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 patient��s 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 patient��s

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 patient��s 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 patient��s 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 patient��s 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 HHA��s internal policies.

(b)(4) When services are provided on the basis of a physician��s verbal orders, a registered nurse, or

other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance

with state law and the HHA��s policies must document the orders in the patient��s 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 HHA��s 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

patient��s 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 patient��s 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 patient��s updated comprehensive

assessment, and contain information concerning the

patient��s 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 HHA��s 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.

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