HCSSA Pre-Survey Computer-Based Training

Module 5: Licensed and Certified Home Health Services

Health and Human Services Commission

Long-Term Care Regulation

Welcome to Module Five of the HCSSA Presurvey Computer-Based Training. This computer-based training (CBT) is designed to prepare Home and Community Support Services Agency (HCSSA) administrators, supervising nurses, and their alternates for the initial HCSSA survey.

System requirements

Before beginning this course, ensure that your computer meets the following system requirements.

At the end of this course, you will need to verify that you've fulfilled the course requirements and obtain a learning certificate.

To access the course, your internet browser must be set to allow pop-ups.

Browser Requirements: Google Chrome, Firefox, Microsoft Edge or Safari

• You will not be able to receive credit for quizzes taken on Internet Explorer.

Printer: The ability to print hard copies of your learning certificate.

Navigation

To navigate through this course, use the buttons at the bottom left of the screen.

Click "next page" to proceed to the next page and click "previous page" to go back to the previous page.

You may also access content directly by using the page numbers at the top of the page.

In this training, be sure to click the text that appears in blue underlined text for important additional information.

This CBT is designed to provide an introduction to most HCSSA regulations and laws, but regulations and laws will not be covered in their entirety.

It is the full responsibility of each agency to remain in compliance with applicable federal, state, and local regulations and laws governing HCSSAs and the services they provide.

Agencies must be able to demonstrate compliance with applicable regulations and laws during the initial HCSSA survey and during any subsequent regulatory visits.

Successful completion of all required modules of the Presurvey CBT satisfies the Presurvey Training licensure requirement at Texas Administrative Code (TAC), Title 26, Part 1, Chapter 558, §558.13. Please note that this training cannot be used to satisfy initial and continuing education requirements for administrators outlined in 26 TAC §558.259 and 26 TAC §558.260.

For policy/course content questions contact a HCSSA policy specialist at (512) 438-3161 or email LTCRPolicy@hhs.texas.gov.

For licensing/application questions contact a HCSSA licensing specialist at (512) 438-2630 or email LTC_HCSSA_Licensing@hhs.texas.gov.

On the HCSSA license application, HCSSA license applicants must designate appropriate service categories for the type of services they plan to offer.

This module covers Licensed and Certified Home Health Services (L&CHHS).

26 Texas Administrative Code, Chapter 558 defines home health service as "the provision of one or more of the following health services required by an individual in a residence or independent living environment:

• nursing, including blood pressure monitoring and diabetes treatment;
• physical, occupational, speech, or respiratory therapy;
• medical social service;
• intravenous therapy;
• dialysis;
• service provided by unlicensed personnel under the delegation or supervision of a licensed health professional;
• the furnishing of medical equipment and supplies, excluding drugs and medicines; or
• nutritional counseling.

Other modules in the presurvey CBT provide in-depth focus on other service categories.

In order to apply for an initial HCSSA license, license applicants must verify that certain personnel have completed this training.

• HCSSA license applicants planning to provide licensed and certified home health services with or without home dialysis designation are required to verify that their administrator, alternate administrator, supervising nurse, and alternate supervising nurse have successfully completed this training.
• HCSSA license applicants planning to offer any of the other service categories are required to verify that their administrator, alternate administrator, supervising nurse, and alternate supervising nurse have successfully completed this training

Remember that each required participant must submit a signed certificate of completion.

Application packets will not be accepted without these documents!

The certificate of completion will be available after you complete the quiz for each module.

HHSC will not accept HCSSA license applications without these signed certificates for each required participant.

Agencies must keep copies of these signed certificates on file and available.

This module ends with a short quiz. Required participants must pass the quiz with a minimum score of 80%.

If a score of at least 80% is not earned, required participants must retake the course and quiz until they pass the quiz.

If you quit this module before completing the quiz, you must retake the module from its beginning.

Since HCSSA Presurvey CBT Module 5 focuses entirely on L&CHHS agencies, you will need to have access to all the L&CHHS laws and regulations, which are listed below. Click on the titles and add the URLs to your computer's "favorites" list.

• Health and Safety Code, Title 2, Chapter 142
• Texas Administrative Code, Title 22, Part 11, Chapter 224
• Texas Administrative Code, Title 22, Part 11, Chapter 225
• Texas Administrative Code, Title 26, Part 1, Chapter 558
• Texas Administrative Code, Title 26, Part 1, Chapter 560
• Texas Administrative Code, Title 40, Part 1, Chapter 93
• Code of Federal Regulations, Title 42, Part 484 (Conditions of Participation — Home Health)

• Social Security Act (Title XVIII — Medicare, Title XIX — Medicaid)

The Centers for Medicare and Medicaid Services (CMS) provides many resources to the general public. Guidance for surveyors of certified home health services can be found in: CMS State Operations Manual (SOM), Appendix B. This document contains the language of 42 Code of Federal Regulations Part 484, as well as interpretive guidance for surveyors.

