HCSSA Pre-Survey CBT
Module 5: Licensed and Certified Home Health Services

Welcome

Overview

HCSSA Service Categories

Required Participants

Required Documentation of Successful Participation

Required Score

Required Resources

Training Objectives for Module 5

Applicable State Regulations

Applicable State Regulations

What is the Difference between HCSSA and HHA?

Change in Agency Certification Status

State Regulations Specific to the LCHHS Category

Home Health Aide Training-1

The training portion of a training and competency evaluation program for home health aides must be conducted by or under the general supervision of a registered nurse (RN) who possesses a minimum of two years of nursing experience, at least one year of which must be in the provision of home health care.  

The training program may contain other aspects of learning, but must contain the following:

• a minimum of 75 hours as follows: an appropriate number of hours of classroom instruction; and a minimum of 16 hours of clinical experience, which will include in-home training and must be conducted in a home, a hospital, a nursing home, or a laboratory; and
• completion of at least 16 hours of classroom training before a home health aide begins clinical experience working directly with clients under the supervision of qualified instructors.

Note: There is no registry, certification, or state exam for home health aides in Texas.

Source: 40 TAC §97.701(d)

Home Health Aide Training-2

If licensed vocational nurse (LVN) instructors are used for the training portion of the program, the following qualifications and supervisory requirements apply:

• An LVN may provide the home health aide classroom training under the supervision of an RN who has two years of nursing experience, at least one year of which must be in the provision of home health care.
• LVNs, as well as RNs, may supervise home health aide candidates in the course of the clinical experience.
• An RN must maintain overall responsibility for the training and supervision of all home health aide training students.

Source: 40 TAC §97.701(d)

Home Health Aide Training-3

The classroom instruction and clinical experience content of the training portion of a training and competency evaluation program must include, but is not limited to, the following:

• communication skills;
• observation, reporting, and documentation of a client's status and the care or service furnished;
• reading and recording temperature, pulse, and respiration;
• basic infection control procedures and instruction on universal precautions;
• basic elements of body functioning and changes in body function that must be reported to an aide's supervisor;
• maintenance of a clean, safe, and healthy environment;
• recognizing emergencies and knowledge of emergency procedures;
• the physical, emotional, and developmental needs of, and ways to work with, the populations served by the agency, including the need for respect for the client and his or her privacy and property;
• appropriate and safe techniques in personal hygiene and grooming;
• safe transfer techniques and ambulation;
• normal range of motion and positioning;
• adequate nutrition and fluid intake; and
• the rights of the elderly.

Source: 40 TAC §97.701(e)

Home Health Aide Training-4

The competency evaluation program or the competency evaluation portion of a training and competency evaluation program has the following requirements:

• The competency evaluation must be performed by an RN.
• The competency evaluation must address each of the subjects listed on the previous slide except communication skills and the rights of the elderly.
• Some of the subject areas must be evaluated by observation of the home health aide's performance of the task with a client or person.
• Other subject areas may be evaluated through written examination, oral examination, or by observation of a home health aide with a client.
• A home health aide is not considered to have successfully completed a competency evaluation if the aide has an unsatisfactory rating in more than one of the subject areas except communication skills and rights of the elderly.
• If an aide receives an unsatisfactory rating, the aide must not perform that task without direct supervision by an RN or LVN until the aide receives training in the task for which he or she was evaluated as unsatisfactory and successfully completes a subsequent competency evaluation with a satisfactory rating on the task.
• If an individual fails to complete the competency evaluation satisfactorily, the individual must be advised of the areas in which he or she is inadequate.

Source: 40 TAC §97.701(f)

Applicable Federal Regulations

Section 1864 of the Social Security Act authorizes the state to enforce standards for Medicare. Although the Centers for Medicare & Medicaid Services (CMS) contracts with the Health and Human Services Commission (HHSC) to carry out the Medicare certification process, the CMS regional office is ultimately responsible for deciding whether or not an agency may participate in the Medicare program.

The Social Security Act is the federal law governing Medicare certification.

Medicare regulations that HHAs must follow are located in the Code of Federal Regulations (CFR), Part 484. Applicable definitions are located in 42 CFR §484.2.

Licensed and certified HHAs must continuously remain in compliance with Medicare and state requirements. Agency compliance is regularly verified through the survey process.

Certification is originally obtained through the administration of an initial survey. After an agency has a successful initial survey, HHSC surveys the agency regularly to ensure future continuous compliance.

Note: Surveys are always unannounced.

Accreditation

HHSC recognizes certain accrediting organizations as having standards that meet or exceed those enforced by HHSC. Agencies that obtain accreditation are exempt from regular HHSC surveys. There are three accrediting organizations that are recognized by HHSC for both federal certification and state licensing standards:

• Community Health Accreditation Program (CHAP);
• The Joint Commission (TJC); and
• Accreditation Commission for Health Care (ACHC).

