Quality Reporting for Hospice Providers

The Affordable Care Act (ACA) requires that CMS use nationally endorsed quality measures in the Hospice Quality Reporting Program (HQRP). The ACA also allows CMS to specify measures that are not yet endorsed if a feasible and practical measure in the quality area is determined appropriate by the Secretary. The HQRP requires hospices to submit data to CMS via the Hospice Item Set (HIS) and to participate in the CAHPS® Hospice Survey. HIS data can be used to calculate seven National Quality Forum (NQF)-endorsed measures and two non-NQF-endorsed measures. Descriptions of the nine HIS-based measures are provided below. Additional details about the measures can be found in the QM User’s Manual located in the Downloads section at the bottom this web page


Training Material for the April 2017 Hospice Data Submission and Reporting Webinar Available

The presentation (without answers to polling questions) for the upcoming Hospice Data Submission and Reporting Webinar on Tuesday, April 25, 2017, from 12:00 p.m. to 1:45 p.m. ET is now available under the downloads section below.


Home Health Agency Final Conditions of Participation Revisions Released by CMS

The Center for Medicare and Medicaid Services has issued a final rule that revises and modernizes the Conditions of Participation (COP) for Home Health Agencies.  The Final Rule can be found in its entirety at: Final Home Health Rule (CMS-3819-F).

The new rules describe the conditions that Home Health Agencies (HHA) must meet in order to participate in the Medicare and Medicaid programs. The new Final Rules reflect some significant changes in the rules that apply to Medicare HHAs and require HHAs to take a solid look at their policies and procedures and operations to be certain that they comply with the new requirements by the effective date of July 13, 2017.

The changes reflected in the new rules are intended by CMS to be an integral part of an overall effort to achieve broad-based, measurable improvements in the quality of care furnished through the Medicare and Medicaid programs, while at the same time eliminating unnecessary procedural burdens on providers.

The new rules generally focus on the care delivered to patients, reflect an interdisciplinary view of patient care, allow HHAs greater flexibility in meeting quality care standards, and eliminate unnecessary procedural requirements.  The primary coverage areas of the new rules include:

  • A focus on assuring the protection and promotion of patient rights.
  • Enhancement of the process for care planning, delivery, and coordination of services.
  • Building a foundation for ongoing, data-driven, agency-wide quality improvement.
  • Expansion of patient rights requirements that enumerate the rights of home health agency patients and the steps that must be taken to assure those rights.
  • Expansion of comprehensive patient assessment requirements that focuses on all aspects of patient wellbeing.
  • A focus on measures intended to assure that patients and caregivers have written information about upcoming visits, medication instructions, treatments administered, instructions for care that the patient and caregivers perform, and the name and contact information of a home health agency clinical manager.
  • New requirements to promote an integrated communication system to help ensures that patient needs are identified and addressed, care is coordinated among all disciplines, and that there is active communication between the home health agency and the patient’s physician(s).
  • New standards for a data-driven, agency-wide quality assessment and performance improvement (QAPI) program that continually evaluates and improves agency care for all patients at all times.
  • Enhanced infection prevention and control requirements with a focuses on the use of standard infection control practices, and patient/caregiver education and teaching.
  • Streamlining of some of the requirements relating to skilled professional services which emphasize appropriate patient care activities and supervision across all disciplines.
  • An expanded patient care coordination requirement that makes a licensed clinician responsible for all patient care services, such as coordinating referrals and assuring that plans of care meet each patient’s needs at all times.
  • Revisions to simplify the organizational structure of home health agencies while continuing to allow parent agencies and their branches.
  • Revised personnel qualifications for home health agency administrators and clinical managers.



CMS Extends Compliance Date for New Home Health Conditions of Participation

conditions of participation home health agenciesThe Centers for Medicare & Medicaid Services (CMS) has proposed that the effective date of new Conditions of Participation for Home Health Agencies (CoP)be delayed.  The original effective date of the new regulations was July 13, 2017.  The recently proposed rule would delay the effective date of the new CoP until January 13, 2018.

The new CoP were published in January of this year and were the first major revisions made to the rules in nearly 20 years.   The new rule reflects an increased focus on a patient centered, data-driven, outcome-oriented process that continually promotes high quality patient care at all times. The regulations represent a move away from regulatory focus on enforcement of prescriptive health and safety standards toward improving the quality of care for all patients.  Regulatory priorities are more focused on stimulating broad-based improvements in quality of care rather than expending resources on enforcing standards against marginal providers.

