Healthcare: An Industry Focused on Regulatory Compliance

The number of regulations that govern the healthcare market today is staggering and seems to be growing daily.  However, dealing with regulatory compliance efficiently and effectively is critical to the success of your home health agency.  You and your team must be ready at any time to withstand scrutiny from surveyors or auditors.  Oftentimes, agencies feel that they spend more time ensuring they are in compliance than caring for patients.  So what needs to be considered in order to ensure your agency does not become jeopardized?

First, let’s consider CMS (Centers for Medicare and Medicaid Services).  CMS retains the authority to conduct random validation surveys and complaint investigations in all certified home health agencies.  Its accreditation surveys have intensified to include many more deficiencies.  These deficiencies frequently cite one-time events.  The number of survey days has increased too, which means surveyors have additional time to scrutinize more clinical records, conduct an increasing number of home visits and review many different aspects of an agency.

In particular, it is critical that an agency avoids any condition-level deficiencies because they can put you in jeopardy of losing your Medicare certification.  With a condition-level deficiency a certain CoP (conditions of participation) is considered not in substantial compliance. The timeframe for correcting these types of deficiencies is very short.  In many cases, a return survey can occur anywhere from 15 to 60 days from the last day of the first survey.  Immediate jeopardy must be avoided at all costs.  Immediate jeopardy is defined as a situation in which the provider’s non-compliance with one or more of the requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death.  When investigating a potential immediate jeopardy situation, surveyors must find that serious harm has occurred or has the potential to occur, that the threat of future harm is immediate, and that there is facility culpability that resulted in the situation.  An example that could result in immediate jeopardy is rising high blood sugars that are documented, but a physician is never notified about this condition.  A return visit would occur in 14 days, which is a very short timeframe to correct this issue.  An agency must always focus on areas of vulnerability that could attribute to condition-level deficiencies and immediate jeopardy.

In addition, it is critical that your agency is aware of the clinical assessment and documentation that is required for CoPs, CMS accreditation and ICD-10.  Clinicians must be knowledgeable about what is needed in documentation in order to understand what causes condition-level deficiencies and immediate jeopardy.  Furthermore, clinicians must be aware in order to ensure proper coding according to ICD-10.
ICD-10 requires much more specific information related to the diagnoses.  With ICD-9 there were a little over 14,000 codes and now there are approximately 69,000 codes in ICD-10.  In order to be successful and in compliance, the clinician needs to collect more assessment information on admission, recert and roc, and this information must be documented.  Also the clinician is responsible for querying the physician regarding information related to symptoms and specific diagnoses.  Without this information being obtained by the clinician, the coders are not able to code, which means that it will be sent back to the clinician.  This will result in delays for getting the POC (plan of care) out the door, the OASIS (outcome and assessment information set) finalized and the RAP (request for anticipated payment) billed.   Again, this can result in survey deficiencies, which this time are attributed to a late OASIS and CMS-485s.

Do not have sleepless nights due to worries regarding compliance issues.  5 Star Consultants offer webinars or onsite training sessions that provide information about critical areas of compliance, detailed action plans to ensure continued survey readiness as well as tips and strategies to help guarantee that you are always in the know about regulatory compliance.


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