Get Your Care Planning and Coordination in Line With New CoPs
Get Your Care Planning and
Coordination in Line With New CoPs
Arlene Maxim
VP of Program Development, QIRT
1 | Get Your Care Planning and Coordination in Line With New CoPs
? The woven theme throughout the
current proposed rule is
integration, communication, and
coordination.
CMS Releases
Proposed
Changes to CoPs
C Transition toward a patient outcome
based system.
C An intent to stimulate improvements in
processes, outcomes of care, and
patient satisfaction.
C Patient\centered.
C Supported by patient outcomes data.
C Interdisciplinary in the approach to care
delivery, reflecting the team approach
to health care delivery.
C The new release date is set for January
13, 2018.
2 | Get Your Care Planning and Coordination in Line With New CoPs
A Sea Change
? What does Sea Change mean? What is the impact?
C
C
C
C
Culture change
Thought process change: no longer business as usual
Behavior change: boards, management, staff
Difficult and lengthy learning curve
? Agencies: staff, management, and owners
? Surveyors
? Expected to cost agencies a great deal of time and
money
3 | Get Your Care Planning and Coordination in Line With New CoPs
2017 Copyright, DecisionHealth, an H3.Group division of Simplify Compliance LLC.
All rights reserved. These materials may not be copied without written permission.
Page 1
New CoPs
? During this segment, we will explore two of the new
Conditions:
1. 484.60 \ Care Planning, Coordination of Services, and
Quality of Care.
2. 484.80 \ Home Health Aide Training and Competency.
4 | Get Your Care Planning and Coordination in Line With New CoPs
? 484.60\Care Planning, Coordination of Services, and
Quality of Care.
Combines 484 .18 Acceptance of patients, plan of care,
medical supervision and 484.14(g) Coordination of care.
C New care planning and care coordination requirements are at
the core of the new CoPs.
C CMS requires clinicians to create individualized plans of care
specific for each patient.
C Some of language is slightly different; some is significantly
changed.
C 484.60 Care Planning, Coordination of Services, and Quality of
Care are added as all one category.
C Theme of integration and uniqueness are woven into this
condition.
5 | Get Your Care Planning and Coordination in Line With New CoPs
HH CoPS 484.60 Care Planning, Coordination
of Services, and Quality of Care
? 484.60\ Condition of Participation: Care planning, coordination
of services, and quality of care
C Patients are accepted for treatment on the reasonable expectation that an
HHA can meet the patients medical, nursing, rehabilitative, and social
needs in his or her place of residence.
C Each patient must receive an individualized written plan of care, including
any revisions or additions.
C The individualized plan of care must specify the care and services
necessary to meet the patient\specific needs as identified in the
comprehensive assessment, including identification of the responsible
discipline(s), and the measurable outcomes that the HHA anticipates will
occur as a result of implementing and coordinating the plan of care.
C The individualized plan of care must also specify the patient and caregiver
education and training that the HHA will provide, specific to the patients
care needs.
C Services must be furnished in accordance with accepted standards of
practice.
6 | Get Your Care Planning and Coordination in Line With New CoPs
2017 Copyright, DecisionHealth, an H3.Group division of Simplify Compliance LLC.
All rights reserved. These materials may not be copied without written permission.
Page 2
HH CoPS 484.60 Care Planning, Coordination
of Services, and Quality of Care
? Services must be furnished in accordance with
accepted standards of practice.
? Standards:
C
C
C
C
C
(a) Plan of care
(b) Conformance with physician orders
(c) Review and revision of the plan of care
(d) Coordination of care
(e) Discharge or transfer summary
7 | Get Your Care Planning and Coordination in Line With New CoPs
The Home Health Plan of Care
(POC)
Care planning in accordance with the CoPs
8 | Get Your Care Planning and Coordination in Line With New CoPs
Plan of Care
(a) Standard Plan of Care
C (1) 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,
and which is 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.
9 | Get Your Care Planning and Coordination in Line With New CoPs
2017 Copyright, DecisionHealth, an H3.Group division of Simplify Compliance LLC.
All rights reserved. These materials may not be copied without written permission.
Page 3
Plan of Care: Elements
(a) (2) Plan of care. The individualized plan of care must include the
following:
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
All pertinent diagnoses
The patients mental, psychosocial, and cognitive status
The types of services, supplies, and equipment required
The 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
xii.
A description of the patients risk for emergency department visits and hospital
re\admission and all necessary interventions to address the underlying risk
factors.
? Attempts to reduce re\hospitalizations by identifying risks and necessary interventions.
? Removed risk scale (low, medium, and high).
10 | Get Your Care Planning and Coordination in Line With New CoPs
Plan of Care: Elements
xiii. Patient\specific interventions and education; measurable outcomes
and goals identified by the HHA and the patient
xiv. Information related to any advanced directives
xv. Any additional items the HHA or physician may choose to include
(a)(3) All patient care orders, including verbal orders must be
recorded in the plan of care
?
?
?
Pg. 4536: The plan of care is an evolving document that outlines the patients 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.
11 | Get Your Care Planning and Coordination in Line With New CoPs
Plan of Care: Elements
(b) Standard: Conformance with Physician Orders
(b)(1)Drugs, services, and treatments are administered only as ordered by the physician who is
responsible for the home health plan of care.
(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in
consultation with a physician, and after an assessment of the patient to determine for
contraindications.
(b)(3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws
and regulations and by the HHAs internal policies.
(b)(4) When services are provided on the basis of a physicians verbal orders, a registered nurse, or
other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance
with state law and the HHAs policies must document the orders in the patients clinical record, and sign,
date, and time the orders.
Verbal orders must be authenticated and dated by the physician in accordance with applicable state
laws and regulations, as well as the HHAs internal policies.
12 | Get Your Care Planning and Coordination in Line With New CoPs
2017 Copyright, DecisionHealth, an H3.Group division of Simplify Compliance LLC.
All rights reserved. These materials may not be copied without written permission.
Page 4
Plan of Care: Elements
(c) Standard: Review and Revision of the Plan of Care
(c)(1) 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
patients 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 physician who is responsible for the
HHA plan of care to any changes in the patients condition or needs
that suggest that outcomes are not being achieved and/or that the
plan of care should be altered.
13 | Get Your Care Planning and Coordination in Line With New CoPs
Plan of Care: Elements
(c) Standard: Review and Revision of the Plan of Care
(c)(2) A revised plan of care must reflect current
information from the patients updated comprehensive
assessment, and contain information concerning the
patients 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 HHAs internal policies.
14 | Get Your Care Planning and Coordination in Line With New CoPs
Plan of Care: Elements
(c) Standard: Review and Revision of the Plan of Care.
(c)(3) Revisions to the plan of care must be
communicated as follows:
(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.
15 | Get Your Care Planning and Coordination in Line With New CoPs
2017 Copyright, DecisionHealth, an H3.Group division of Simplify Compliance LLC.
All rights reserved. These materials may not be copied without written permission.
Page 5
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