What’s Going on with Home Healthcare Conditions of Participation (COPs)?

April 1, 2021
April 1, 2021

This blog post is taken from a recent Webinar featuring Gina Mazza, Director of the Regulatory and Compliance Division, Fazzi Associates.

The conditions of participation for home health agencies have been revised by CMS for the first time in a couple of decades, setting the stage for what will amount to a cultural change in home health in 2018. While many standards will remain the same, other COPs have been reorganized, combining some and moving others. Once the interpretive guidelines are released, we will have much more information on how to comply. In the meantime, here are some recommendations and highlights.

Name Leaders and Train Staff

We recommend acting now to appoint leaders who can prepare for the implementation of each major section of the COPs. The patient rights changes are especially complex, so you should name someone without delay to head up that implementation; more on that below.

Education is also critical. Ensure your staff is well informed about the changes, what you are doing, and why you are doing it. Many of these changes will require you to review your policies and possibly some of your procedures. Flag any policy changes to help you develop a good road map for education and training.

Focus on Patient Rights

Your patient rights materials are subject to the most prescriptive of the COP-related changes, so appointing a leader for this purpose is essential. Compliance will be labor-intensive. Many agencies are either updating or adopting admission booklets to include patient rights information. I like this approach because it helps you comply and gives the patient and caregiver a single document.

You must also be able to share the rights in a language the patient understands. This means you must have a translator (think translation service) who can summarize these rights in an understandable way, but there is no requirement to go through the entire document.

CMS requires a two-step process for communicating patient rights. You must inform the patient of his rights before care is provided and provide a verbal notice by the end of the second visit. If the patient has a patient representative approved to be part of his care, that person must also be informed. Document the verbal notice of rights by having the patient initial the form or by making a note in the documentation.

Review, Establish, and Train for QAPI Program

You will be required to have an agency-wide data-driven quality assurance and performance improvement program. This must be a top-down program with the involvement and approval of your governing body, and projects must be data-based. If you start on QAPI now, including at least the one required PI project, you should be in good shape for January 2018. Your performance improvement project must reflect your agency’s data, customer reports, and audit results and should be focused on a metric capable of demonstrating improvement.

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