) The statutory authority for applying CoPs to HHAs is found in §§1861(o) and 1891 of the Act. The regulations are found in 42 CFR Part 484 (§484.) Appendix B contains Investigative Procedures and Interpretive Guidance for surveyors. The CMS has a web site for information pertaining to HHA survey and certification, including links to HHA policy memos, HHA-related information in the State Operations Manual, §§ 2180 - 2202.19, and Appendix B, Part I-Investigative Procedures and Part II Interpretive Guidelines available at: http://www.cms.gov/Medicare/Provider-EnrollmentandCertification /SurveyCertificationGenInfo/index.html?redirect=/SurveyCertificationGenInfo/ Additional information can also be found at the Home Health Agency (HHA) Center at: http://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA- Center.html?redirect=/center/hha.asp. 2180B - Types of Agencies (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) An HHA may be a public, nonprofit or proprietary agency or a subdivision of such an agency or organization. 1. Public agency is an agency operated by a State or local government. Examples include State-operated HHAs and county hospitals. For regulatory purposes, “public” means “governmental.” 2. Nonprofit agency is a private (i.e., nongovernmental) agency exempt from Federal income taxation under §501 of the Internal Revenue Code of 1954. These HHAs are often supported, in part, by private contributions or other philanthropic sources, such as foundations. Examples would include non-profit visiting nurse associations or non-profit hospitals. 3. Proprietary agency is a private, profit-making agency or profit-making hospital. 2180C - General Requirements (Rev. 1, 05-21-04) Section 1861(o) of the Act defines an HHA as an agency or organization which: • Is primarily engaged in providing skilled nursing services and other therapeutic services; • Has policies established by a group of professionals (associated with the agency or organization), including one or more physicians and one or more registered professional nurses, to govern the services which it provides; • Provides for supervision of above-mentioned services by a physician or registered professional nurse; • Maintains clinical records on all patients; • Is licensed pursuant to State or local law, or has approval as meeting the standards established for licensing by the State or locality; • Has in effect an overall plan and budget for institutional planning; • Meets the CoPs in the interest of the health and safety of individuals who are furnished services by the HHA; and • Meets additional requirements as the Secretary finds necessary for the effective and efficient operation of the program. For purposes of Part A home health services under Title XVIII, the term “home health agency” does not include any agency or organization which is primarily for the care and treatment of mental diseases. The CoPs for a Medicare-approved HHA found in 42 CFR Part 484 are also based on §1891 of the Act. These CoPs are listed in Appendix B, Interpretive Guidelines for HHAs. Section 1891 of the Act requires, among other things, that the HHA: • Protect and promote the rights of each individual under its care; • Disclose ownership and management information required under the Act; • Not use as a home health aide (on a full-time, temporary, per diem, or other basis) any individual to provide items and services described in §1861(m) of the Act, unless the individual has completed a training and competency evaluation program (CEP) or a CEP that meets minimum standards established by the Secretary, and is competent to provide such items and services; • Operate and provide services in compliance with all applicable Federal, State, and local laws and regulations (including the requirements of §1124 of the Act); • Operate and provide services in compliance with accepted professional standards and principles which apply to professionals providing items and services for the HHA; • Include an individual’s plan of care (PoC) required under §1861(m) of the Act as part of the clinical record described in §1861(o)(3) of the Act; and • Comply with the requirements of §1866(f) of the Act relating to maintaining written policies and procedures respecting advance directives. 2180D - Services Provided (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) All HHAs must provide skilled nursing services and at least one of the following other therapeutic services: physical therapy, speech language pathology, or occupational therapy, medical social services, or home health aide services in a place of residence used as a patient’s home. The HHA must provide at least one of these services (i.e., skilled nursing, physical therapy, speech language pathology, occupational therapy, medical social services, or home health aide services) directly and in its entirety by employees of the HHA. The other therapeutic services and any additional services may be provided either directly or under arrangement. An HHA is considered to provide a service “directly” when the person providing the service for the HHA is an HHA employee. For the purpose of meeting §484.14(a), an individual who works for the HHA on an hourly or per visit basis may be considered an agency employee if the HHA is required to issue a Form W-2 on his/her behalf. An HHA is considered to provide a service “under arrangements” when the HHA provides the service through contractual or affiliation arrangements with other agencies or organizations, or with an individual(s) who is not an HHA employee. The HHA is