Note: To demonstrate that an agency is exempt it must send the accreditation documentation from CHAP, TJC, or ACHC to the HHSC designated survey office no later than six months after the effective date of its license.

Initial Survey

Each new agency seeking Medicare certification must pass an initial survey in which a surveyor evaluates whether the agency adequately meets federal home health regulations.

There are six prerequisite steps a LCHHS agency must complete before an initial certification survey can be administered. These steps must be completed within six months.

The six steps are as follows:

• Complete the state licensing process.
• Complete and submit form CMS-855A.
• Complete an OASIS test transmission.
• Provide nursing and one other skilled service.
• Obtain the required patient census.
• Complete and submit HHSC Form 2020.

1 - Complete the State Licensing Process

Upon applying for the licensed and certified category of service, the agency must comply with all relevant parts of 40 TAC, Chapter 97, including 40 TAC §97.402 (Standards Specific to Licensed and Certified Home Health Services) and 42 CFR, Part 484, which contains the Medicare Conditions of Participation (CoPs).

It is possible for an agency to successfully pass the initial licensure survey and not be recommended for certification if one or more of the Medicare CoPs are not met.

If the agency passes both the licensed and the licensed and certified survey, the surveyor recommends certification for the agency.

Source:   40 TAC §97.257

2 - Complete and Submit Form CMS-855A

The agency must apply to CMS for certification by completing and submitting:

• printed form CMS-855A Home Health Enrollment Application; or
• online CMS-855A Home Health Enrollment Application.

It is the agency's responsibility to ensure the CMS-855A is current. The CMS-855A is valid for six months, unless the initial survey is delayed by processing limitations. For more information, see Regional Survey & Certification (RS&C) Letter #06-04 .

Applicants seeking an initial parent or alternate delivery site license to provide licensed and certified home health services (authorization to provide services to Medicare beneficiaries) should read Provider Letter No. 15-09 , Direction from the Centers for Medicare & Medicaid Services (CMS) on Prioritization of Initial Medicare Certification Surveys (Home Health).

3 - Complete an OASIS Test Transmission

The Outcome and Assessment Information Set (OASIS) is a group of data elements that:

• represent core items of a comprehensive assessment for an adult home care patient; and
• form the basis for measuring patient outcomes for the purposes of outcome-based quality improvement.

The agency must have successfully completed an OASIS test transmission on one patient prior to the initial survey.

Note: More information on OASIS is available at the OASIS website. HHSC encourages providers to take advantage of the OASIS Provider Training courses on the HHSC website.

4 - Provide Nursing and one other Skilled Service

 All agencies must provide skilled nursing services and at least ONE of the following additional services:

• Physical therapy
• Occupational therapy
• Speech-language pathology
• Home health aide services
• Medical social work

Agencies may contract any service (including skilled nursing) to outside entities, but they must provide at least one service directly and entirely with their own employees.

5 - Obtain Required Patient Census

The agency must have seven active patients and have provided skilled services to ten patients. Patients who are Medicare beneficiaries must be homebound; however, not all patients must be Medicare beneficiaries.

Agencies' patients who have been admitted to a hospital may be included in the minimum active patient count as long as they have not been discharged by the agency.

6 - Complete and Submit HHSC Form 2020

The agency must notify the designated survey office when it is ready for the initial survey by completing HHSC Form 2020 Notification of Readiness for Initial Survey. The form must be submitted no later than six months after the effective date of the agency's initial license.

Please note that the agency must admit and provide services to clients before submitting the initial request for survey as described in 40 TAC §97.521(b).

Source: 40 TAC §97.521(a)-(c)

Summary: Initial Survey

Remember that a LCHHS agency must complete six prerequisite steps before an initial certification survey can be administered.

It is important to remember that these steps must be completed within six months:

• Complete the state licensing process.
• Complete and submit form CMS-855A.
• Complete an OASIS test transmission.
• Provide nursing and one other skilled service.
• Obtain the required patient census.
• Complete and submit HHSC Form 2020.

Delay in Initial Survey

The initial survey may be delayed by an agency's failure to complete the six steps.

If the initial survey is not conducted and/or accreditation is not obtained within six months of submitting the CMS-855A (Step 2), then the CMS-855A must be updated or resubmitted with a new certification statement.

Important Note:

As directed by CMS, HHSC is currently not conducting initial Medicare certification surveys unless CMS agrees that a verifiable access-to-care issue exists.

It is not known when CMS will direct HHSC to resume initial certification surveys.

Agencies may pursue Medicare certification through the services of accrediting agencies, as discussed in earlier modules of this training.

HHSC continues to conduct all other LCHHS surveys, including complaint surveys, to ensure continuous compliance.

See Provider Letter (PL) #15-09 for more information.

