Basic Training: Home Health Edition. Home Care Rules and Regulations. March 21, 2013

Transcription

1 Basic Training: Home Health Edition Home Care Rules and Regulations March 21, 2013 Presented by: Rhonda Will, RN, BS, COS-C, BCHH-C Assistant Director of the Competency Institute Fazzi Associates, Inc. 243 King Street, Suite 246 Northampton, MA Fax:

2 Fazzi Associates, Inc Continuing Educational Activity Required Disclosures to Participants Successful Completion of this Continuing Nursing Education Activity: In order to receive full contact hour credit for this CNE activity, you must: Listen to entire educational activity Complete the evaluation Conflicts of Interest A conflict of interest occurs when an individual has an opportunity to affect educational content about health care products or services of a commercial company with which she/he has a financial relationship. The planners and presenters of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity. Commercial Company Support There is no commercial company support for this CNE activity. Noncommercial Sponsor Support There is no noncommercial support for this CNE activity. Non-Endorsement of Products Fazzi Associates, Inc. s accredited provider status refers only to continuing nursing education activities and does not imply that there is real or implied endorsement of any product, service, or company referred to in this activity.

3 Instructions and Handouts for: Basic Training: Home Health Edition Home Care Rules and Regulations March 21, :00pm - 2:15pm EST Eastern Standard Time 1:00 PM to 2:15 PM Central Standard Time 12:00 PM to 1:15 PM Mountain Standard Time 11:00 AM to 12:15 AM Pacific Standard Time 10:00 AM to 11:15 AM It is very important that you have these materials printed and ready to use prior to the start of the training. In order to participate in this training you will need to do the following: 1. Dial +1 (646) at least 10 minutes prior to the start of the tele-training. 2. When prompted, enter Conference ID Passcode: You can also participate using your microphone and speakers. To do so select Mic & Speakers in the control panel. Please ensure your speaker volume is turned on. 4. To view the presentation online, you must click on the link sent to you from GoToWebinar. * Note: Please do not forward your own webinar login information as each one is specific. Once you are logged in to the webinar anyone else that tries to use your information will not be allowed in.

4 Objective for this session 1. Recognize the rules & regulations of home care. Presenter Bio Rhonda Will RN, BS, COS-C, BCHH-C, has experience as a registered nurse since 1971 and has worked in home health care since 1979 in various clinical, administrative and management roles. Rhonda has extensive experience as a trainer. Her areas of expertise include PPS and OASIS assessment skill building, documentation, care planning and care management, regulatory compliance, and policy and procedure development. With Fazzi Associates Rhonda has developed the OASIS audit and clinical and management training programs and basic ICD-9-CM Coding training and oversees the clinical auditors and trainers. She presents OASIS and basic coding training on site and by audio conferencing for home health agencies, state home health associations and national professional and commercial organizations. She provided clinical leadership for the M National OASIS Integrity Project, clinical director of the National OASIS-C Best Practices Project 2009, and a facilitator at the Delta National Excellence in Therapy Forum September In January of 2008, in collaboration with a physical therapy colleague, she developed and produced a series of electronic streaming videos for home health care orientation. Rhonda has developed a reputation in the home health industry as an OASIS Expert: reviewed the draft OASIS-C Guidance Manual for CMS 2009; reviewed Tina Marelli s.handbook of Home Health Standards: Quality Documentation and Reimbursement, 5 th edition 2009; Editorial board member and peer reviewer for Home Healthcare Nurse 2012; Speaker for national and state home care associations and vendor conferences. Nurses Only Directions on how to Receive Contact Hours This continuing nursing education activity was approved for 1.25 Contact Hours. Fazzi Associates is an approved provider of continuing nursing education by the Massachusetts Association of Registered Nurses, Inc., an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. 1. Each participant must complete an electronic evaluation in order to receive contact hours. Please be sure to complete all contact information as all certificates are ed. 2. There is a four week processing period to process the contact hours. 3. Click on the following link in order to access the online evaluation form:

5 BASIC TRAINING: HOME HEALTH EDITION HOME CARE RULES & REGULATIONS PRESENTED BY: Rhonda Marie Will, RN, BS, COS-C, BCHH-C Assistant Director OASIS Competency Institute Fazzi Associates, Inc. DISCLOSURES Successful Completion of Education Activity Listen to entire program Complete evaluation Disclosures No conflict of interest for presenters & planners No commercial company support No noncommercial company support No endorsement of any products, services, or company 1

6 Objective: Recognize the rules & regulations of home care NEED TO KNOW REGULATIONS Medicare Conditions of Participation 42 CFR Services, Patient rights, Plan of Care (POC), Care Coordination, HHAide Supervision Comprehensive assessments, drug regimen review, OASIS data collection Prospective Payment System (PPS) Home Healthcare Qualifying and Coverage Requirements (Medicare Program Integrity Manual) Eligibility: skilled care, homebound, under care of physician Skilled care definitions: reasonable and necessary NEED TO KNOW REGULATIONS HIPPA Privacy and transmission standards Home Health Advance Beneficiary Notice (HHABN) State Regulations Accreditation Standards State Practice Act Safety Standards OSHA and Biomedical waste Infection control Agency policy and procedures 2

7 PATIENT RIGHTS COP Notice of Rights Informed orally and in writing in advance of providing care with documentation of compliance. Includes OASIS collection and reporting information. Exercise of rights and respect for property and person. To be informed and participate in care planning and treatment. PATIENT RIGHTS Confidentiality of medical record Liability for payment Toll free home health hotline number ORGANIZATION, SERVICES AND ADMINISTRATION COP Personnel records include current qualifications and licensure. Written contract with hourly or per visit contract staff specifying: Patients accepted for care only by the primary agency Services to be furnished Necessity to conform with applicable agency P and P Responsibility to participate in developing plans of care Procedures for submitting notes, scheduling visits and periodic patient evaluation How services will be controlled, coordinated and evaluated by the primary HHA Procedures for payment of professional services 3

8 ORGANIZATION, SERVICES AND ADMINISTRATION COP Coordination of patient services All personnel furnishing services maintain liaison Ensures efforts are coordinated effectively Support the objectives outlined in the plan of care Evidence in clinical record and/or in minutes of case conferences Written summary sent to physician every 60 days ACCEPTANCE OF PATIENTS, POC, MEDICAL SUPERVISION COP Patients accepted if able to meet immediate care and support needs Initial assessment visit Admission policies Care follows written POC established and reviewed periodically by a doctor of medicine, osteopathy or podiatric medicine Therapy service orders Include specific procedures and modalities to be used and the amount, frequency and duration Therapist and HHAgency personnel participate in developing POC ACCEPTANCE OF PATIENTS, POC, MEDICAL SUPERVISION COP POC reviewed as required and at least every 60 days by the physician and HHAgency. Prompt alerts to the physician when changes needed. Drugs and treatments administered only as ordered. Verbal orders put in writing and signed and dated with date of receipt. Verbal orders accepted by authorized personnel. 4

9 MEDICARE HOME HEALTH CARE Qualifying vs. Coverage Criteria QUALIFYING CRITERIA In need of skilled nursing care on an intermittent basis OR physical therapy OR speech language pathology; have a continuing need for occupational therapy. Confined to the home. Under the care of a physician. Receiving services under a plan of care established and periodically reviewed by a physician. Once the qualifying criteria are met, the patient may also receive the dependent services of an occupational therapist, medical social worker, registered dietician and/or home health aide. INTERMITTENT SKILLED NURSING CARE When nursing is the qualifying service: Provided or needed on fewer than 7 days a week, less than 8 hrs a day for 21 days or less. Medically predictable recurring need for skilled nursing services. Have an established plan for more than one visit. Exception: daily for diabetics unable to administer their insulin and no able and willing caregiver. Special consideration for > daily for 2-3 weeks in the physician's judgment. Obtain medical documentation justifying need and estimate finite and predictable end point, forwarding to the Regional Home Health Intermediary. 5

