TABLE OF CONTENTS CAHSAH. Medicare Conditions of Participation & Interpretive Guidelines

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1 TYPES OF SURVEYS Initial Certification 1 Standard Survey 1 Partial Extended Survey 2 Level 1 and Level 2 Standards 2 Extended Survey 3 Recertification Surveys 3 Frequency of Surveys 3 SUBPART A - GENERAL PROVISIONS Basis and Scope Definitions 4 Bylaws 4 Branch Office 4 Clinical Note 5 HHA 5 Parent Home Health Agency 5 Primary Home Health Agency 5 Progress Note 5 Proprietary Agency 5 Public Agency 5 Subdivision 5 Subunit 6 Summary Report 6 Supervision 6

2 484.4 Personnel Qualifications 7 Administrator, Home Health Agency 7 Audiologist 7 Home Health Aide 7 Occupational Therapist 8 Occupational Therapy Assistant 10 Physical Therapist 12 Physical Therapy Assistant 14 Physician 15 Practical (Vocational) Nurse 15 Public Health Nurse 15 Registered Nurse (RN) 15 Social Work Assistant 16 Social Worker 16 Speech-Language Pathologist 17 SUBPART B - ADMINISTRATION 17 G Condition of Participation: Patient Rights 17 G101 Paragraph 1 of G102 - G (a) Standard: Notice of Rights 18 G104 - G (b) Standard: Exercise of Rights and Respect for Property and Person 20 G106 - G (b) Standard: Exercise of Rights and Respect for Property and Person 20 G108 - G (c) Standard: Right to be Informed and to Participate in Planning Care and 21 Treatment G111 - G (d) Standard: Confidentiality of Medical Records 24 G113 - G (e) Standard: Patient Liability for Payment 24 G (f) Standard: Home Health Hotline 26

3 G Condition of Participation: Release of Patient Identifiable OASIS Information. 26 G Condition of Participation: Compliance With Federal, State, and Local Laws, 29 Disclosure and Ownership Information, and Accepted Professional Standards and Principles G (a) Standard: Compliance with Federal, State, and Local Laws and Regulations 29 G119 - G (b) Standard: Disclosure of Ownership and Management Information 29 G (c) Standard: Compliance with Accepted Professional Standards and Principles 30 G122 - G Condition of Participation: Organization, Services, Administration 32 G (a) Standard: Services Furnished 34 G128 - G (b) Standard: Governing Body 34 G133 - G (c) Standard: Administrator 35 G138 - G (d) Standard: Supervising Physician or Registered Nurse 35 G (e) Standard: Personnel Policies 36 G (f) Standard: Personnel Under Hourly or Per Visit Contracts 36 G143 - G (g) Standard: Coordination of Patient Services 37 G (h) Standard: Services Under Arrangements 38 G147 - G (i) Standard: Institutional Planning 39 G (j) Standard: Laboratory Services 41 G151 - G Condition of Participation: Group of Professional Personnel 43 G154 - G (a) Standard: Advisory and Evaluation Function 43 G156 - G Condition of Participation: Acceptance of Patients, Plan of Care, Medical 43 Supervision G159 - G (a) Standard: Plan of Care 44 G163 - G (b) Standard: Periodic Review of Plan of Care 47

4 G165 - G166, G167 (Expired) AND G (c) Standard: Conformance with Physician s Orders 48 G Condition of Participation: Reporting OASIS Information 49 G (a) Standard: Encoding OASIS Data 50 G (b) Standard: Accuracy of Encoded OASIS Data 51 G , G (c) Standard: Transmittal of OASIS Data 52 G (d) Standard: Data Format 56 SUBPART C - FURNISHING OF SERVICES 57 G168 - G Condition of Participation: Skilled Nursing Services 57 G171 - G (a) Standard: Duties of the Registered Nurse 57 G179 - G (b) Standard: Duties of the Licensed Practical Nurse 59 G184 - G Condition of Participation: Therapy Services 59 G190 - G (a) Standard: Supervision of Physical Therapy Assistant and Occupational 61 Therapy Assistant G (b) Standard: Supervision of Speech Therapy Services 62 G194 - G Condition of Participation: Medical Social Services 62 G202 - G Condition of Participation: Home Health Aide Services 62 G204 - G (a) Standard: Home Health Aide Training 63 G211 - G (b) Standard: Competency Evaluation and In-service Training 67 G223 - G (c) Standard: Assignment and Duties of the Home Health Aide 70 G228 - G (d) Standard: Supervision 71

5 And G301 - G302 G (e) Standard: Personal Care Attendant: Evaluation Requirements 73 G Condition of Participation: Qualifying to Furnish Outpatient Physical Therapy 73 or Speech Pathology Services G235 - G Condition of Participation: Clinical Records 74 And G303 G237 - G (a) Standard: Retention of Records 77 G239 - G (b) Standard: Protection of Records 78 G242 - G Condition of Participation: Evaluation of the Agency s Program 78 G248 - G (a) Standard: Policy and Administrative Review 79 G250 - G (b) Standard: Clinical Record Review 80 G Condition of Participation: Comprehensive Assessment of Patients 81 G331 - G (a) Standard: Initial Assessment Visit 84 G334 - G (b) Standard: Completion of the Comprehensive Assessment 88 G (c) Standard: Drug Regimen Review 91 G338 - G (d) Standard: Update of the Comprehensive Assessment 93 G (e) Standard: Incorporation of OASIS Data Items 97 APPENDIX 1 SURVEY PROTOCOLS Home Health Agency (HHA) Survey Protocols 1-12 HHA Survey Investigation Worksheet 1 HHA Survey Investigation Worksheet 2 HHA Survey Investigation Calendar