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2 Kinnser is software for better post-acute care. HOME HEALTH. THERAPY. PRIVATE DUTY. HOSPICE 4,500 + Agency Customers 49% Faster Documentation 27% More Productive 52% Faster Billing 33% Less Expense sales@kinnser.com

3 Today s educational presentation is provided by The software that powers HOME HEALTH. THERAPY. PRIVATE DUTY. HOSPICE sales@kinnser.com

4 About the presenter JILL DYER BSN, RN, HCS-D, HCS-O Home Health Executive, Consultant J.I.D. Consulting

5 About the presenter SHARON HARDER President C3 Advisors, LLC More info: c3advisors.com

6 Today s Focus! Pa1ent Rights! Representa1ves! No1ces! Exercise of Rights! Involvement in Care and Care Planning! Transfers and Discharges! Complaints Documenta1on, Inves1ga1on and Resolu1ons! OASIS Privacy and Data Submission

Breaking News Interpre=ve Guidance! DraA Interpre=ve Guidance were issued on October 27 th! Available at hfp://report.nahc.org/wp-content/uploads/2017/10/3819-f-homehealthagency-cops_igs.pdf!

7 Breaking News Interpre=ve Guidance! DraA Interpre=ve Guidance were issued on October 27 th! Available at hfp://report.nahc.org/wp-content/uploads/2017/10/3819-f-homehealthagency-cops_igs.pdf! CMS will not entertain individual comments, but will accept comments from NAHC! Comments for NAHC s considera1on should be submifed to Mary Carr at mkc@nahc.org! Today s slides marked with show the most recent draz interpre1ve guidance

8 Key Defini=on Pa=ent Representa=ve! Pa1ent s legal representa1ve or a pa1entselected representa1ve who par1cipates in care decisions! Can be a family member or other pa1ent advocate! The pa1ent determines the representa1ve s role to the extent possible! Representa1ve s role based on the pa1ent s stated preference should be documented in the record

9 Key Defini=on In advance! Means that the agency s staff must complete the task prior to performing any hands-on care or pa1ent educa1on! Will be a key defini1on during surveys and medical review

10 Pa=ent Rights The pa1ent and representa1ve (if any) have the right to be informed of the pa1ent s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights.

484.50 Pa=ent Rights a) No1ce of rights b) Exercise of rights c) Rights of the

11 Pa=ent Rights a) No1ce of rights b) Exercise of rights c) Rights of the pa1ent d) Transfer and discharge e) Inves1ga1on of complaints f) Accessibility

484.50 (a) - No=ce of Rights! Pa1ent and his/her representa1ve must receive the following in wri1ng before care is provided:! No1ce of Pa1ent Rights and Responsibili1es!

12 (a) - No=ce of Rights! Pa1ent and his/her representa1ve must receive the following in wri1ng before care is provided:! No1ce of Pa1ent Rights and Responsibili1es! Informa1on concerning the agency s transfer and discharge policies! Contact informa1on for the Administrator! OASIS Privacy No1ce! The No1ce must be signed by the pa1ent and/or the legal representa1ve and maintained in the pa1ent s record

13 WriUen No=ce of Pa=ent Rights! If the pa1ent s representa1ve is not legally appointed via a guardianship, POA or other legal instrument, informa1on must be provided directly to the pa1ent! If the pa1ent has a legally designated representa1ve, the wrifen no1ce must be provided prior to ini1a1ng care, but there is one available excep1on to the 1ming of no1ce for the representa1ve! If the pa1ent declines no1ce to his/her representa1ve, the agency should document the declina1on in the pa1ent s record! The form that is used should contain a confirma1on statement that the No1ce of Pa1ent Rights has been received by the signer(s)

Legal Representa=ve Excep=on! If the pa1ent s legal representa1ve is not available and the pa1ent has not declined to have the representa1ve informed as to pa1ent rights and responsibili1es,!

14 Legal Representa=ve Excep=on! If the pa1ent s legal representa1ve is not available and the pa1ent has not declined to have the representa1ve informed as to pa1ent rights and responsibili1es,! The agency may provide the wrifen documenta1on to the pa1ent representa1ve within four days of ini1a1ng care! Informa1on can be provided to the representa1ve electronically or in wrifen form through the mail

Administrator Contact Info! Administrator informa1on is for the purpose of enabling the pa1ent or his/her representa1ve to lodge a complaint!