The new regulations purport to permit greater flexibility in how home health agencies are permitted to meet quality standards.  The new focus stresses interdisciplinary patient care and aims at creating broad-based measurable improvements in quality of care while streamlining procedural burdens that impede providers.

A few areas of change include new requirements for:

  • More continuous, integrated care process across all aspects of home health services, based on a patient-centered assessment, care planning, service delivery, and quality assessment and performance improvement.
  • Use a patient-centered, interdisciplinary approach that recognizes the contributions of various skilled professionals and their interactions with each other to meet the patient’s needs.
  • Emphasis on quality improvements by incorporating an outcome-oriented, data-driven, quality assessment and performance improvement program specific to each HHA.
  • Eliminate the focus on administrative process requirements that lack adequate consensus or evidence that they are predictive of either achieving clinically relevant outcomes for patients or preventing harmful outcomes for patients.
  • A focus on safeguards on patient rights.

The extension of the effective date for the new regulations responds to concerns that were voiced by industry groups that there would be difficulties meeting the required timeline for implementing new quality assessment and improvement requirements.

Video Recordings of November Dallas Home Health QRP Provider Training.  Video recordings of presentations made at the November 16 and 17, 2016, Home Health QRP Provider Training in Dallas, TX, are now available via YouTube.


Home Health Quality Reporting Requirements.  Statutory Authority for Use of the OASIS Data Item Set and Home Health Quality Reporting. 

The reporting of quality data by home health agencies (HHAs) is mandated by Section 1895(b)(3)(B)(v)(II) of the Social Security Act (“the Act”).  This statute requires that ‘‘each home health agency shall submit to the Secretary such data that the Secretary determines are appropriate for the measurement of health care quality. Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this clause.’’

OASIS reporting is mandated in the Medicare regulations at 42 C.F.R.§484.250(a), which requires HHAs to submit OASIS assessments and Home Health Care Consumer Assessment of Healthcare Providers and Systems Survey (HH CAHPS) data to meet the quality reporting requirements of section 1895(b)(3)(B)(v) of the Act.

Home Health Quality Reporting Requirements

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OIG Compliance Guidance – Listing of Nursing Home Risk Areas

Some of these items are duplicative with the Hospital standards.  However, many are unique to nursing facilities.

Quality of Care

The OIG believes that a nursing facility’s compliance policies should start with a statement that affirms the facility’s commitment to providing the care and services necessary to attain or maintain the resident’s ‘‘highest practicable physical, mental and psychosocial well-being.’’

    •  accurate assessment of each resident’s functional capacity and a comprehensive care plan that includes measurable objectives and timetables to meet the resident’s medical, nursing, and mental and psychosocial needs;

  • inappropriate or insufficient treatment and services to address residents’ clinical conditions, including pressure ulcers, dehydration, malnutrition, incontinence of the bladder, and mental or psychosocial problems;
  • failure to accommodate individual resident needs and preferences;
  • failure to properly prescribe, administer and monitor prescription drug usage;
  • inadequate staffing levels or insufficiently trained or supervised staff to provide medical, nursing, and related services;
  • failure to provide appropriate therapy services;
  • failure to provide appropriate services to assist residents with activities of daily living (e.g., feeding, dressing, bathing, etc.);
  • failure to provide an ongoing activities program to meet the individual needs of all residents; and
  • failure to report incidents of mistreatment, neglect, or abuse to the administrator of the facility and other officials as required by law.


Residents Rights.  To protect the rights of each resident, the OIG recommends that a provider address the following risk areas as part of its compliance policies:



  • discriminatory admission or improper denial of access to care;
  • verbal, mental or physical abuse, corporal punishment and involuntary seclusion;
  • inappropriate use of physical or chemical restraints;
  • failure to ensure that residents have personal privacy and access to their personal records upon request and that the privacy and confidentiality of those records are protected;
  • denial of a resident’s right to participate in care and treatment decisions;
  • failure to safeguard residents’ financial affairs.


Billing Issues.