Helpful Hints

Put in your request well in advance.

The agency notifies the designated survey office when it is ready for the initial survey by completing HHSC Form 2020 and submitting it to HHSC.

To avoid enforcement actions, request an initial licensing survey no later than six months after the effective date of the initial license by submitting a notification of readiness form.

Also, remember that all surveys are unannounced.

Administration of Initial Survey

After an agency completes steps 1-6, HHSC surveyors conduct the initial survey.

The initial survey establishes whether an agency should be recommended for licensure and Medicare certification based on the agency's compliance with 42 CFR, Part 484, and the state guidelines found in 40 TAC, Chapter 97.

For ease of understanding and citation, 42 CFR, Part 484 is divided into 14 CoPs. Agencies must fully understand these conditions and remain in constant compliance with all of them.

If an agency is found to be out of compliance with a COP, certification will not be recommended.

Note: The statutory authority for applying the CoPs to HHAs is found in Sections 1861(o) and 1891 of the Social Security Act.

14 Conditions of Participation (CoPs) for HHAs

There are 14 CoPs for home health agencies:

• Release of patient identifiable OASIS information (42 CFR §484.40)
• Reporting OASIS information (42 CFR §484.45)
• Patient rights (42 CFR §484.50)
• Comprehensive assessment of patients (42 CFR §484.55)
• Care planning, coordination of services, and quality of care (42 CFR §484.60)
• Quality assessment and performance improvement (42 CFR §484.65)
• Infection prevention and control (42 CFR §484.70)
• Skilled professional services (42 CFR §484.75)
• Home health aide services (42 CFR §484.80)
• Compliance with federal, state, and local laws and regulations related to the health and safety of patients (42 CFR §484.100)
• Emergency preparedness (42 CFR §484.102)
• Organization and administration of services (42 CFR §484.105)
• Clinical records (42 CFR §484.110)
• Personnel qualifications (42 CFR §484.115)

Effective Date of Certification

Without Initial Survey Deficiencies

If no deficiencies are identified during the initial survey, CMS will notify the agency of the effective date of certification, which will be the date that the survey was completed.

After passing the initial survey, the agency will be surveyed regularly to ensure the delivery of quality home health services and to determine whether it should be recertified.

With Initial Survey Deficiencies

If deficiencies are identified during the initial survey, the recommended effective date of certification will be the date that the plan of correction (POC) is approved by the state agency (HHSC). The agency may not bill Medicare for services to Medicare beneficiaries until the effective date of Medicare participation has been determined by the CMS regional office. For additional information regarding initial certification, see CMS Survey and Certification (S&C) Letter #01-02 .

For information on FY 2011 Inpatient Prospective Payment System (IPPS) Rule Changes Affecting Survey and Certification, see CMS S&C Letter #11-04 .

Note: Surveyors document deficient practices on form CMS-2567.

Frequency of Recertification Surveys

HHSC conducts a survey within 18 months after conducting an initial survey and at least every 36 months thereafter.

Types of Recertification Surveys

There are four types of surveys HHSC may conduct at a certified agency:

1. Standard Survey
2. Partial Extended Survey
3. Extended Survey
4. Revisit

All recertification surveys begin as standard surveys. If areas of concern are identified during a standard survey, HHSC may expand the survey to a partial extended survey or an extended survey. HHSC conducts revisits to assess the correction of deficiencies identified during a prior survey.

Standard Survey

The standard survey is conducted to determine the quality of care and services furnished by the agency as measured by indicators of medical, nursing, and rehabilitative care.

The surveyor incorporates home visits, interviews, and clinical record reviews.

During the standard survey, the surveyor reviews the HHA's compliance with a select number of regulations most related to high quality patient care and address 8 of the 14 CoPs.

The standard survey includes a review of the highest-priority Level 1 standards as addressed in the following CMS Memorandum.

Partial Extended Survey

A partial extended survey is conducted to further examine areas of concern when condition-level deficiencies are suspected during a standard survey.

The surveyor does a more comprehensive review, which includes at a minimum, the next highest Level 2 standards identified in the CMS Memorandum to determine: 

• whether condition-level, rather than standard-level, deficiencies exist; and
• whether standard or condition-level deficiencies are present in the CoPs not examined during the standard survey.

Extended Survey

Extended surveys are conducted to review and identify the agency's policies and procedures that produced the substandard care (one or more condition-level deficiencies) identified under the standard or partial extended survey.

The surveyor determines whether the agency is in compliance with all conditions and standards of participation.

The extended survey covers any relevant conditions and standards of participation found in 42 CFR, Part 484.

Selected Federal Regulations

The following section will review some selected federal regulations applicable to the LCHHS category.

This section covers the Level 1 priority standards reviewed during a standard survey.

It is the responsibility of each agency to fully understand and comply with all CoPs and associated standards, including those not covered in this CBT.