15 Administrator Contact Info! Administrator informa1on is for the purpose of enabling the pa1ent or his/her representa1ve to lodge a complaint! Viewed by CMS as an essen1al func1on of leadership! Name, business address and business phone number of the administrator are required as a part of the no1ce of rights

16 OASIS Privacy No=ce! Must be in addi1on to other required no1ces such as HIPAA privacy! This no1ce should be a part of the overall Pa1ent Rights No1ce and must be provided and documented at the ini1al assessment visit! Applies to all pa1ents for whom OASIS data is gathered

Verbal No=ce of Pa=ent Rights! Verbal no1ce of pa1ent rights and responsibili1es must also be provided in the individual s primary or preferred language,!

17 Verbal No=ce of Pa=ent Rights! Verbal no1ce of pa1ent rights and responsibili1es must also be provided in the individual s primary or preferred language,! And, in a manner that the individual understands! If an interpreter is needed to fulfill this requirement, the service must be offered without charge to the pa1ent! Verbal no1ce must be delivered no later than the second visit

18 Extenua=ng Circumstances! CMS acknowledges that there are 1mes when it may be difficult to find an interpreter for less common languages! CMS expects that the agency will exhaust all avenues including telephonic transla1on services, video conferencing or online transla1on of wrifen documents! Such op1ons are acceptable as long as they meet the pa1ent s needs

19 Interpre=ve Guidance Pa=ent No=ces! Expected that an agency s pa1ents will be able to confirm during a survey pa1ent visit or other interview that:! Their rights and responsibili1es, and! The transfer and discharge policies of the agency were provided,! In a language that the pa1ent understood, and! In a manner that accommodated any disability the pa1ent might have

20 Interpre=ve Guidance Pa=ent No=ces! Should be a hard copy unless the pa1ent requests an electronic no1ce! If the pa1ent s understanding of English is limited, the informa1on must be provided in a language or format familiar to the pa1ent or his/her representa1ve! Use of bilingual staff, interpreters, formal arrangements with local organiza1ons that provide transla1on services or telephonic interpreta1on for language assistance! Agency staff should be trained to iden1fy pa1ents with language barriers and staff who have ongoing contact with pa1ents should be trained in effec1ve communica1on techniques including the use of an interpreter

21 Interpre=ve Guidance - Transla=on! If the pa1ent speaks a language that has not been translated by the agency into its wrifen pa1ent rights materials, the agency can delay the no1fica1on of pa1ent rights and responsibili1es un1l an interpreter is present to translate! The permifed delay only extends to the second visit! Agency should document that the verbal discussion of rights took place and that the pa1ent or his/her representa1ve was able to confirm understanding of the conversa1on

484.50 (b) - Exercise of Rights! If there is lack of legal capacity based on a court decision or provision of state law,!

22 (b) - Exercise of Rights! If there is lack of legal capacity based on a court decision or provision of state law,! Rights of the pa1ent may be exercised by the person appointed by the court to act on the pa1ent s behalf! In the absence of a court appointed representa1ve, the pa1ent s representa1ve may exercise the pa1ent s rights! If there is a court order as to the pa1ent s legal capacity, the pa1ent may exercise his/her rights to the extent allowed by the court order

23 Interpre=ve Guidance Exercise of Rights! The agency should have documenta1on of any adjudica1on by a court which indicates that a pa1ent lacks capacity to make health decisions! The documenta1on should include the name(s) of those who have been iden1fied by the court to exercise the pa1ent s rights! The agency should have specific policies and procedures in place to direct how documenta1on of legal capacity is included in the pa1ent record

24 (c) Rights of the pa=ent 1. To have his/her property treated with respect 2. To be free from verbal, mental, sexual and physical abuse including injuries of unknown source, neglect and misappropria1on of property 3. To make complaints to the agency regarding treatment or care 4. To par1cipate in and be informed about and consent or refuse care in advance of treatment 5. To receive services outlined in the POC 6. To have a confiden1al clinical record and access to that record

25 (c) Rights of the pa=ent 7. To be advised of the extent to which payment may be expected from Medicare, Medicaid or any other federally funded program 8. To receive proper wrifen no1ce, in advance of a change or discon1nua1on of service 9. To be advised of the state toll free home health hot line and contact informa1on 10. To be advised of the contact informa1on for federal and state en11es that serve the pa1ent s area 11. To be free from discrimina1on or reprisal for exercising his/her right to voice grievances 12. To be informed of the right to access auxiliary aids and language services

26 Interpre=ve Guidance Respect for Property and Person! Policy and staff training focused on ensuring that pa1ent property is respected both inside and outside the home! Policy focused on agency considera1on of pa1ent requests within the parameters of the assessment and plan of care! Pa1ent treated as an ac1ve par1cipant in the delivery of care! Pa1ent is informed of the visit schedule and changes to the schedule! Visits should be on a schedule that is convenient to the pa1ent and not necessarily the agency s staff