10 OCCUPATIONAL THERAPY CLARIFIED NOV OT is a dependent service, not a qualifying service. For Medicare to cover (pay for) a dependent service (OT, HHA, MSW) the dependent service must be followed by a qualifying skilled visit (SN, PT, SLP), except when certain unexpected circumstances occur, such as an unexpected inpatient admission or the death of the beneficiary. OT becomes a qualifying service after the 1 st OT visit is followed by a qualifying skilled visit of a SN, PT, SLP. OT remains a qualifying service from that point on. SKILLED NURSING CARE Observation and Assessment Management and Evaluation of a patient s plan of care Teaching and Training PHYSICAL THERAPY SERVICES Assessment Therapeutic exercises Gait training Range of Motion Maintenance therapy Ultrasound, shortwave and microwave diathermy treatments Hot packs, Infra-red treatments, paraffin baths and whirlpool baths Wound care provided within scope of state practice acts 6

11 OCCUPATIONAL THERAPY SERVICES Planning, implementing and supervision of therapeutic programs To restore physical function To restore sensory-integrative function For active treatment for psychiatric illness To improve level of independence in ADL Designing, fabricating and fitting of orthotic and self help devices Vocational and prevocational assessment and training SPEECH THERAPY SERVICES Assessment of rehabilitative needs Reevaluation with a change in functional speech or motivation, clearing of confusion or remission of some other medical condition that previously contraindicated SLP services. Routine reevaluations as part of restorative therapy cannot be billed as a separate visit. Service result from illness or injury and directed toward specific speech/voice production. SPEECH THERAPY SERVICES Establish a hierarchy of speech-voice-language communication tasks. Train patient and family to augment speech-language communication, treatment or establish effective maintenance program. Rehabilitation of speech and language skills for aphasia. Develop control of vocal and respiratory systems for correct voice production. 7

12 CONFINED TO THE HOME A condition due to an illness or injury that restricts their ability to leave their place of residence except with the aid of : Supportive devices, e.g., crutches, cane, wheelchair, walker Use of special transportation The assistance of another person If leaving the home is medically contraindicated The feebleness and insecurity of advanced aged does not confine a person to the home unless they meet the previous criteria. Psychiatric illness manifests in a refusal to leave home or if it would be considered unsafe to leave home unattended. PLACE OF RESIDENCE Wherever the patient makes his/her home. Assisted Living Facilities, Group Home and Personal Care homes if not primarily engaged in providing to inpatients: Diagnostic and therapeutic services Treatment Care of the disabled or sick Rehabilitation services Skilled nursing care or related services for those who require medical or nursing care Licensed/certified day care center does not meet definition. HOMEBOUND CLARIFIED PPS FR 2012 For purposes of the statute, an individual shall be considered confined to the home (that is, homebound) if the following exist: (one of these) The individual has a condition due to an illness or injury that restricts his or her ability to leave their place of residence except with: the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person; OR if leaving home is medically contraindicated. AND (both of these) The individual does not have to be bedridden to be considered confined to the home. However, the condition of the patient should be such that: 1. There exists a normal inability to leave home and, consequently, 2. Leaving home would require a considerable and taxing effort. 8

13 HOMEBOUND STATUS Determining homebound status requires clinical judgment and critical thinking applied to the patient s ability to leave the home setting. The focus is on: Absences from the home are infrequent, of short duration, or needed to receive healthcare treatment. A considerable and taxing effort to leave the home. Condition precludes ability to receive healthcare services outside the home. LEAVING THE HOME The ability to complete all aspects of a successful trip: Getting ready to go Leaving the home Completing the task Returning home Being able to function after the trip ALLOWABLE DESTINATIONS Examples of acceptable times for leaving the home Medical appointments to receive healthcare treatment. Attendance at licensed or state certified or state accredited adult day centers. For purposes of therapeutic, psychosocial or medical treatment. Ongoing outpatient kidney dialysis. Outpatient chemotherapy or radiation therapy. 9

