Medicare's Conditions of Participation (CoP) requires a Home Health Governing Body that must oversee hundreds of policies and procedures to monitor and regulate infection control, quality assurance, fiscal performance and accounting, emergency preparedness, employee credentials and delivery of patient care...to name but a few.
In selecting those who will serve as your HHA's governing body, consider the enormous scope of regulatory responsibility in managing a home health agency. To that end, can your current Governing Body answer the following ten (10) questions? 
1. Date of most recent review of incident reports.
Your Agency's Incident Reporting System is the foundation for compliance with Medicare's CoP §484.65 Quality assessment and performance improvement (QAPI). The practice of documenting all incidences and then taking effort to mitigate the incident (change in policy, employee training etc) and evaluating the effectiveness of the effort (as evidenced by same statistics after policy change, training etc.) is an effective Performance Improvement Program and meets the criteria required by Medicare, JCAHO, CHAP and ACHC. Incident reports should be reviewed every 3 months…4 times per year.
2. Correction plan for most recent incident report review.
Your review should include:
- Total number of incidences,
- Total number by type,
- Trends and/or commonalities between the same incident type – same patient? same employee?
- Training that would mitigate occurrence of future incident,
- Policy and procedure changes to mitigate occurrence of future incident,
- Date of implementation of training or P&P change,
- Date of review of Correction Plan.
3. Date of most recent review of infection surveillance program.
As articulated in the interpretive guidelines for §484.70 Condition of participation: Infection prevention and control, Medicare requires procedures for the identification of infections or risk of infections among patients. The following possible methodologies include, but are not limited to:
• Clinical record review,
• Incident reports,
• Review of lab results,
• Patient ER visits for symptoms of infection, and
• Employee and patient training on infection control.
4. Correction plan for most recent infection surveillance review.
- Total number of infections,
- Trends and commonalities – same patient? same employee?
- Evaluation of infection-control training, policies and procedures,
- Changes to infection-control policies and procedures,
- Date of implementation of training or P&P change,
- Date of review of Correction Plan.
5. Date of most recent review of complaints.
This requirement is found under §484.50 Condition of participation: Patient rights. (e) Standard: Investigation of complaints.
6. Correction plan for most recent complaint review.
- Total number of complaints,
- Trends and commonalities – same patient? same employee?
- Evaluation of patient rights training, policies and procedures,
- Changes to patient right policies and procedure changes,
- Date of implementation of training or P&P change,
- Date of review of Correction Plan.
7. Date of most recent emergency planning drill.
§484.102 Condition of participation: Emergency preparedness. Medicare requires that the HHA performs an emergency plan 'drill' at least annually. With the occurrence of COVID-19, the following standard applies:
"§484.102(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event."
8. Date of most recent review of Agency Profit/Loss and Balance Sheet.
In addition to a full accounting review, the HHA's financial performance must include
- Profit/loss per each 30-day patient episode,
- Profit/loss per each patient certification period,
- Average gross profit per skilled and non-skilled visit,
- Average net profit per skilled and non-skilled visit.
9. Date of most recent review of employee performance.
Condition §484.105 Condition of participation: Organization and administration of services. "The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs".
Timeliness of clinical paperwork impacts patient care. When communication is late, the ability to respond to critical issues is late! Assessments and progress reports must be filed in a timely manner so that critical decisions are not delayed, and effectiveness of goals, interventions and treatment can be accurately evaluated.
The Governing Body's review of compliance with this Condition includes an evaluation of each field staff's...
- Timeliness of OASIS completion (within 24 hours hours of the assessment visit is recommended),
- Timeliness of Progress Note completion (submitted same day is recommended),
- Discharges with Goals Achieved,
- Hospital Re-admissions - are there trends with particular patient types or a particular employee?
10. Correction plan for most recent employee performance review.
- Changes to policies, procedures and employee training to achieve timeliness of OASIS completion and progress note submission within the above recommendations.
- Changes to policies, procedures and training to reduce re-admissions and increase goals-achieved discharges.
- Date of review of Correction Plan.