27 Interpre=ve Guidance Abuse, Injuries and Neglect! Pa1ent has a right to be free from abuse from the agency staff and others! Verbal abuse including wrifen or gestured language! Mental abuse including threats, humilia1on or threats! Sexual abuse! Physical abuse including corporal punishment and restric1ve or intrusive procedures to control behavior! Misappropria1on of property thez from the pa1ent or his/her home! Policies and procedures should be in place to establish the agency s methods for ensuring respect for pa1ents and their property and handling pa1ent complaints or other allega1ons of improper conduct

28 Injuries of Unknown Source! Not witnessed and pa1ent cannot explain the injury! Agency should carefully document and monitor the situa1on! Allega1ons or evidence of abuse may warrant a change in the plan of care and/or referral to an appropriate agency for follow up! Agency must intervene immediately as indicated by the circumstances if an injury is the result of an employee ac1on and staff must be removed! Agencies must be able to demonstrate knowledge of applicable state law

29 Interpre=ve Guidance Filing Complaints! Agency should have wrifen policies for:! Acceptance of complaints! Processing of complaints! Review procedures! Resolu1on process! Policies should include 1meframes for conduc1ng the inves1ga1on, documenta1on of outcomes and ac1ons to be taken! The pa1ent s record and home folder should confirm that informa1on regarding the pa1ent s right to lodge a complaint was provided

30 Interpre=ve Guidance Par=cipa=on and Consent! Pa1ent must be given op1ons regarding care choices and preferences! Informed consent is not intended to be the func1on of a form! Informed consent is ongoing as care changes and evolves! All aspects of care and services and the manner services are to be delivered are a func1on of par1cipa1on and consent! There must be evidence in the record that the pa1ent was consulted and that he/she consented to planned services and care! Changes in the POC must be communicated to the pa1ent no later than the visit that most closely follows the change! Agency must document that the pa1ent was informed of the change

31 More on Par=cipa=on and Consent! Extends to comple1on of assessments! Disciplines that will furnish service and visit frequencies! Expected outcomes of care including pa1entiden1fied treatment goals and benefits! Any factors that could impact treatment effec1veness

32 Interpre=ve Guidance Services in the POC! The pa1ent is en1tled to receive all of the services and treatments outlined in the Plan of Care! Change may be required in the way POCs are set forth with tasks selected by assessing clinicians! Make sure that the POC includes only those tasks and treatments/assessments that are really needed by the pa1ent! If a task is included in the Plan of Care, surveyors and reviewers are going to look for documenta1on that the service was performed

33 Interpre=ve Guidance Services in the POC! CMS has clarified that the Plan of Care and amendments do not have to be provided to the pa1ent and representa1ve! But, other documenta1on must be provided within 5 days of the ini1al assessment 1. Visit schedule with frequency of visits by discipline 2. Medica1on schedule and instruc1ons 3. Treatments that will be administered 4. Per1nent instruc1ons related to the pa1ent s care and treatments 5. Name and contact informa1on of the agency s clinical manager

34 Confiden=ality of Pa=ent Records! Link to HIPAA privacy requirements! Privacy Rule protec1on of health informa1on! Security Rule imposes security requirements for agencies and business associates regarding confiden1ality and integrity of records! Breach No1fica1on Rule requires covered en11es to no1fy HHS of PHI breaches! HIPAA rules also provide for pa1ent rights to obtain copies of their own records and to request correc1ons

35 Pa=ent Inspec=on of Records! Pa1ent has the right, upon verbal or wrifen request, to receive current clinical records! This request would necessitate provision of the Plan of Care as well as other records! Electronic copies should be provided at no charge and hard copies must be charged at a rate not to exceed the community standard for photocopying the record! Timeframe for providing the informa1on is within four business days or at the next home visit, whichever comes first

36 Interpre=ve Guidance Payment for Services and Changes in Care! Pa1ent s record must include documenta1on that the pa1ent was advised, prior to the start of services, of the extent to which services are expected to be reimbursed by Medicare! Documenta1on must include informa1on as to payments that would be expected from the pa1ent if other reimbursement were not available! If the pa1ent s condi1on changes and new or addi1onal services are required, the same advance no1fica1on must occur with respect to those services! No1fica1on must include informa1on about the hot line and expedited appeal rights for diminu1on of services

