Home Health Update - January 2002
of BQA 02-002 (PDF, 14 KB)
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Date: January 10, 2002 DSL-BQA-02-002
To: Home Health Agencies HHA 1
From: Jan Eakins, Chief, Provider Regulation and Quality Improvement
Via: Sue Schroeder, Director, Bureau of Quality Assurance
The purpose of this home health update is to provide guidance on
federal and state requirements for physician orders and documentation of
medications. The information included in this memorandum is currently in
effect and provided as clarification to current Center for Medicare and
Medicaid Services (CMS) and Bureau of Quality Assurance (BQA) policy.
A plan of care, which includes physician orders, must be established
for every patient accepted for care by a home health agency. Wisconsin
Administrative Code, Section HFS 133.20, and the federal Condition of
Participation, 42 CFR 484.18, outline the regulatory requirements for the
plan of care.
Additional Center for Medicare and Medicaid Services (CMS) guidance
related to 42 CFR 484.18: Acceptance of patients, plan of care, and
medical supervision were sent to all home health providers via Bureau of
Quality Assurance (BQA) memorandum DSL-BQA-01-030
in April 2001.
Frequency of visits:
Physician orders for patient care may authorize a specific range in the
frequency of visits for each service. Identifying a specific range for
visits may ensure that the most appropriate level of service is provided
to meet the needs of the patient. If fewer visits than the upper limit of
the range are provided, clinical record documentation must support the
patient specific circumstances that guided the agency’s decision to
provide fewer than the upper limit ordered.
When physician orders specify a visit range, the minimum number within
the range should be at least one unless the physician
identifies the patient specific criteria for no visits
during a given time frame.
Examples may include:
Daily home health aide visits one to
seven days a week to assist with personal care except when a family
member notifies the provider of their availability to
assume the responsibility for the physician ordered care.
Daily skilled nursing visits for wound care (specifics of wound care
would be identified) except on days the patient visits the physician
for dressing change.
Note: If the physician order specifies a range of visits, the
visits must be provided within the range based on the patient’s needs,
not staff availability. Staff availability is not an acceptable
reason for changing the frequency of physician ordered services.
Patient condition changes:
If a home health patient’s condition changes, the physician must
be notified. If the physician determines an adjustment to the visit
frequency is needed, a subsequent physician order should reflect the
change. Clinical record documentation must be evident to demonstrate
physician notification, information exchange, and subsequent orders, as
Documentation of Medications and Diagnoses
The BQA has received questions from providers regarding the following
state and federal requirements related to documentation of medications and
The federal Condition of Participation at
42 CFR 484.55 requires a complete comprehensive assessment of the
patient including a drug regimen review of all the medications
(prescription and over-the-counters) a patient is currently using. The
review is not limited to just the medications related to the primary
or secondary diagnosis.
42 CFR 484.18 (b) of the federal
Condition of Participation and Wisconsin Administrative Code, Section
HFS 133.20 (3), require that the plan of care be reviewed as often as
required by the patient’s condition, but no less often than every 60
Wisconsin Administrative Code, Section HFS 133.21 (5) (f), requires
that the home health agency maintain an up-to-date medication list
including documentation of patient instructions. The medication list
must include all the medications the patient is currently
taking, including over-the-counter medications.
Based on these provisions, the clinician must complete a
"comprehensive assessment" of the patient and their medication
regimen and use his/her professional judgement to determine the impact of all
medications on the patient's total health status.
For example, hypertension or hypothyroidism may not be the primary or
secondary diagnosis for which the patient is receiving home care, but such
diagnoses and related medications may have significant and pertinent
implications for a holistic approach to the patient's care.
The current expectation is that the clinical record reflects
documentation to support the reason the patient is taking medications,
including over-the-counters. This can be accomplished by including
documentation of each medication with either of the following:
A corresponding diagnosis on the plan of
Other supporting clinical record documentation (assessments, summary
reports to the physician, and progress notes).
Internal policies/procedures would delineate the agency’s
expectations related to the location of relevant documentation within the
If the skilled clinician determines through the assessment process that
the patient is experiencing problems with their medication regimen such as
potential adverse effects, drug reactions, ineffective drug therapy,
significant side effects, significant drug interactions, duplicate drug
therapy, and noncompliance with drug therapy, the physician must be
alerted. To maintain compliance with state and federal regulations, the
BQA encourages clinicians to consistently incorporate an evaluation of the
patient’s medication regimen through interview and observation.
Please direct questions, including question related to the CMS memo, to
Juan Flores, Health Care Regulatory
Southern Unit Supervisor (replaced by Jan Heimbruch, email@example.com, (608) 243-2086).
Jane Walters, Chief, Health Services
Section (replaced by Cremear Mims, firstname.lastname@example.org).
Barbara Woodford, Nurse Consultant,
Provider Regulation & Quality Improvement Section (replaced by Marianne Missfeldt, (715) 836-4036) .
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