Refer to PL 19-02 on how to request a copy and print a copy of a rule or subchapter from the Texas Administrative Code (TAC).  

In this module, you will:

• demonstrate an understanding of the initial certification process;
• distinguish between conditions and standards; and
• identify key federal regulations for home health agencies (HHAs).

Listed below are the main topics for Module 5 of the HCSSA Presurvey Training. You must complete all sections of this course, including the quiz.

• Applicable State Regulations
• Initial Medicare Survey
• Medicare Recertification Survey
• Selected Federal Regulations
• Quiz

When you're ready to begin this module, click "next" to proceed.

This section of Module 5 will review some of the state regulations applicable to L&CHHS Agencies.

The Texas Health and Safety Code (HSC) is the state law governing all HCSSAs, including those with a licensed and certified category.

The rules established under the authority of the HSC are found in the TAC, Title 26, Part 1, Chapter 558. All HCSSAs, including those with a licensed and certified category, must follow the rules in 26 TAC Chapter 558. Both the TAC and the HSC are listed as required resources for this module.

26 TAC Chapter 558 is divided into subchapters. You have reviewed much of the information in Subchapters A-C and E-G in prior modules.

26 TAC Chapter 558, Subchapter D contains regulations specific to each license category, including regulations specific to licensed and certified agencies (26 TAC §558.402).

HCSSA is a state term that stands for Home and Community Support Services Agencies. The general state licensure categories for HCSSAs include:

• home health services;
• home health services with dialysis designation;
• hospice services; and
• personal assistance services.

Of these categories, only the first three can become Medicare certified after becoming licensed by the state.

HHA is a federal term that stands for home health agency. This term may only be applied to home health agencies that have Medicare certification.

A branch office is a location or site from which an HHA provides services within a portion of the total geographic area served by the parent agency. The branch office is part of the HHA and is located sufficiently close to the parent agency so that it shares administration, supervision, and services with the parent agency on a daily basis.

As a reminder, a branch office providing licensed and certified home health services (L&CHHS) must comply with the Medicare Conditions of Participation for HHAs in addition to the licensing standards for HCSSAs.

The Centers for Medicare & Medicaid Services (CMS) approves or denies the branch location if an agency is licensed to provide licensed and certified home health services.

Source: §558.27 and State Operations Manual, Section 2182

An agency must notify HHSC through the online portal no later than five days after the agency decides to voluntarily withdraw from the Medicare program or if CMS involuntarily terminates or denies its certification. If an agency's voluntary withdrawal from the Medicare program is based on the permanent closure of the agency, the agency must also comply with §558.217 (relating to Agency Closure Procedures and Voluntary Suspension of Operations).

After a change in certification status, the agency's licensure status is affected as follows:

• If the agency has no other categories on its license after losing Medicare certification, it must cease operation as the license is void. The agency must reapply for an initial license if it wishes to continue providing services.

• If the agency has other categories remaining on its current license, it may continue to provide services under those categories.

Source: 26 TAC §558.216

HHSC may take enforcement action against an agency licensed to provide L&CHHS if the agency fails to maintain its Medicare certification.

The agency may request an administrative hearing in accordance with §558.601 to contest the enforcement action taken by HHSC against the agency.

In addition to the minimum standards in 26 TAC Subchapter C, an agency that provides L&CHHS must comply with the requirements of the Medicare Conditions of Participation (Social Security Act, 42 Code of Federal Regulations (CFR), Part 484).

Later sections of this CBT review some of these regulations.

An agency providing L&CHHS that plans to implement a home health aide training and competency evaluation program or a competency evaluation program must comply with the regulations in 26 TAC §558.701 governing home health aides.

The L&CHHS agency may not use an individual as a home health aide unless:

• The individual has met the requirements as stated in 42 CFR Part 484 and the Social Security Act; or
• The individual qualifies as a home health aide based on either a training and competency evaluation program or a competency evaluation program that meets the requirements of 26 TAC Chapter 558 Subchapter G, "Home Health Aides"; or
• The individual is a licensed health care provider.

Note: A home health aide is not the same as a certified nursing assistant.

Source: 26 TAC §558.402

Click on the +/- to learn more about home health aide training. It is the responsibility of the license applicant to read this information in its entirety.

Source: 26 TAC §558.701

Click on the +/- to learn more about each item related to home health aide training requirements. It is the responsibility of the license applicant to read this information in its entirety.

Source: 26 TAC §558.701(e)-(f)

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.  

The term "Accreditation Organization" encapsulates any AO with current HHSC approval listed on the HCSSA Provider Portal page under the Accreditation Agencies tab. 

For more information on Medicare Accreditation, visit the Accreditation of Medicare Certified Providers & Suppliers page.

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 five prerequisite steps a L&CHHS agency must complete before an initial certification survey can be administered. These steps must be completed within six months.

The steps are as follows:

1. Complete the state licensing process through HHSC.
2. Complete and submit form CMS-855A.
3. Provide nursing and one other skilled service.
4. Obtain the required patient census.
5. Complete and submit HHSC Form 2020.