37 Interpre=ve Guidance Federal and State Assistance! Pa1ents must be given contact informa1on name, address and telephone number of the following agencies:! Area Agency on Aging! Center for Independent Living! Protec1on and Advocacy Agency! Aging and Disability Resource Center! Quality Improvement Organiza1on

38 Interpre=ve Guidance Freedom from Reprisal! Discrimina1on against a pa1ent who has filed a complaint is prohibited! Discrimina1on is defined as treatment that differs from that provided to other pa1ents following a complaint without jus1fica1on of the disparity! Examples include! Reduc1on of services! Discon1nua1on of services! Discharge without medical jus1fica1on for the change

484.50 d) Transfers and Discharges! Agency may only discharge the pa1ent under limited circumstances which must be documented in the no1ce to pa1ents! Necessary for pa1ent welfare!

39 d) Transfers and Discharges! Agency may only discharge the pa1ent under limited circumstances which must be documented in the no1ce to pa1ents! Necessary for pa1ent welfare! Reimbursement no longer available! Agency and physician agree that goals have been met! Pa1ent refuses services or elects to be transferred! Discharge for cause based on agency policy! Pa1ent death! Agency ceases to operate

Transfer and Discharge No=fica=on! Advance no1ce of the poten1al discharge or transfer should be provided! Pa1ent preferences at the 1me of discharge or transfer must be documented and considered!

40 Transfer and Discharge No=fica=on! Advance no1ce of the poten1al discharge or transfer should be provided! Pa1ent preferences at the 1me of discharge or transfer must be documented and considered! Pa1ents have the right to refuse the transfer which must be documented! Pa1ents and representa1ves have the right to appeal the transfer or discharge decision! Ongoing communica1on with the pa1ent and representa1ve during the process is cri1cal

41 Interpre=ve Guidance Transfer/DC for Pa=ent Welfare! Invoked when the pa1ent requires more than intermifent service! Transfer for specialized services that the agency cannot provide! Expecta1on of poten1al adverse outcome that prompts the transfer/dc! Pa1ent and physician must be informed and documenta1on must be present in the record! Alterna1ve providers must be iden1fied! Transfer must be facilitated by the home health agency and pa1ent medical record must be provided to the receiving en1ty prior to or upon transfer

42 Transfer/DC for Lack of Reimbursement! Generally involves lack of ongoing medical necessity for services! No1ce must be provided at least two days in advance of complete discharge! Some states require more no1ce that can go up to five days! Lack of reimbursement due to agency failure to comply with coverage or eligibility requirements

43 Interpre=ve Guidance Transfer/DC with Goals Met! Intent is that when the pa1ent is stabilized and health and safety goals have been sufficiently met, services would no longer be needed and discharge is appropriate! If pa1ent disagrees with the discharge, he/she should be apprised of the opportunity to appeal the decision azer receiving proper wrifen no1ce of the intent to discharge

44 Interpre=ve Guidance Transfer/DC for Refusal of Services! Pa1ents have always had the right to refuse service! Declines of a single type of service are differen1ated from refusal of service! Declining service from a par1cular discipline may not warrant discharge! Refusals that would have poten1al adverse effects on the pa1ent or compromise the agency s ability to safely deliver care could warrant a DC! Documenta1on of physician no1fica1on of discharge decisions should be commifed to the pa1ent s record! Measures that the agency took to educate the pa1ent must also be documented

45 Interpre=ve Guidance Transfer/DC for Cause! Abusive or disrup1ve behavior! Threats - both verbal and non-verbal! Sexual harassment or other incidents involving the safety of staff! Other impediments to the safe delivery of care! Repeated declina1on of service or persistent and counterproduc1ve hos1le antudes and behavior

46 No=fica=on Requirements DC for Cause! Pa1ent and physician must have advance no1ce that the DC is being considered! Others also caring for the pa1ent should also be no1fied prior to DC! Clinical record must reflect! Problems encountered with the pa1ent! Assessment of the situa1on! Communica1on with management and the physician! Plan for resolving issues! Resolu1on implementa1on results

47 DC for Cause Immediate Ac=on Excep=on! When staff are threatened or endangered! Can open the door for immediate ac1on without a plan to resolve the situa1on! Evidence should be in the record that the agency provided the pa1ent and/or representa1ve with informa1on on alternate community resources! Pa1ents and representa1ves should also be given names of other agencies that might be able to provide service

48 Interpre=ve Guidance Agency Cessa=on of Services! Agency is unable to con1nue opera1ons! Sufficient no1ce of planned cessa1on of business is required! Pa1ents must be given informa1on of other providers! Agency must facilitate the safe transfer of pa1ents to other agencies

