Big Changes with Condition 484.60 – Care Planning, Coordination of Services and Quality of Care

In the recently revamped home health CoPs (Conditions of Participation) some conditions have been more extensively updated than others. Condition 484.60, which covers care planning, coordination of services and quality of care is one that has gone through some major changes.  It combines Condition 484.18 – Acceptance of Patients, Plan of Care, and Medical Supervision with Condition 484.14 Coordination of Care.

Below we will review the five standards that comprise Condition 484.60.

Plan of Care

Under the Plan of Care standard each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals.  It must be established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration.  If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan.

The individualized plan of care must include the following:

  • All pertinent diagnoses
  • Patient’s mental, psychosocial, and cognitive status
  • Types of services, supplies, and equipment required
  • Frequency and duration of visits to be made
  • Prognosis
  • Rehabilitation potential
  • Functional limitations
  • Activities permit
  • Nutritional requirements
  • All medications and treatments
  • Safety measures to protect against injury

Within the individualized Plan of Care, a new mandatory addition is (xii) a description of the patient’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors.

RESPONSE – “Attempts to reduce re-hospitalizations by identifying risk and necessary interventions.  Removed the terms ‘‘low, medium, high’’, and are not suggesting a specific tool or process at this time.”

Furthermore, it also includes:

(xiii) Patient and caregiver education and training to facilitate timely discharge.

(xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the home health agency (HHA) and the patient.

(xv) Information related to any advanced directives.

(xvi) Any additional interventions/orders the HHA or physician chose to include.

Another big change is that all patient care orders, including verbal orders must be recorded in the Plan of Care.

RESPONSE – “The plan of care is an evolving document that outlines the patient’s journey throughout HHA care and treatment.  It is essential that the plan of care be reflective of past orders and current orders that are actively ongoing.  As new orders are given to initiate or discontinue an intervention, the plan of care is updated to reflect those changes.  New versions of the plan of care are created as needed to assure that each clinician is working on the most recent plan of care, with older versions being filed away in the clinical record in any manner that meets the needs of the HHA.”

Conformance with Physician Orders

The next standard deals with conformance with physician orders.  It covers areas such as:

  • Drugs, services, and treatments are administered only as ordered by a physician.
  • Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, and after and for contraindications.
  • Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies.
  • The following is new to the standard. When services are provided on the basis of a physician’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law, and the home health agency’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders.

RESPONSE – “We believe that timing the receipt of verbal orders is necessary …. There are times when a patient’s condition rapidly changes …  Therefore, … it is necessary and appropriate to proactively record the time of day that each verbal order is received by an HHA clinician from a physician.  This requirement corresponds with the clinical record authentication requirements at 484.110(b), which requires all entries in the clinical record to be timed.”

Review and Revision of the Plan of Care

According to this next standard, the individualized plan of care must be reviewed and revised by the physician who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date.  The HHA must promptly alert the relevant physician(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered.  A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care.  Verbal orders must be authenticated and dated by the physician in accordance with applicable state laws and regulations, as well as the HHA’s internal policies.

A new component of this standard involves revisions to the Plan of Care and how they must be communicated.  Below are further details:

(i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and the physician who is responsible for the HHA plan of care.

COMMENT – “. . . requested that CMS clarify whether all changes to the plan of care require the plan of care to be re-signed by the physician, and if not, explicitly when that would and would not be required.”

RESPONSE – “The signature of the physician who is responsible for issuing orders related to the condition(s) that led to the initiation of home health services should be on all iterations of the individualized plan of care for each patient in accordance with the requirements of § 484.60(a).”

Revisions to the plan of care must be communicated as follows:

(ii) Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians issuing orders for the HHA plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any).

Coordination of Care

The next standard covering coordination of care requires the HHA integrate services to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness, the coordination of care provided by all disciplines, and communication with the physician.

RESPONSE – “Coordination of patient care entails assuring that patient needs are continually assessed, addressed in the plan of care, that care is delivered in a timely and effective manner, and that goals of care are achieved.  HHAs may document these activities in a manner that suits their needs to demonstrate compliance.”

The HHA must do the following:

  • Assure communication with all physicians involved in the plan of care.
  • Integrate orders from all physicians involved in the plan of care and interventions provided to the patient.

RESPONSE – “HHAs that choose to accept orders from multiple physicians are responsible for:

  • Assuring communication with all physicians involved in the plan of care.
  • Integrating orders from all physicians involved in the plan of care to assure the coordination of all services and interventions are provided to the patient. The purpose of assuring communication and integrating orders is to avoid duplicate or contradictory physician orders and to assure that all patient needs are being met (whether directly by the HHA or by the physicians). We would expect HHAs to have appropriate systems and processes in place to both identify and resolve conflicting or duplicative orders.
  • Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness, and the coordination of care provided by all disciplines.
  • Coordinate care delivery to meet the patient’s needs and involve the patient, representative (if any) and caregiver(s), as appropriate, in the coordination of care activities.
  • Ensure that each patient and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care.

The HHA must provide training, as necessary, to ensure a timely discharge.

Written Information to the Patient

This standard is new also.  According to it, the HHA must provide the patient and caregiver with a copy of written instructions outlining:

  • Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA.
  • Patient medication schedule / instructions, including: medication name, dosage and frequency as well as which medications will be administered by HHA personnel and personnel acting on behalf of the HHA.
  • Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services.
  • Any other pertinent instruction related to the patient’s care and treatments that the HHA will provide, specific to the patient’s care needs.
  • Name and contact information of the HHA clinical manager.

We Offer Multiple Ways to Help Ensure CoPs Compliance

Our team of experts at 5 Star Consultants is always up-to-date on the constant changes occurring in the home health industry.  And, CoPs compliance is no exception.  We offer many training options to ensure your team is knowledgeable about the revised CoPs before the January 2018 compliance date.  These training options include live webinars, pre-recorded webinars on CD, onsite training and a NEW Home Health Administrative Policy and Procedures Manual.

For further information about any of these training alternatives, please contact us at [email protected] or 866-428-4040.

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