responsible for ensuring that the applicable CoPs are met, as though the HHA was furnishing the services directly. When hourly or per visit contracts are used, or when services are provided under arrangement, there must be a written agreement or contract between such personnel, or this agency or organization, and the HHA which specifies: • Patients are accepted for care only by the primary HHA; • The services to be furnished under the contract or agreement; • The necessity to conform to all applicable agency policies, including personnel qualifications; • The responsibility for participating in development of plans of care; • The manner in which services will be controlled, coordinated, and evaluated by the primary HHA; • The procedures for submitting clinical and progress notes, scheduling of visits, periodic patient evaluation; and • The procedures for payment for services furnished under the agreement or contract. 2180E – Application of Home Health Agency Conditions of Participation to Patients Receiving Chore Services Exclusively (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) In addition to the home health services listed in §1861(m) of the Act, and Medicaid State Plan services identified in §1905(a) of the Act, some HHAs choose to offer additional services which are clearly non-medical in nature. Such services are typically comprised of housekeeping, chore, or companion services. The HHA makes these services available to individuals who choose to pay for them privately, and/or individuals who are provided these services from other programs, such as a State Medicaid Home and Community- Based Services (HCBS) Waiver Program under §1915(c) of the Social Security Act. The HHA may offer these services to current patients of the HHA (to supplement the skilled services available), to previous patients who have been discharged from skilled care, and to other individuals in the community who request them. Many individuals who receive these non-medical services are frail, elderly or disabled and request these services because they are unable to perform them independently and need this kind of assistance to remain in the home environment. In addition to promoting the health and safety of individuals, §1891(b) of the Social Security Act also directs the Secretary to ensure that requirements “promote the effective and efficient use of public moneys.” This statutory direction is especially pertinent in the question of whether expenses ought always to be incurred for a comprehensive assessment and care plan when the only service requested from an HHA by an individual is a chore or other clearly non-medical service. When this is the case, we will not consider the individual to be a patient of the HHA in the traditional sense of the term, and requirements that must apply to patients will not be required in such limited situations (e.g., the requirement for a comprehensive assessment under §484.55 will not apply). The Medicare HHA CoPs do not apply to those individuals who receive only chore services or other clearly non-medical services from the HHA. Non-medical services include chore services, companion services, household maintenance and repair services, lawn and tree services, and clearing walkways. To the extent that there is ambiguity as to whether a service is non-medical or medical, we will incline towards the medical interpretation and consider the CoPs to apply. CMS considers as a medical service any hands-on service, personal care service, cueing, or activity that is in any way involved in monitoring the patient’s health condition. As soon as the HHA provides any Medicare service to an individual, or any standard service permitted by Federal law under the Medicaid State Plan (such as personal care), we will consider the individual to be receiving medical care. The CoPs will apply for all services rendered to such an individual. For example, the CoPs would apply in the case of an individual who received both chore services and personal care (regardless of funding source), but would not apply in the case of an individual receiving only chore services from the HHA. HHAs are required as a part of the patient rights CoP to advise the patient of the extent to which payment for HHA services may be expected from Medicare or other sources and the extent to which payment may be required from the patient. The HHA should explain to a beneficiary who is ending a Medicare episode and continuing to receive chore services that Medicare does not pay for those services. HHAs may develop their own comprehensive assessment for each required time point under the regulations at §484.55 for those patients receiving personal care services only regardless of payer source. The assessment may be performed any time up to and including the 60th day from the most recently completed assessment. The HHA must continue to meet all State licensure and State practice regulations governing the provision of service to this population. Where state law is more restrictive than Medicare, (e.g., State law or State Medicaid HCBS requires the HHA to comply with CoPs when providing only chore services) the provider needs to apply the State law standard as well. Note that this instruction does not supersede any current policy related to Medicare coverage and eligibility rules or instructions from the Medicare Administrative Contractors (MACs). The HHAs that provide non-medical services must also ensure that fiscal accounts are structured and maintained in conformance with CMS regulations and generally accepted accounting standards.