49 Agency Issues Lack of Available Staff! Not addressed in the Interpre1ve Guidance but was covered in the FR comments! Lack of staff is not considered an appropriate reason to discharge or transfer a pa1ent! Agency is responsible for assuring availability of staff when the pa1ent is admifed for care

50 Agency Failures Acquisi=on of the F2F! Not addressed in the Interpre1ve Guidance but was covered in the comments in the FR! Coverage requirements not being met due to failure to complete the F2F should be excep1onally rare given the 120 day 1meframe! When the F2F requirement is not met, the agency cannot hold the pa1ent accountable for payment! The HHA is also precluded from an abrupt discharge the pa1ent unless there is proper no1fica1on and a valid discharge reason

484.50 (e) Inves=ga=on of Complaints! The agency must inves1gate all complaints made by pa1ents, their representa1ves, caregivers and family!

51 (e) Inves=ga=on of Complaints! The agency must inves1gate all complaints made by pa1ents, their representa1ves, caregivers and family! Treatment or care that is or fails to be furnished! Inconsistent treatment! Inappropriate treatment! Mistreatment, neglect or verbal, mental, sexual or physical abuse! Misappropria1on of property

Documenta=on and Handling of Complaints! All complaints must be documented! Includes both the existence of the complaint and the resolu1on that was achieved!

52 Documenta=on and Handling of Complaints! All complaints must be documented! Includes both the existence of the complaint and the resolu1on that was achieved! Ac1on must be taken by the agency to avoid further poten1al viola1ons including retalia1on against the person who lodged the complaint! Agencies should also pay close afen1on to state laws and requirements related to complaints

Complaints Agency Staff Obliga=ons! Whether directly employed or providing services under arrangement! Normal course of providing services to pa1ents!

53 Complaints Agency Staff Obliga=ons! Whether directly employed or providing services under arrangement! Normal course of providing services to pa1ents! Iden1fica1on of incidents or circumstances that could be sugges1ve of mistreatment, neglect, abuse or injury! Iden1fica1on of misappropria1on of pa1ent property! All actual events or incidents must be promptly reported to the agency and other appropriate authori1es

54 Interpre=ve Guidance - Complaints! Systems must be in place to record, track and inves1gate complaints! WriFen policies and procedures! Acceptance of complaints! Processing complaints! Complaint review and inves1ga1on 1meframes! Resolu1on and outcomes! Communica1on

55 Interpre=ve Guidance - Complaints! Complaint inves1ga1ons should be part of the QAPI program! During a survey the agency should be able to provide documenta1on to confirm that inves1ga1ons were conducted! Documenta1on should describe any ac1ons taken by the agency to remove risks to the pa1ent during complaint inves1ga1ons

484.50 (f) - Accessibility! Informa1on must be provided in plain language and in an accessible manner! Persons with disabili1es must be given access to websites!

56 (f) - Accessibility! Informa1on must be provided in plain language and in an accessible manner! Persons with disabili1es must be given access to websites! Auxiliary aids and services may be required and cannot be at a cost to the pa1ent! Those with limited English must be able to access interpre1ve services and wrifen transla1ons of documents at no cost to the pa1ent

57 Release of OASIS Informa=on! Agencies must have wrifen contracts with third par1es that process OASIS informa1on! Contracts must obligate the par1es to ensure protec1on of pa1ent iden1fiable informa1on contained in the medical record including OASIS data! Confiden1al pa1ent informa1on may not be released to the public

58 Repor=ng of OASIS Informa=on! OASIS data must be encoded and transmifed to the CMS system within 30 days of the assessment comple1on! OASIS data must accurately reflect the pa1ent s condi1on! The transmifal format must meet CMS requirements! Transmission sozware must conform to FIPS standards! Branch iden1fica1on numbers must be included

59 Interpre=ve Guidance - OASIS! Agencies are responsible for the policies of their vendors related to security, confiden1ality of informa1on, and impermissible uses or disclosures! Agencies must ensure that their workforces are compliant and that their vendors also have compliance procedures in place to protect the confiden1ality of personal health informa1on! The HHA is ul1mately responsible for compliance with these confiden1ality requirements and is the responsible party if the agent does not meet the requirements.

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The software that powers HOME HEALTH. THERAPY. PRIVATE DUTY. HOSPICE

Today s educational presentation is provided by The software that powers HOME HEALTH. THERAPY. PRIVATE DUTY. HOSPICE 877.399.6538 sales@kinnser.com www.kinnser.com About the presenter SHARON HARDER President