  • billing for items or services not rendered or provided as claimed;
  • submitting claims for equipment, medical supplies and services that are medically unnecessary;
  • submitting claims to Medicare Part A for residents who are not eligible for Part A coverage;
  • duplicate billing;
  • failing to identify and refund credit balances;
  • submitting claims for items or services not ordered;
  • knowingly billing for inadequate or substandard care;
  • providing misleading information about a resident’s medical condition on the MDS or otherwise providing inaccurate information used to determine the RUG assigned to the resident;
  • upcoding the level of service provided;
  • billing for individual items or services when they either are included in the facility’s per diem rate or are of the type of item or service that must be billed as a unit and may not be unbundled;
  • billing residents for items or services that are included in the per diem rate or otherwise covered by the third-party payor;
  • altering documentation or forging a physician signature on documents used to verify that services were ordered and/ or provided;
  • failing to maintain sufficient documentation to support the diagnosis, justify treatment, document the course of treatment and results, and promote continuity of care;
  • false cost reports;
  • routinely waiving coinsurance or deductible amounts without a good faith determination that the resident is in financial need, or absent reasonable efforts to collect the cost-sharing amount;
  • agreements between the facility and a hospital, home health agency, or hospice that involve the referral or transfer of any resident to or by the nursing home;
  • soliciting, accepting or offering any gift or gratuity of more than nominal value to or from residents, potential referral sources, and other individuals and entities with which the nursing facility has a business relationship;
  • conditioning admission or continued stay at a facility on a third-party guarantee of payment, or soliciting payment for services covered by Medicaid, in addition to any amount required to be paid under the State Medicaid plan;
  • arrangements between a nursing facility and a hospital under which the facility will only accept a Medicare beneficiary on the condition that the hospital pays the facility an amount over and above what the facility would receive through PPS;
  • financial arrangements with physicians, including the facility’s medical director;
  • arrangements with vendors that result in the nursing facility receiving non-covered items (such as disposable adult diapers) at below market prices or no charge, provided the facility orders Medicare-reimbursed products;
  • soliciting or receiving items of value in exchange for providing the supplier access to residents’ medical records and other information needed to bill Medicare;
  •  joint ventures with entities supplying goods or services;
  •  swapping.

 410.78 Telehealth services.

(a) Definitions. For the purposes of this section the following definitions apply:

(1) Asynchronous store and forward technologies means the transmission of a patient’s medical information from an originating site to the physician or practitioner at the distant site. The physician or practitioner at the distant site can review the medical case without the patient being present. An asynchronous telecommunications system in single media format does not include telephone calls, images transmitted via facsimile machines and text messages without visualization of the patient (electronic mail). Photographs visualized by a telecommunications system must be specific to the patient’s medical condition and adequate for furnishing or confirming a diagnosis and or treatment plan. Dermatological photographs, for example, a photograph of a skin lesion, may be considered to meet the requirement of a single media format under this provision.

(2) Distant site means the site at which the physician or practitioner delivering the service is located at the time the service is provided via a telecommunications system.

(3) Interactive telecommunications system means multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner. Telephones, facsimile machines, and electronic mail systems do not meet the definition of an interactive telecommunications system.

(4) Originating site means the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs. For asynchronous store and forward telecommunications technologies, the only originating sites are Federal telemedicine demonstration programs conducted in Alaska or Hawaii.

(b) General rule. Medicare Part B pays for office and other outpatient visits, professional consultation, psychiatric diagnostic interview examination, individual psychotherapy, pharmacologic management, end-stage renal disease-related services included in the monthly capitation payment (except for one visit per month to examine the access site), individual medical nutrition therapy, the neurobehavioral status exam, and follow-up telehealth consultations furnished by an interactive telecommunications system if the following conditions are met:

(1) The physician or practitioner at the distant site must be licensed to furnish the service under State law. The physician or practitioner at the distant site who is licensed under State law to furnish a covered telehealth service described in this section may bill, and receive payment for, the service when it is delivered via a telecommunications system.

(2) The practitioner at the distant site is one of the following:

(i) A physician as described in  410.20.

(ii) A physician assistant as described  410.74.

(iii) A nurse practitioner as described in  410.75.

(iv) A clinical nurse specialist as described in  410.76.

(v) A nurse-midwife as described in  410.77.

(vi) A clinical psychologist as described in  410.71.

(vii) A clinical social worker as described in  410.73.

(viii) A registered dietitian or nutrition professional as described in  410.134.

(3) The services are furnished to a beneficiary at an originating site, which is one of the following:

(i) The office of a physician or practitioner.

(ii) A critical access hospital (as described in section 1861(mm)(1) of the Act).

(iii) A rural health clinic (as described in section 1861(aa)(2) of the Act).

(iv) A Federally qualified health center (as defined in section 1861(aa)(4) of the Act).

(v) A hospital (as defined in section 1861(e) of the Act).

(vi) A hospital-based or critical access hospital-based renal dialysis center (including satellites).

(vii) A skilled nursing facility (as defined in section 1819(a) of the Act).

(viii) A community mental health center (as defined in section 1861(ff)(3)(B) of the Act).

