New Conditions of Participation for Discharge Planning for Hospitals: Access to Medical Records

The Centers for Medicare and Medicaid Services (CMS) published a final rule on September 30, 2019, that requires hospitals to make substantial changes to discharge planning. The final rule is effective sixty days from publication so it becomes effective on November 29, 2019.

We will present a teleconference on October 23, 2019, from 1:00 to 2:30 p.m. EST to review the changes to the Conditions of Participation (CoPs) in depth. Click here for more information. It’s not too late to register or to purchase a CD!

In the meanwhile, discharge planners/case managers must comply with new requirements related to patients’ right to access their medical records, including current records, as of November 29, 2019. Specifically, patients may make either verbal or written requests for their medical records, including current records. Medical records must include all discharge planning documents.

Records must be provided in the form and format requested by patients or their representatives, if readily producible in the requested form and format, including in an electronic form or format when records are maintained electronically. If not readily available in the format requested, then a readable hard copy or another form and format agreed to by both the hospital and patients or their representatives must be provided.

Access to records must be provided in a reasonable time frame. Hospitals must not “frustrate” the legitimate efforts of individuals to gain access to their own medical records and must actively seek to meet patients’ requests as quickly as record keeping systems permit.

A key issue is how this requirement “squares” with standards established by the HIPAA Privacy Rule. CMS makes it clear that this requirement is not intended to establish a different standard for providers subject to the HIPAA Privacy Rule.

The Office for Civil Rights (OCR) recently issued FAQs about access to medical records in which it clarified that the requirement to send medical records to patients and others is within thirty days or sixty days, if an extension is applicable after receiving requests. OCR went on to say, however, that “in most cases, it is expected that the use of technology will enable the covered entity to fulfill the individual’s request in far fewer than thirty days.

Stay tuned for more information about these important changes.

©2019 Elizabeth E. Hogue, Esq. All rights reserved.

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New Conditions of Participation for Discharge Planning for Home Health Agencies

The Centers for Medicare and Medicaid Services (CMS) published a final rule on September 30, 2019, that requires home health agencies to make substantial changes in discharge planning. The final rule is effective sixty days from publication so it becomes effective on November 29, 2019.

We will present a teleconference on October 23, 2019, from 1:00 to 2:30 p.m. EST to review the changes to the Conditions of Participation (CoPs) in depth. Click here for more information. Please join us!

In the meanwhile, a significant changes in CoPs for home health agencies with regard to discharge planning is that agencies will be required to assist patients who are transferred to another home health agency or discharged to a SNF, IRF, or LTCH to select a post-acute provider.

Home health agencies must use and share data with patients and their caregivers that includes, but is not limited to, home health agency, skilled nursing facility (SNF), independent rehab facility (IRF), or long-term care acute hospital (LTCH) quality measures and data on resource use measures. The data shared with patients and their caregivers must be relevant and applicable to patients’ goals of care and treatment preferences.

The basis for this requirement is that CMS believes that recognizing patient preferences and assisting patients with transfer options will support communication between patients and home health agencies and ultimately support patient-informed decision-making and improve patient care and satisfaction.

CMS goes on to say information provided to patients and their caregivers must include data from IRF Compare, Home Health Compare, Nursing Home Compare and Long-Term Care Compare to assist patients and their caregivers to make decisions about post-acute providers.

CMS says home health staff members are not expected to provide patients and their caregivers with detailed and complex analyses of quality and resource use data that may confuse patients and their caregivers.

Home health agencies are also not expected to attempt to provide patients with data that does not exist. In other words, no “homemade data!”

According to CMS, home health agency staff members must put forth their “best effort” to answer patients’ questions about data presented to them. CMS says that home health agencies should also refer to www.medicare.gov
for additional resources and help with regard to data presented to patients and their caregivers.

Further information mandated by the IMPACT Act will be available in forthcoming regulations. CMS will also provide interpretive guidelines at some point after publication of the final rule. More to come in future articles on this topic!

©2019 Elizabeth E. Hogue, Esq. All rights reserved.

