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Webinar 2 Recap: Home Health Conditions of Participation Series

by Chip Schneider

The second webinar in the series Home Health Conditions of Participation: Charting a Course for Your Success was an eye-opener. Renowned home health consultant Arlene Maxim, RN of Quality in Real Time (QIRT) explored the aspects of the CoPs that are sure to represent the most radical changes for agencies — the changes to the plan of care.

Attendees described the webinar as “a great presentation with lots of information” and shared opinions like “Arlene is a very polished speaker and very well informed. I trust her opinion on home health matters.” This important webinar (and Webinars 1-5) is available for on-demand viewing now at

Watch Now — Webinar 2: Focus on the Plan of Care, Physician Orders, and the Comprehensive Assessment


Highlights from Webinar 2:

Care Expectations:
The new CoP for Care Planning, Coordination of Services, and Quality of Care (§ 484.60) lays out the following, new expectations:

  • Each patient will receive an individualized written plan of care.
  • Each plan of care will specify the care and services necessary to meet the patient’s needs, including patient and caregiver education and training the agency will provide specific to patient care needs.
  • The individualized plan of care will be revised or added to at intervals, as necessary, to continue to meet the patient needs.
  • The plan of care will include patient-specific, measurable outcomes that will occur as a result of carrying out the plan of care.

The individualized plan of care must include the following required items:

  • Frequency and duration of therapeutic interventions – established, periodically reviewed, and signed by a physician 
  • All pertinent diagnoses 
  • Mental, psychosocial, and cognitive status 
  • Types of services required 
  • Types of supplies and equipment 
  • Frequency and duration of visits to be made 
  • Prognosis 
  • Rehabilitation potential 
  • Functional limitations 
  • Activities permitted 
  • Nutritional Requirements 
  • All medications and treatments 
  • Safety Measures to protect against injury 
  • Patient and Caregiver education and training to facilitate timely discharge or referral
  • Patient-specific interventions and education; measurable outcomes/goals 
  • Information related to any advanced directives 
  • Any additional interventions/orders needed 

Physician Orders:

  • Orders may be taken only by personnel who are authorized by state laws and regulations and internal agency policies.
  • An RN or other qualified practitioner who is licensed to practice by the state must document a verbal order in writing in the record. The documentation must include:
    • A signature
    • The time of the order 
    • The date 
  • Verbal orders must be included in the patient’s plan of care. 
  • If orders are faxed or electronically transmitted, those orders are also required to be included in the clinical record and plan of care. 

Written Information to Patients:
Agencies must provide patients and caregivers with written instructions that outline the following five items:

  1. The visit schedule, including the frequency of visits by agency staff.
  2. The patient’s medication schedule/instructions including the medication name, dose, and frequency of administration. Identify which medications will be administered by agency personnel.
  3. All treatments that will be administered by agency personnel and personnel acting on behalf of the agency.
  4. Any other pertinent instruction related to patient needs. 
  5. The name and contact information of the agency’s clinical manager.


Frequently Asked Questions, Answered by Arlene Maxim, RN:

Question: Where can I find the full text of the new Conditions of Participation?
 Here is the link that I use and refer to in my presentations: Medicare and Medicaid Program: Conditions of Participation for Home Health Agencies

Question: You mentioned that the new individualized plan of care must include measurable outcomes. How will the Jimmo v. Sebelius settlement be considered here since improvement or progress is not necessary as long as skilled care is required?
 Jimmo v. Sebelius would continue to be met as long as goals reflect either maintenance therapy, or management and evaluation of an unskilled care plan are documented to reflect the long-term need.

Question: Can the recertification statement for continued need for home health services be written by the agency based on a comprehensive assessment and plan of care orders? We are already having physicians write in the recertification estimate on a verbal order, but based on Webinar 2, I am thinking of using the addendum to the plan of care to incorporate both the recertification statement and recertification estimate.
 While there is no specific direction from CMS on this, the reviewers we see are currently satisfied with language written by the agency. It's important however for the physician to provide the date of potential discharge. Note that the recertification estimate is typically applied to the Plan of Care itself. However you accomplish this, be certain it is clear to the reviewer where to find it! Consider adding a title above the information indicating "Recertification Summary."

Question: Regarding "canned" plans of care, our agency has a standardized home safety measure plan. Many agencies utilize a standard assessment order for specific diagnoses. (For example, "Nurse will assess patient's blood sugar at each visit" for diabetics.) Can we still use these frameworks if we customize and add to them as needed for each individual patient? 
 Yes, you will be able to use these types of strategies, just be certain that the information clearly pertains to the individual patient and isn't language used on every patient.

Question: Can you provide more detail about the information that must be provided to patients?
Please refer to the Rule at 484.60(e) "Written information to the patient." It lists five items: “The new provision requires the HHA to provide written instructions to the patient and caregiver outlining visit schedule, including frequency of visits; medication schedule/instructions; treatments administered by HHA personnel ad personnel acting on the behalf of the HHA; pertinent instruction related to patient care; and the name and contact information of the HHA clinical manager."

Watch Now — Webinar 2: Focus on the Plan of Care, Physician Orders, and the Comprehensive Assessment

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About Kinnser software

Kinnser Software, Inc. provides web-based solutions that deliver clinical and business results to the home health, hospice and private duty industries. Founded in 2003 and headquartered in Austin, Texas, Kinnser Software serves more than 4,000 home health, therapy, hospice, and private duty home care providers nationwide. Kinnser helps thousands of clinicians and other staff in post-acute healthcare to manage scheduling, billing, electronic visit verification, day-to-day operations, and patient referrals. 

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