CMS Approval Necessary for Non-Parent Locations

2182.4 - CMS Approval Necessary for Non-Parent Locations (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) As part of the provider certification process, an existing Medicare-approved HHA must provide notification to CMS through the SA of its proposal to add a non-parent location, i.e., branch or subunit. (See §3224.) In the absence of notification by the HHA to add a branch office, CMS cannot determine whether the requirements critical to health and safety are met at the non-parent location. A provider may not bill Medicare for services provided by either a branch or subunit where the branch or subunit is not a part of an approved HHA or where the branch or subunit has not been determined to meet the applicable CoPs. The Form CMS-855A applications are used to gather information on providers for the purpose establishing eligibility to furnish services to Medicare beneficiaries. 42 CFR 424.540(a)(2) requires a provider or supplier to update its enrollment information, and recertify its accuracy when any changes are made. Additionally, §424.515 requires revalidation of the enrollment information by providers and suppliers every 5 years and (every 3 years for suppliers of durable medical equipment, prosthetics, orthotics and suppliers) or when determined by CMS policy. See also Chapter 10 and 15 of the Program Integrity Manual which can be found at: http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/pim83c10.pdf and http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/pim83c15.pdf Before a subunit can be approved, it must seek initial certification and apply to CMS to receive a separate provider agreement and CCN. These steps are outlined in Part I of Appendix B of the SOM under the section on Initial surveys. 2182.4A - Notification by HHA to Add a Branch (Rev 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) When an HHA requests approval to add a branch location, it should contact the SA and provide the following information: Address and phone number of the branch; Organizational chart delineating lines of authority, professional and administrative control for the HHA, including the branch; Defined geographic service area (counties, cities, zip codes), and any intention to cross State lines (which would require a reciprocal agreement between the affected States as well as RO approval); Services shared with the HHA parent; Services provided directly and under arrangement; Contracts for any services provided under arrangement; Identification of any high-tech services provided (e.g., infusion therapies such as artificial nutrition and hydration, or chemotherapy, mechanical ventilation, tracheostomy care, etc.); Names of all branch staff and their job descriptions; Proof of branch staff qualifications (resume, licensure, aide training, etc.); Explanation of how supervision by the HHA parent will occur; Identification of the person who will resolve patient care issues at the branch; Explanation of how staff will coordinate care and services; Policies for addressing clinical and other emergency situations; Plans for addressing staff absenteeism; and State issued certificate of need, if applicable. 2182.4B - SA Review of Request for Branch Determination (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) The decision to approve a branch should be based on the HHA’s ability to adequately supervise the branch and monitor all services to assure that the quality and scope of items and services provided to all patients promotes the highest practicable functional capacity for each patient so as to meet their medical, nursing, and rehabilitative needs. The SA reviews the ability of the branch location to meet the definition of a branch as provided in §484.2. The regulations require the branch to be within the HHA parent’s geographical service area and sufficiently close enough to the HHA parent to share administration, supervision, and services on a daily basis. The SA should review the HHA’s request to open a branch and consider the HHA’s ability to comply with the following: Administration, Supervision and Services: • The HHA’s governing body is responsible for the overall operations of the parent and branch. • The lines of authority and professional and administrative control are clearly delineated in the HHA’s organizational structure and in practice and are traced to the HHA parent. • 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. The HHA’s supervising nurse or physician, as required by § 484.14(d), is available at all times by phone or other means of communication during operating hours for individuals who meet the qualifications specified at §484.4. 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 §484.4. The HHA may formally appoint a supervisor or manager who is under the direct supervision of the HHA parent to assist with supervision at the branch. (The HHA parent may use technological means for supervision in conjunction with periodic onsite visits. However, the use of telephones, pagers, facsimile machines, or other technological or electronic devices does not eliminate the requirement for the physical presence of the supervisor when required.) • The group of professional personnel required by §484.16 reviews the agency’s policies and service delivery throughout the entire agency, both parent and any branch(es). • The HHA parent is aware of the staffing, patient census and any issues/matters affecting the operation of the branch. • The HHA administrator maintains an ongoing liaison with the branch to ensure that staff is competent and able to provide appropriate, adequate, effective and efficient patient care and to ensure that any clinical and/or other emergencies are immediately addressed and resolved. • The HHA maintains a system of communication and integration of services throughout the agency, whether provided directly or under arrangement, that ensures the identification of patient needs, an ongoing liaison between all disciplines providing care, and physician availability when necessary for relevant medical issues. • The HHA parent has a system in place to review patient records and care at the branch to ensure that the branch is implementing all policies and procedures and complying with the CoPs for all patients. • The HHA parent monitors branch activities (clinical and administrative) and the management of services, as well as personnel and administrative issues. Depending on the organization, the administrator, quality improvement personnel, supervisory personnel, etc. should conduct periodic on-site visits to the branch to ensure the delivery of quality care. • The HHA parent provides ongoing in-service training to ensure that all staff are competent to provide care and services; • The HHA parent is responsible for any contracted arrangements with any individuals or organizations, even when the contracted services are used exclusively by the branch; • Services offered by the HHA parent are also offered by the branch. Distance • While mileage and travel times from the parent to the branch