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New Conditions of Participation for Hospital Discharge Planning: Patients’ Right to Freedom of Choice

The Centers for Medicare and Medicaid Services (CMS) published a final rule on September 30, 2019, that requires hospitals to make substantial changes in discharge planning. The final rule is effective sixty days from publication, so it becomes effective on November 29, 2019.

We will present a teleconference on October 23, 2019, from 1:00 to 2:30 p.m. EST to review the changes to the Conditions of Participation (CoPs) in depth. Click here for more information. Please join us!

In the meanwhile, many hospital discharge planners/case managers and post-acute providers who receive referrals from hospitals are especially interested in any changes regarding patients’ right to freedom of choice.

First, CMS clarifies that CoPs for hospitals apply to acute care hospitals, long-term care hospitals (LTCHs), independent rehab facilities (IRFs), short-term acute care hospitals, rehabilitation hospitals, psychiatric hospitals, children’s hospitals and cancer hospitals.

CMS then clarifies that discharge planners/case managers cannot make decisions on post-acute services on behalf of patients and their caregivers. Hospitals must focus instead on person-centered care to ensure the active participation of patients and their caregivers in decisions about post-acute care.

CMS also states that the IMPACT Act requires hospitals to take into account quality, resource use and other measures in the discharge planning process. Specifically, CMS says that hospitals’ discharge planners/case managers must use IRF Compare, Home Health Compare, Nursing Home Compare and Long-Term Care Compare to assist patients and their caregivers to make decisions about post-acute providers.

CMS says that hospital discharge planners/case managers are not expected to provide patients and their caregivers with detailed and complex analyses of quality and resource use data that may confuse patients and their caregivers. Case managers/discharge planners are also not expected to attempt to provide patients with data that does not exist. In other words, no “homemade data!”

According to CMS, discharge planners/case managers must put forth their “best effort” to answer patients’ questions about the data.

CMS says that case managers/discharge planners should also refer to www.medicare.gov for additional resources and help with regard to data presented to patients. Further information mandated by the IMPACT Act will be available in forthcoming regulations. CMS will also provide interpretive guidelines at some point after publication of the final rule.

In response to concerns about hospital discharge planners/case managers that may attempt to “steer” patients to particular post-acute providers, CMS says that they must present objective data on quality and resource measures specifically applicable to patients’ goals of care and treatment preferences, “taking care to include data on all available PAC providers and allowing patients and/or their caregivers the freedom to select a PAC provider of their choice.”

CMS says that providers will have to document all interactions regarding freedom of choice in patients’ medical records.

We will provide more information soon. Stay tuned!

©2019 Elizabeth E. Hogue, Esq. All rights reserved.

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Are you caught in a Regulatory Nightmare? How to be proactive with a methodology to avoid “Survey Panic”.

One year after Medicare’s new Home Health Conditions of Participation (CoP) have gone into effect in the home health industry, many agencies have struggled with understanding and implementing the new regulations. We have seen the “Deer in the Headlight” phenomena in some agencies, leaving the agency out of compliance, and the management extremely stressed about what to do to comply.  Unfortunately, we have been engaged by many agencies after they have had an unsuccessful survey under the new CoPs and have been cited with numerous standard level deficiencies, condition level deficiencies and even immediate jeopardy.

Although the new CoPs are numerous, complex and at times head scratching, having a plan and working towards the goal of continued survey readiness is very possible.  In addition to agencies being cited on new conditions and standards, there have been many deficiencies cited in areas that have not changed at all.  This indicates that an agency must continue to focus on all of the CoPs and not solely on the new ones. There are some standards that are easy to comply with, thus agencies should ensure compliance with those (example: content of the patient bill of rights, Administrator and the clinical manager contact information and contact information for federally funded organizations must be given to the patient).

What further steps can be taken to avoid unsuccessful surveys?

To start with, the Administrator must ensure that all management in the agency have read and clearly understand the CoPs, utilizing the State Operations Manual which includes the Interpretive Guidelines (IG).  The IGs are so important because they offer clarification and are what surveyors utilize.  This sounds so basic and yet we have seen many times in which these have not been read or fully understood.

Do not neglect the state regulations and if accredited, those standards. Remember to always follow the most stringent regulations. When the management fully understands the regs, this is the time to prioritize areas in which your agency is noncompliant – often just reading them, you realize that you are noncompliant.

