Guidelines for Determining Parent, Branch, or Subunit

2182.2 - Guidelines for Determining Parent, Branch, or Subunit (Rev. 1, 05-21-04) The following guidelines should be used when making a determination as to whether a proposed HHA unit is a parent, branch, or subunit as defined at 42 CFR Part 484.2: A. Supervision Supervision of the branch staff is critical to the provision of quality care for patients. The regulations require the branch to be within the parent’s geographical service area and close enough to the parent to share supervision, administration, and services on a daily basis. Supervision means authoritative procedural guidance by a qualified person for the accomplishment of a function or activity. Supervision at the branch must be adequate to support the care needs of the patients. Supervision of services requires that a qualified person be physically present to directly supervise the provision of services by any individual who does not meet the qualifications specified at 42 CFR Part 484.4. For individuals that do meet the qualifications specified at 42 CFR Part 484.4, the supervisor does not have to be physically present during the provision of all services. The use of telephones, pagers, facsimile machines, or other electronic devices does not eliminate the requirement for the physical presence of the supervisor. The parent may appoint an effective full time branch supervisor or manager as long as this individual is and remains under the supervision of the parent. B. Distance Mileage and travel times from the parent to the branch are significant factors to consider because they are implicitly referenced in the regulations. However, each alone would not be the single issue in determining appropriateness. The regulations require that a branch be “sufficiently close” to share administration, supervision, and services in a manner that makes it unnecessary for the branch to meet the CoPs on its own. To accomplish this, the parent agency must be physically located so that sharing of administration, supervision, and services with the branch can occur on a daily basis. If the parent is not capable of sharing such functions with the branch on a daily basis, then the non-parent office or location must independently meet the CoPs. C. Geographic Area “Geographic area” generally means the location, i.e., address of the clients served by the parent and non-parent. If the non-parent office is located within a portion of the total geographic area served by the parent, but serves patients outside the geographic area, then the non-parent should not be a branch and would be classified as a subunit. (If the State does not recognize subunits, the HHA would seek a new provider number and establish a parent location.) This is consistent with the subunit definition that applies to a non-parent office that serves patients in a geographic location different from the parent. D. Sharing Administration, Supervision, and Services In addition, consider that the sharing of HHA administration, supervision, and services may occur at any time and could flow in either direction, i.e., parent to branch or branch to parent. If an entity within the HHA’s organizational structure reports directly to the home or corporate office or some other office other than the alleged parent HHA, it is more likely a subunit rather than a branch. As a subunit it would need to independently meet the CoPs. If the parent HHA and the non-parent use totally different staffs, it is less likely they are sharing functions on a daily basis, and it is therefore less likely that a parent/branch relationship exists. The fact that the non-parent office is located in a different metropolitan statistical area (MSA) from that of the parent is a consideration in making determinations about geographic areas. Commuting patterns are one consideration in the establishment of MSAs. If the parent and non-parent are in different MSAs, it may reflect that the non- parent is not within sufficient proximity to the parent to share functions on a daily basis. This is especially true if the parent and non-parent are in non-contiguous MSAs. If the parent and non-parent are incapable of sharing emergency functions, including services, on a daily basis, the non-parent is probably not a branch. State licensure laws that define parent, branch, and/or subunit are a consideration in making non-parent determinations, but it is the definitions in the Federal regulations (42 CFR Part 484.2) that must be satisfied in making parent, branch, or subunit determinations. If an HHA operates across State lines, follow the instructions in §2184 of the State Operations Manual. The SA in the State in which the parent is located should take the lead in coordinating with the adjacent State to resolve parent and non-parent issues. The fact that the Joint Commission on the Accreditation of Healthcare Organizations or the Community Health Accreditation Program has awarded branch status to a location will not affect CMS’ parent/non-parent decision. CMS’ determination will be based on its independent application of its regulations to the facts in the case.