For more information, click on this link to read more about the Medicare Provider enrollment steps.

Upon applying for the licensed and certified category of service, the agency must comply with all relevant parts of 26 TAC, Chapter 558, including 26 TAC §558.402 (Standards Specific to Licensed and Certified Home Health Services) and 42 CFR, Part 484, which contains the Medicare Conditions of Participation (CoPs).

If the agency passes both the licensed and the licensed and certified survey, the surveyor recommends certification for the agency. After HHSC receives written approval from CMS, HHSC amends the licensing status to include the licensed and certified home health services category.

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.

Source: 26 TAC §558.257

There are two options when completing and submitting an application for CMS certification:

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

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 (PL) 2015-09, Direction from the Centers for Medicare & Medicaid Services (CMS) on Prioritization of Initial Medicare Certification Surveys (Home Health).

Agencies will complete the CMS 855A and submit the application to their Medicare Administrator Contact (MAC). I.e. Palmetto GBA, Novitas Solutions, etc.

To facilitate your enrollment into the Medicare program, respond promptly and fully to any request for additional or clarifying information from the fee-for-service contractor.

All HCSSAs with a category of L&CHHS 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.

Source: State Operations Manual, Appendix B

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.

The agency must notify the designated survey office when it is ready for the initial certification survey by completing HHSC Form 2020 Notification of Readiness for Initial Survey through the online portal. 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 26 TAC §558.521.

Remember that a L&CHHS agency must complete five prerequisite steps before an initial survey can be administered.

It is important to remember that these steps must be completed within six months. Hover the mouse over each step below to reveal the five steps to licensure for L&CHHS HCSSAs.

Step 1

Step 2

Step 3

Step 4

Step 5

The instrument/data collection tool used to collect and report assessment data by home health agencies is called the Outcome and Assessment Information Set (OASIS). OASIS data is used for multiple purposes including calculating several types of quality reports which are provided to home health agencies to help guide quality and performance improvement efforts.

The OASIS test transmission is not a requirement for agencies to request their initial certification survey. However, agencies may contact the OASIS Help Desk to obtain their OASIS Facility ID before OASIS assessments can be submitted into the Internet Quality Improvement and Evaluation System (iQIES).

Agencies cannot get access to iQIES until they receive their certification number in their CMS approval letter.

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.

To learn more about the iQIES process, visit this link.

These additional documents are required if the agency is seeking certification or is currently certified through the Medicare program along with the CMS 855A.

CMS 1561 Health Insurance Benefit Agreement (PDF) [with original signatures, completing the entire top half and signing under "Accepted for the provider of services by"].

Civil Rights Clearance for Medicare Provider Applicants (copy of evidence of successful electronic submission through HHS Assurance of Compliance portal).

The agency must pay the application fee electronically through Pay.gov, with a bank account (ACH), credit or debit card. The application fee applies to CMS 855 applications.

Once you are on Pay.gov:

• Type "CMS" in the search box under "Find Forms, Agencies... ";
• Click the Page 1 of 4 "Search" button;  
• Find the "CMS Medicare Application Fee" section;
• Select the "Continue to the Form" button;  
• Complete the form; and
• Submit payment as directed.

The following links provides additional information and the current application fee process:

• CMS Home Health Center
• Implementation of Provider Enrollment Provisions (PDF)
• Pay.gov FAQs

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

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 sections of this training.

An Accreditation Organization (AO) may not conduct an initial certification survey of a prospective provider or supplier for Medicare certification purposes until the Medicare Administrator Contact (MAC) has completed its initial review of the enrollment application and has made a recommendation for approval to CMS.

HHSC continues to conduct all other L&CHHS surveys, including complaint surveys, to ensure continuous compliance.

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

Source: SOM, Chapter 2, The Certification Process

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.

After an agency completes steps 1-5, 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 26 TAC, Chapter 558.

For ease of understanding and citation, 42 CFR, Part 484 is divided into 15 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.

There are 15 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)
• Discharge planning (42 CFR §484.58)
• 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)

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.

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

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

There are four types of surveys HHSC may conduct at a certified agency. Hover and click the mouse over each item below to reveal the survey information.

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.

The following sections will review some selected federal regulations applicable to the L&CHHS 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.

Condition of Participation

§484.50 - Patient Rights

Level 1 Standards (Priority Standards for a Standard Survey)

§484.50(a) - Notice of rights

§484.50(b) - Exercise of rights

§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

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

Condition of Participation

§484.58(a) - Discharge planning

Level 1 Standards (Priority Standards for a Standard Survey)

§484.58(b) - Discharge or transfer summary content

§484.58(b)(1) - Necessary medical information

§484.58(b)(2) - Additional clinical information necessary for patient treatment

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

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

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

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

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

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).

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.

Congratulations!

You have reached the end of the HCSSA Presurvey CBT Module 5.

Please continue to next page and complete the quiz.

You must score 80% or higher to receive credit and print your certificate.