Staff Awareness

2183.3 - Staff Awareness (Rev 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) The HHA staff should be knowledgeable about the HHA’s policies and procedures, the regulatory requirements related to their role in the delivery of care in an HHA, and be able to identify the difference in services they provide for the HHA and other programs, departments, or entities of the organization. Personnel who divide time between the separate entity and the HHA must be appropriately trained to deliver HHA services. The HHA maintains separate time sheets for each individual’s assigned time to the HHA. If the SA determines, based on the information provided by the HHA or for other reasons, that the HHA does not have a separate entity, or if the HHA or parent organization is unable or unwilling to provide the information, inform the HHA that: • It is in violation of the provisions of §§1861(o) and 1891 of the Act which require compliance with the CoPs, particularly those conditions that relate to clinical records and disclosure of the ownership of the HHA; • It is in violation of its agreement with the Secretary under §1866 of the Act and the regulations related to this agreement (§489.53(a)) because it has failed to provide information about ownership and information concerning clinical records; • It is in violation of §1128(b)(12)(A) of the Act because it has denied access to records to determine compliance with the CoPs, including those that relate to the OASIS requirements; and • It may be in violation of various requirements related to its Medicare cost reports, which mandate information about all of the HHA’s clients in order to properly pay Medicare costs, and that the HHA’s MAC must be notified about the allegation of separate entities. (See §413.5(b)(3), §413.9, §413.13(f)(2)(ii), §413.17, §413.50(b), §413.53(a), and §413.80(d).) The SA must report these separate entity situations to the CMS RO, along with any recommendations the State has concerning the operation of two distinct entities. The State must also indicate whether the HHA refused access to records or information that make it impossible for the surveyor to make a determination concerning whether the applicant or approved HHA complies with the HHA CoPs. The surveyor will inform the approved HHA that the SA must report the alleged separate entity to the CMS RO that in turn must report this information to the MAC and, if necessary, to the State Medicaid Director.