are significant factors to consider because they are implicitly referenced in the regulations, each factor alone should not be the single issue in determining approval or denial of the branch. The HHA may use current technology to meet the requirement for shared supervision, administration and services with the branch where onsite supervision is not required. A detailed description, including examples, of the application of this technology must be included in the HHA’s request to add a branch. • If the parent and non-parent location are incapable of sharing functions, including services on a daily or emergency basis, the non-parent location is probably not a branch. Geographic area “Geographic area” generally means the location, i.e., address of the clients served by the parent and non-parent location(s). • The branch and its service area are located within the HHA parent’s geographic service area. If the branch is extending the current geographic service area, the new geographic area must be contiguous. If the non-parent location is located within a portion of the total geographic area served by the parent, but serves patients which are located outside of and non-contiguous to that geographic area, then the non-parent would be classified as a subunit (not a branch) and be required to submit an enrollment application and to seek a separate CCN. (If the State does not recognize subunits, the HHA would not be classified as a subunit and would seek a new CCN and become a separate HHA provider.) • The fact that the non-parent office is located in a different core based statistical area (CBSA) from that of the parent is a consideration in making determinations about geographic areas. Commuting patterns are one consideration in the establishment of CBSAs. If the parent and non-parent locations are in different CBSAs, 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 locations are in non-contiguous CBSAs. • If the state has a Certificate of Need requirement or other restrictions on geographic area or expansion of areas, the state rules apply. • If the HHA intends to operate 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. In addition, the SA should review the HHA’s past compliance history, including prior complaints, survey results, number of CoPs and standards out of compliance, and length of participation in Medicare. While the HHA may notify the SA (or AO as applicable) of its proposal to establish a branch, and the SA or AO may make a recommendation to the CMS RO in a particular case, it is the CMS RO (not the SA or AO) that has the authority for approving the request for a Medicare approved branch. The CMS RO will review each HHA’s request for a branch office on a case-by-case basis, and consider all the CMS guidance. The CMS RO will communicate its final decision in writing to the parent HHA with a copy to the SA or AO and the HHA’s Medicare Administrative Contractor (MAC). The approval letter should include notification of the branch approval and the assigned Federal branch ID number and effective date, if approved. The effective date of coverage for services provided from the branch is the date RO determines that the branch meets all CMS requirements. The RO should enter the branch ID number into the Automated Survey Processing Environment (ASPEN) prior to sending the approval letter to the HHA, so that the branch can begin providing services and collect and submit OASIS data. Any decision to deny the request for a branch office should include the full range of the reasons supporting the denial and include discussion of the above criteria. Use the Model Denial Letter, Exhibit 284, as appropriate and copy the SA. 2182.4C - Onsite Monitoring of Approved Branches by the SA (Rev 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) During a survey of an HHA with approved branch offices, the surveyor will ascertain from HHA records whether the branch office is provided adequate supervision by the parent agency and whether they are, in fact, sufficiently close to the parent agency to be considered a branch office rather than subunit. When reviewing records and conducting visits to patients’ homes, the surveyor will select records and/or if possible, schedule home visits to patients who are served by each branch office. The surveyor may conduct a standard survey of the HHA at a branch office instead of the parent location. When conducting a survey at a branch location, the surveyor may request that all necessary documentation for review, such as a sample of clinical records from the parent and any other branches, governing body minutes, personnel records, etc., be transported to the branch. When reviewing branches during the survey process, the operations of an approved branch must demonstrate that: A copy of the HHA’s policies and procedures is maintained in each branch. Branch office personnel should be knowledgeable of the policies and consistently apply them; • Methods of communication between HHA parent and branch assure that all patients receive the necessary care and services identified through the comprehensive assessment and plan of care; • The branch retains the active clinical records for its patients. Duplicate clinical records need not be maintained at the HHA parent, but must be available to the surveyor upon request; • Patients are receiving appropriate care and services at the branch, and • The HHA is in compliance with OASIS submission requirements. To assist in the decision making process of determining adequate branch supervision by the parent and whether the branch is sufficiently close to the parent, the surveyors may review and utilize the HHA’s branch-specific outcome based reports during the survey and determine if the CoPs continue to be met with the inclusion of the additional location. 2182.4D - Drop Sites (Rev 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) Where permitted by state and local law, an HHA may utilize a drop site for field staff convenience. These drop sites are not considered branches and should not meet the Medicare definition of a branch or operate as such. HHAs that allow these locations to cross the line from drop site to branch are out of compliance with the Medicare requirements. The HHA should not assign staff to these locations, accept referrals at these locations, advertise them as a part of the HHA, or operate them in any other way as branches of the HHA. HHAs that are unsure if the location meets the definition of a branch may seek advice from the SA. If the location does meet the definition of a branch, it must request CMS approval before providing services from this location. The HHA’s policies on drop sites should reflect current Federal and State requirements, including compliance with the Health Insurance Portability and Accountability Act of 1996 privacy requirements. While these sites would not be subject to routine surveys, they may be subject to state or RO inspection at any time. Any violation would be addressed by the SA and referred to the CMS RO for any necessary program integrity investigation and follow up.