The Centers for Medicare & Medicaid Services (CMS) released a draft of the Interpretive Guidelines to the final Conditions of Participation scheduled to be implemented January 13, 2018. CMS has asked for feedback on the Draft Interpretive Guidelines. The draft Interpretive Guidelines offer specific guidance to surveyors, including additional survey procedures and probes also found under MyHomecareBiz.
484.80 (g) Standard: Home health aide assignments and duties.
484.80 (g) (l) Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist).
Interpretive Guidelines §484.80 (g) (l)
The act of assigning a “specific patient” is an intentional & deliberate decision that takes under consideration the skills of the aide, the availability of an aide for patient care continuity, patient preference whenever possible, and other considerations as determined by the patient’s care needs.
Most generally, home health aide services are provided in conjunction with and as an adjunct to a skilled nursing service. However, it is possible that a skilled therapist may identify the need for home health aide services as discussed in §484.80 (b) (3) in association with a skilled therapy service only. In these cases the skilled therapist may develop the plan for the aide and may perform the supervisory visit. Any concerns identified by the therapist during the supervisory visits must be communicated to the HHA clinical manager or HHA supervising nurse.
484.80 (g) (2) A home health aide provides services that are:
Ordered by the physician; Included in the plan of care; permitted to be performed under state law; and consistent with the home health aide training
484.80 (g) (3) The duties of a home health aide include: The provision of hands on personal care; the performance of simple procedures as an extension of therapy or nursing services; assistance in ambulation or exercises; and assistance in administering medications ordinarily self-administered.
Interpretive Guidelines §484.80 (g) (3)
At a minimum any procedure performed by a HHA aide must be within the scope of any nurse aide practice guidelines within the State and the HHA aide must have been trained to perform the procedure.
Self-administration of medications means that the patient (or the patient’s caregiver) is able to manage all aspects of taking her or his medication, including safe medication storage, removing the correct dose of medication from the container, taking the medication at the correct time, and knowing how to contact the pharmacy for refills or other questions.
Assistance in administering medications in this requirement means that the HH Aide may take only a passive role in this activity. This assistance is limited to getting water or fluids for the patient to take their medication.
484.80 (g) (4) Home health aides must be members of the interdisciplinary team, must report changes in the patient’s condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA’s policies and procedures.
Interpretive Guidelines §484.80 (g) (4)
The term “interdisciplinary” is used as a generic term for an approach to healthcare that includes a range of health service workers, both professionals and non-professionals, with the majority being from professional groups. The home health interdisciplinary team, which meets together, is composed of the disciplines including MDs, RNs, LPN/LVN, PT& PTA, OT & OTA, SLP, MSW, and HH aides.
During interdisciplinary team meetings all HHA staff involved in the patient’s care must be present for and contribute to the discussion. The HHA aide may participate in person, electronically or via telephone.
484.80 (h) Standard: Supervision of home health aides.
484.80 (h) (1) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in §484.80 (g), must make an onsite visit to the patient’s home no less frequently than every 14 days. The home health aide does not have to be present during this visit. If an area of concern in aide services is noted by the supervising registered nurse or other appropriate skilled professional, then the supervising individual must make an on-site visit to the location where the patient is receiving care in order to observe and assess the aide while he or she is performing care. (iii) A registered nurse or other appropriate skilled professional must make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care.
Interpretive Guidelines §484.80 (h) (1)
If, during the supervisory visit, a concern is identified at a patient’s home without the aide being present, the skilled professional must go on site with the aide at the next scheduled aide visit to address the concern.
The on-site supervisory visit must be made while the aide is providing care at least once annually.
484.80 (h) (2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care.
484.80 (h) (3) If a deficiency in aide services is verified by the registered nurse or other appropriate skilled professional during an on-site visit, then the agency must conduct, and the home health aide must complete a competency evaluation in accordance with paragraph (c) of this section.
484.80 (h) (4) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements:
Following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional;
- Maintaining an open communication process with the patient, representative (if any), caregivers, and family;
- Demonstrating competency with assigned tasks;
- Complying with infection prevention and control policies and procedures;
- Reporting changes in the patient’s condition; and
- Honoring patient rights.
Interpretive Guidelines §484.80 (h) (1)
Each supervisory visit would need to document how home health aide supervision evaluated the elements of this standard. Documentation of the on-site supervisory visit addresses at a minimum the elements in (i) through (vi). An individual may furnish personal care services, as defined in §440.167 of this chapter, on behalf of an HHA. Before the individual may furnish personal care services, the individual must meet all qualification standards established by the state. The individual only needs to demonstrate competency in the services the individual is required to furnish.
484.80 (h) (4) (ii) - Maintaining an open communication process with the patient and/or representative, means that the aide is able to explain what he/she is going to do with the patient, ask the patient open-ended questions, seek feedback from the patient, and respond to the needs and requests of the patient, representative (if any), caregivers, and family.
484.80 (h) (5) If the home health agency chooses to provide home health aide services under arrangements, as defined in §1861 (w) (1) of the Act, the HHA’s responsibilities also include, but are not limited to: Ensuring the overall quality of care provided by an aide; Supervising aide services as described in paragraphs (h) (l) and (2) of this section; and Ensuring that home health aides who provide services under arrangement have met the training or competency evaluation requirements, or both, of this part.
484.80 (i) Standard: Individuals furnishing Medicaid personal care aide-only services under a Medicaid personal care benefit.
For more information on Medicare's Home Health Care Quality Indicators click here.