14 ALLOWABLE DESTINATIONS Examples of acceptable times for leaving the home. Non medical purposes (occasional and of short duration) Church Beautician/barber visits Walk around the block or a drive Special family events The ultimate test is the frequency and effort involved and that absences do not indicate the patient has the capacity to obtain health care outside rather than in the home. UNDER THE CARE OF A PHYSICIAN Physician: doctor of medicine, osteopathy or podiatric medicine Face to Face Encounter 90 days prior to the SOC or within first 30 days after the SOC Plan of Care Services, Interventions, Goals, Nutritional Requirements, Functional Limitations, Activity Limitations Certifies that the patient is homebound and needs skilled care Periodically reviewed At least every 60 days MEDICARE COVERAGE OF HHA SERVICES Eligible Medicare beneficiary Qualifies for coverage Services are covered by Medicare Medicare is appropriate payer Medicare as Secondary Payment (MSP) 10

15 MEDICARE SECONDARY PAYER MSP function to ensure that federal funds are not used to pay for services reimbursable under a private insurance plan. Workers Compensation Auto or other Liability Insurance Group Health Plans End Stage Renal Disease Black Lung Program VA AVAILABLE CAREGIVER Entitled by law to reasonable and necessary home health services without regard to whether someone is available to furnish the services. Ordinarily presumed that there is no able or willing caregiver unless: Patient/family identifies otherwise and objects to agency services or Agency has first hand knowledge to the contrary REASONABLE AND NECESSARY Avoid duplicative services Facility required by law to provide Services included in base contract of facility Access to appropriate care from a willing caregiver 11

16 REASONABLE AND NECESSARY NURSING SERVICES Service that must be provided by a registered nurse or a licensed practical nurse under the supervision of a registered nurse to be safe and effective. Consider inherent complexity of the service Condition of the patient Accepted standards of medical and nursing practice Not considered a skilled service merely because it is performed by the a nurse. REASONABLE AND NECESSARY A service, which by its nature, requires the skills of a nurse to be provided safely and effectively continues to be a skilled service even if it is taught to the patient, caregivers or family. To be reasonable and necessary for the diagnosis or treatment of the patient s illness or injury, the services must be consistent with the nature and severity of the illness or injury, the patient s particular medical needs and accepted standards of medical and nursing practice. GOVERNING PRINCIPLES REGARDING THERAPY SERVICES Services provided with the expectation, based on the assessment made by the physician of the patient s rehabilitation potential, that the condition of the patient will improve materially in a reasonable and generally predictable period of time; or Services are necessary to the establishment of a safe and effective maintenance program. Excludes services involving activities for the general welfare of the patient, e.g. general exercises to promote overall fitness or flexibility and activities to provide diversion or general motivation. 12

17 EVERY 30 DAYS Minimally : Starts with the first visit from therapy Continues until discharge May cross certification periods DON T wait until the last minute COUNTING VISITS 13 (before 14) 19 (before 20) Single Therapy: On literal 13 th Rural exception (11-13) Completion resets 30 days Specific to each cert period Single Therapy: On literal 19 th Rural exception (17-19) Completion resets 30 days Specific to each cert period Multiple Therapy: Range of Closest to exception Completion resets 30 days Specific to each cert period Multiple Therapy: Range of Closest to exception Completion resets 30 days Specific to each cert period REASSESSMENT DOCUMENTATION Clinically supported statement of expectation that the patient can continue to progress or resume progress after plateau or regression. Speak to the effectiveness of therapy in relation to the goals. Plans to continue or discontinue: Refer to clinical findings (objective assessments) and treatment plan revisions. 13