It is so important for each of the HHA staff to also understand the CoPs / state regs/ AO standards as these are the rules that they must follow.  Management can teach specific standards to all staff, rather than having them read the entire regulations at once. Ofttimes, once I have shown and explained a standard to a field clinician, then they comply, as now they know the reason for having to perform some task or documentation.

This concept of involving all staff is what 5 Star’s philosophy is for agencies to understand the regulations and QAPI, infection control, patient rights, clinical standards and more. Involving all staff empowers and educates them, ensuring better compliance and engagement in the agency.

Agency Assessment / Mock Survey

It is so important to do a complete assessment, i.e., mock survey of your agency in the same manner that a surveyor will perform one.  Covering all the same functions as for an actual survey is the only way that an Administrator can really know where the agency stands. I recommend performing these once a year so that the agency can work towards continued survey readiness.

This mock survey can be done by a qualified person in your agency, or if you are a multi-site agency, it is good to assess each other’s locations for objectivity. Note that I said qualified, as the person must know how to review clinical records, what to look for on home visits, what constitutes a compliant QAPI program etc. Therefore, some training may be needed prior to having an in-house mock survey. Of course, you can utilize outside companies who provide mock surveys, however, ensure they too are qualified.

During the mock survey, you will look at many areas, including clinical records, home visits, HR files, education/competency, Emergency preparedness, QAPI, infection surveillance, Governing body minutes, staff interviews, policies, and more.

The results of the mock survey will indicate vulnerabilities of your agency. Some of these can be corrected easily by revising a policy whereas others may need a task force that focuses on a specific project, such as medication management.  As you review this information, you can concurrently develop your QAPI program.  Easy fixes would not typically be a quality indicator.  But many areas noted in the clinical records, home visits etc. would be quality indicators and/or performance improvement projects (PIP)- such as the example of medication management (this is a complex, high risk area involving numerous people, documentation and coordination which can require a PIP).

QAPI Program

By developing a formal QAPI program post mock survey, with further monitoring of the data, trending/analyzing and implementing action plans, you have a compliant QAPI program. The agency’s non-compliant areas will improve with the QAPI monitoring, particularly when all staff are involved. At the same time, you will be improving your patient and agency outcomes, by including data driven outcomes from CASPER outcome reports.

When you have your quarterly data that indicates deficient areas, ensure that your action plan is very specific. Typical components of an action plan will include education, policy and/or process change and quality monitoring.

Example Findings/ Action Plan:

Finding:

In 6 of 8 wound patients, clinical records indicated physician orders for wound care were not followed. (State for each chart specifically what was not followed)

  • Patient 6 – Wound care was not followed to physician orders Jan 10 – Jan 12 (state order and care)

Action Plan:

Quality Indicator:   The DPS to review 100% of wound care patient records a quarter to focus on following physician orders with a goal of 90% compliance.   After goal is achieved, review will decrease to 20% records a quarter.

  • Audit Tool – Have the audit tool designed for this particular deficiency (Example: Wound Care)
  • Education – In-service to ALL skilled nursing will be done. (Example: 2/15 by DPS – following physician orders for wound care; 3/1 by Wound Care Consultant regarding wound care types)
  • Home Visits with wound certified nurse and all nurses on wound patient by end of May.

Interdisciplinary Team Management

Another key portion to ensure your clinical aspects of the agency are in compliance is to have interdisciplinary care teams working together on patients from admission through discharge. This team must ‘talk’ regularly and ‘report’ to each other whenever there are any changes to the patient and/or if the current POC is not meeting patient goals, such as ineffective pain management. Compliance can be achieved with follow through of patient changes through physician notification, as an example, if the entire patient team is on the same page. All of the communication can be documented in coordination of care sections in the EMR, so that each clinician and aide can easily view ‘reports’ given to each other with actions taken.

Not only will this assist your agency with compliance but will improve the agency standing for VBP and Star ratings.  Often, your patient’s CAHP scores will improve as your clinical team is goal oriented towards improving the patient’s outcomes.

As you can see, the stated proactive methodology to ensure compliance with the CoPs can make your agency a high-quality agency that will ensure your agency’s viability for the future.

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