The complete listing of conditions and standards of participation is found in the Code of Federal Regulations, Title 42, Part 484 (Conditions of Participation - Home Health Services) .

An agency found to be noncompliant with any CoP may lose its Medicare certification.

Patient Rights

Condition of Participation

§484.50 - Patient Rights

Level 1 Standards (Priority Standards for a Standard Survey)

§484.50(c)(4) - Participate in care

§484.50(e)(1) - Investigation of complaints

§484.50(e)(1)(i) - Investigate complaints made by patient

§484.50(e)(1)(i)(A) - Treatment or care

§484.50(e)(1)(i)(B) - Mistreatment, neglect, or abuse

§484.50(e)(1)(ii) - Document complaint and resolution

§484.50(e)(1)(iii) - Protect patient during investigation

§484.50(e)(2) - Immediate reporting of abuse by all staff

Comprehensive Assessment of Patients

Condition of Participation

§484.55 - Comprehensive Assessment of Patients

Level 1 Standards (Priority Standards for a Standard Survey)

§484.55(a) - Initial assessment visit

§484.55(a)(1) - RN performs assessment

§484.55(b) - Completion of the comprehensive assessment

§484.55(b)(1) - Five calendar days after start of care

§484.55(b)(2) - Eligibility for Medicare home health benefit

§484.55(b)(3) - Therapy services determine eligibility

§484.55(c)(5) - A review of all current medications

§484.55(d) - Update of the comprehensive assessment

§484.55(d)(2) - Within 48 hours of the patient's return from hospital

Care Planning, Coordination of Services, and Quality of Care

Condition of Participation

§484.60 - Care Planning, Coordination of Services, and Quality of Care

Level 1 Standards (Priority Standards for a Standard Survey)

§484.60(a)(1) - Plan of care

§484.60(a)(2) - Plan of care must include the following

§484.60(b) - Conformance with physician orders

§484.60(b)(1) - Only as ordered by a physician

§484.60(b)(2) - Influenza and pneumococcal vaccines

Skilled Professional Services

Condition of Participation

§484.75 - Skilled Professional Services

Level 1 Standards (Priority Standards for a Standard Survey)

§484.75(b) - Responsibilities of skilled professionals

§484.75(b)(1) - Interdisciplinary assessment of the patient

§484.75(b)(2) - Development and evaluation of plan of care

§484.75(b)(3) - Provide services in the plan of care

§484.75(b)(4) - Patient, caregiver, and family counseling

§484.75(b)(5) - Patient and caregiver education

§484.75(b)(6) - Preparing clinical notes

§484.75(b)(7) - Communication with physicians

Home Health Aide Services

Condition of Participation

§484.80 - Home Health Aide Services

Level 1 Standards (Priority Standards for a Standard Survey)

§484.80(g)(1) - Home health aide assignments and duties

§484.80(h)(1)(i) - Onsite supervisory visit every 14 days

Organization and Administration of Services

Condition of Participation

§484.105 - Organization and Administration of Services

Level 1 Standards (Priority Standards for a Standard Survey)

§484.105(b)(1) - Administrator responsibilities

§484.105(b)(1)(i) - Administrator appointed by governing body

§484.105(b)(1)(ii) - Responsible for all day-to-day operations

§484.105(b)(1)(iii) - Ensure clinical manager is available

§484.105(f)(2) - In accordance with current clinical practice

Clinical Records

Condition of Participation

§484.110 - Clinical Records

Level 1 Standards (Priority Standards for a Standard Survey)

§484.110(a) - Contents of clinical records

§484.110(a)(1) - Required items in clinical record

§484.110(a)(2) - Interventions and patient response

§484.110(a)(3) - Goals in the patient's plan of care

Partial Extended and Extended Surveys

In partial extended and extended surveys, surveyors examine additional conditions and standards not covered in this CBT.

For example, in a partial extended survey a survey will review the following Level 2 standard: CFR §484.100 - Compliance with Federal, State, and Local Laws and Regulations

Note: All Medicare CoPs may be found in the Code of Federal Regulations, Title 42, Part 484 (Conditions of Participation - Home Health Services) .

Compliance with Civil Rights Requirements

Before new agencies or agencies undergoing changes of ownership can become Medicare certified, they must be found to be in compliance with federal civil rights requirements.

Section 2010 of the State Operations Manual requires CMS to obtain information from new providers and those providers that have undergone changes of ownership related to their compliance with civil rights requirements.   This information is forwarded to the U.S. Department of Health and Human Services' Office of Civil Rights (OCR), which determines if the provider is in compliance with the Civil Rights Act and other relevant statutes.   If the provider is found to be in compliance, a civil rights clearance is issued.

 In practice, CMS regional offices will approve a provider's initial certification pending clearance from OCR.

 For further guidance, see Section 2010 of the SOM.

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