18 MEDICAL SOCIAL SERVICES Covered services: Services necessary to resolve social or emotional problems that are expected to be an impediment to the effective treatment of the patient s medical condition or rate of recovery. Assessment of social and emotional factors related to the patient s illness. Assessment of the relationship of the patient s medical and nursing requirements to the home situation. Appropriate action to obtain available community resources. Counseling services for the patient. Short term services for the family or caregiver to remove a clear and direct impediment to the effective treatment of the patient s medical condition or rate of recovery. HOME HEALTH AIDE SERVICES The reason for the visits: To provide hands-on personal care of the patient. To provide services needed to maintain the patient s health. To facilitate treatment of the patient s illness or injury. INTERMITTENT SKILLED NURSING When Skilled Nursing and Home Health Aide services are provided in combination Furnished any number of days per week and Combined = less than 8 hours each day and 28 or fewer hours each week 14

19 COVERAGE OF FINAL VISIT Dependent services (OT*, MSW, HHA, RD) furnished after the final qualifying skilled service are not covered under the home health benefit, except when the dependent service was followed by an unexpected inpatient admission or death of the patient or due to some other unanticipated event. *OT not a dependent service once the service meets the criteria for a qualifying service. HIPPA The privacy and transmission standards apply to the home health setting. Being mobile providers adds additional challenges to compliance. Agencies are required to have policies and procedures to protect the confidentiality of protected health information about their patients. Think before you share any information. HHABN Home Health Advanced Beneficiary Notice. Since 2002, HHABNs (currently Form CMS-R-296) have been used by Medicare home health agencies (HHAs) to inform Medicare beneficiaries about possible noncovered items and/or services provided by the HHA and to alert beneficiaries that they may be liable for payment. The HHABN allows HHAs to collect payment for these services from Medicare beneficiaries based on section 1879 of the Social Security Act (SSA). 15

20 HHABN Financial liability, change of care agency reasons, change of care physician reasons Triggering Events Initiation of a non covered service Reduction of a service Termination of a services or all services Discharge planning is a process that starts at the beginning of an episode of care. Patients need to be actively involved in this process. Agencies are required to notify patients in writing at least 2 days prior to discharge. COMPLIANCE WITH FEDERAL, STATE AND LOCAL LAWS COP The HHA and staff must: Operate and furnish services in compliance with all applicable Federal, State, and local laws and regulations. Comply with accepted professional standards and principles that apply to professionals furnishing services in the HHA. STATE REGULATIONS If the individual state has a more strict rule, home health agencies will be held to it. Need to know what the applicable rules are in your state. 16

21 ACCREDITATION STANDARDS An agency may choose to participate in accreditation programs such as: TJC The Joint Commission CHAP - Community Health Accreditation Program ACHC - Accreditation Commission for Health Care, Inc. Participation is voluntary and additional standards may be applied. Surveys are involved so preparation is key. PRACTICE ACTS Each state has discipline specific Practice Acts. It is a professional responsibility to know and adhere to these standards. SAFETY STANDARDS The home setting is a unique environment in which to deliver care. Specific standards are to be followed: OSHA Biomedical waste Infection control Learning the specific measures in place for personal and patient safety is an important part of orientation. 17

22 LOCAL COVERAGE DETERMINATIONS Title XVIII of the Social Security Act allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. CMS provides national coverage determinations. Regional Home Health Intermediaries have a list of local decisions for nursing and therapy services. Guidelines for indications and limitations of coverage and/or medical necessity. AGENCY POLICIES AND PROCEDURES As an employee, you need to know what specific policies and procedures apply to your role. Policies and procedures align with state and federal rules and are subject to review during a survey. Fazzi Associates, Inc. 243 King Street, Suite 246 Northampton, MA (800) Questions: training@fazzi.com Evaluation Link: 18