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CoP Educational Series Part 7: Organization and Administrative Services and the Clinical Record

Posted on Thursday, July 13, 2017 8:10 PM

This post will cover Organization and Administrative Services and the Clinical Record as outlined in the new Conditions of Participation. 

CoP 484.105 Organization and Administrative Services requires agencies to organize, manage and administer all services in a manner which maintains the “highest level of practicable functional capacity” and provide “optimal care” in accordance with each patient’s plan of care.

Home Health agencies are not allowed to delegate administrative and supervisory functions to other home health agencies or organizations.

Each home health agency is required to place, in writing, their organizational structure, including the lines of authority and all services provided. The agencies operating and capital budgets must be prepared under the direction of the agencies governing body.   It is also required to have a budget and planning committee which includes representatives of the governing body, administrative staff and medical staff if the agency has medical staff. The same committee must review and if necessary revise the plan at least annually under the direction of the governing body.

The home health agencies governing body has full legal authority for the operations and management of the agency. Included is the provision of all home health services, fiscal operations, budget, operational plans and the oversite of the agencies Quality Assessment and Process Improvement program (QAPI).

The agency Administrator must be appointed by the governing body and has responsibility for running the home health agency daily operations. When the Administrator is not available, he/she must delegate a qualified individual to assume the Administrator responsibilities.  This designation should be made by both the Administrator and the governing body and the time allotment to do so should be outlined in the agencies policies and procedures.

Home health agencies must also have one or more qualified Clinical Managers to oversee all patient care and agency personnel. This oversight includes all patient and personnel assignments, the coordination of patient care, the coordination of referrals, the assessment of patient needs, and to ensure the plan of care is developed, implemented and updated as needed. The CoP does state the Clinical Manager may also be the designated qualified individual when the Administrator is not available.

The Clinical Manager must also be available during all operating hours of the agency, which is defined as all hours the agency staff is providing care and services to patients. 

With the new CoPs, the Parent-Branch relationship regarding home health agencies has changed. Home health agencies are required to report all branch locations to the state survey agency when they are initially certified, when surveyed and when an agency seeks to add a branch or close a branch location. The agency is required to provide administrative control and support over each branch location. The distance of parent-branch locations is no longer a consideration. Sub-units will no longer be recognized.  Agencies will need to either close or convert sub-units to branches or free-standing home health agencies. There has been recent discussion regarding the elimination of sub-units and the parent-branch information and opinions regarding this being in the CoPs, although no proposed changes have been published at this time.

The remainder of the CoPs and standards regarding Organization and Structure contain renumbering and minor verbiage revisions or additions and will not be covered in this course.

Clinical Records – 484.110 requires home health agencies to maintain a clinical record of past and current information of all patients receiving home health services. The clinical record must contain accurate information on each patient and adhere to the standards of practice for accurate documentation. The clinical record must be available to physicians and other staff that may be issuing orders for patient services.  The clinical record may also be electronic.

There are requirements with regards to the contents of the clinical record. The patient’s current record must contain the most current comprehensive assessment, or the assessment with the most recent date. In addition to the most current comprehensive assessment the record must also contain all assessments related to the patient’s current admission.  In addition, all clinical notes, plans of care and physician orders must be contained in the record. All patient goals and interventions, medication administration, treatments and services and the progress towards goals and responses interventions must be included as well. Contact information for the patient, patient representative, the primary patient caregivers, the patient’s practitioner and any other health care professionals providing care or services to the patient is also part of the clinical record. 

A discharge summary must be sent to the primary physician or practitioner and other health care professionals providing care for the patient. The agency must send the summary within 5 days of the patients discharge from the home health agency. This summary is not to be confused with the transfer summary, which is required to be sent within 2 business days of planned or an unplanned transfer if the patient is receiving care in a health care facility at the time the home health agency is made aware of the transfer.

All contents of the clinical record must be legible, clear, complete, appropriately authenticated, dated and timed. Authentication includes both a signature and a title. For those records that are contained in an electronic or computer record, a unique identifier is approved. It is important to know that CMS does allow electronic signatures, but the original, signed paper documents should be retained as part of the authentication in the clinical record. 

Clinical records are required to be retained for at least 5 years, unless a specific state law requires a longer time-period. All home health agencies must have a policy in place that accounts for the process surrounding the clinical record in the event the agency closes. As part of this, they must notify the state agency as to where clinical records will be stored.  All home health agencies must safeguard the clinical record from loss or unauthorized use and comply with HIPAA regulations regarding protected health information. 

Lastly, the home health agency must provide, free of charge, a copy of the patient’s clinical record if the patient makes the request. If the request is made, the record must be made available to the patient on the next home visit or within 4 days, whichever comes first. As with record retention, state laws may have stricter requirements surrounding this provision.

Written by Peggy Patton, Vice President of Education Services

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