(4) Originating sites must be located in either a rural health professional shortage area as defined under section 332(a)(1)(A) of the Public Health Service Act (42 U.S.C. 254e(a)(1)(A)) or in a county that is not included in a Metropolitan Statistical Area as defined in section 1886(d)(2)(D) of the Act. Entities participating in a Federal telemedicine demonstration project that have been approved by, or receive funding from, the Secretary as of December 31, 2000 qualify as an eligible originating site regardless of geographic location.

(5) The medical examination of the patient is under the control of the physician or practitioner at the distant site.

(c) Telepresenter not required. A telepresenter is not required as a condition of payment unless a telepresenter is medically necessary as determined by the physician or practitioner at the distant site.

(d) Exception to the interactive telecommunications system requirement. For Federal telemedicine demonstration programs conducted in Alaska or Hawaii only, Medicare payment is permitted for telehealth when asynchronous store and forward technologies, in single or multimedia formats, are used as a substitute for an interactive telecommunications system.

(e) Limitation. A clinical psychologist and a clinical social worker may bill and receive payment for individual psychotherapy via a telecommunications system, but may not seek payment for medical evaluation and management services.

(f) Process for adding or deleting services. Changes to the list of Medicare telehealth services are made through the annual physician fee schedule rulemaking process.



Nursing Home Compliance Plans are Mandatory Under ACA

nursing home compliance programsHealth care reform legislation  includes statutory provisions requiring nursing homes to have a compliance and ethics program in place.  The compliance program must be effective in preventing and detecting criminal, civil, and administrative violations and in promoting quality of care.  DHHS and OIG were required to develop regulations setting forth the requirements for a nursing home compliance program within 2 years of the enactment of the ACA.  those regulations have not yet been released.  However, the statutory mandate is in place and is not dependent upon the issuance of regulations.  Nursing home providers should not make the mistake of ignoring the statutory mandate due to the lack of regulatory guidance.  The OIG has issued guidance on what should be addressed in a nursing home compliance plan.  There is plenty of existing guidance out there to demonstrate the elements that should go into an effective compliance program.

A “compliance and ethics program” is defined in Section 6102 of PPACA.  The definition provides a basic structure for what should be included in the program.  The basics elements described in the statute mirror the requirements in the Federal Sentencing Guidelines which established the original basic requirements that effective compliance programs should contain.   Based on the statutory definition, a compliance program should include:

  • compliance standards and procedures that are reasonably capable of reducing the prospect of criminal, civil, and administrative violations;
  • a high-level manager assigned responsibility to oversee compliance with the standards and procedures;
  • allocation of sufficient resources and authority to assure that the compliance program can be operated;
  • systems to avoid the Provider delegating authority to individuals who have a  propensity to engage in criminal, civil, and administrative violations;
  • a system to effective communicate compliance standards  and procedures to all employees and other agents, such a structured training programs, compliance publications and the like;
  • reasonable steps to proactively monitor compliance with its standards and to detect potential infractions;
  • a system to permit and encourage reporting of potential  violations without fear of retribution;
  • s system to identify and address potential compliance risk areas;
  • consistent enforcement at all levels of the organization through appropriate disciplinary standards;
  • reasonable steps to respond to detected infractions including investigation process and corrective action;
  • periodic reassessment of the compliance and ethics program to identify gaps and to changes necessary to maintain an effective compliance process.

Compliance Program Nursing Homes

The above are the minimum requirement and guiding components of an effective compliance program.  The program will require much more detail to appropriately address the compliance issues that are specific to the particular organization.  Nursing providers should avoid using “pre-canned” compliance policies.  Granted, some of the language in policies and procedures can be somewhat uniform across provider types.  However, it is critical that the provider go through its own process to create a system that is unique to its own operations and set of risks.  Simply adopting compliance policies is missing the forest through the trees.  Certain policies must be in place in order for there to be an effective compliance program.  But a c

ompliance program is not a set of policies.  Rather, it is an ongoing operating system to detect, prevent and address the compliance risk that is specific to the organization.  Policies on the shelf will do more harm than good if the processes contained in those policies are not made operational on an ongoing basis.


John Fisher is a health care attorney with over 25 years of experience in health care compliance.  He is certified in health care compliance by the Health Care Compliance Association.  John has assisted a variety of healthcare providers, including numerous nursing facilities in the creation of compliance programs and in investigation of detected compliance issues.  John can be contacted through the “Contact” page in this website.  

Extension of EHR Donation Rules

I just wanted to mention a blog post that I did a while back on the PhysiciansLawyers blog site.  The Blog was on the extension of the electronic health record donation rules.

EHR Donation Rule