CMS Manual System Department of Health

1 CMS Manual System Department of Health & Human Services (DHHS) Pub. 100-07 State Operations Provider Certification Centers for Medicare & Medicaid Services (CMS) Transmittal 125 Date: October 31, 2014 SUBJECT: Revisions to State Operations Manual (SOM) Chapter 2 I. SUMMARY OF CHANGES: Chapter 2, Sections 2180 through have been reorganized and updated. Corresponding to these revisions, Exhibit 103 has been deleted. Sections have been updated to include revised web sites and policy information. The sections on HHA branches have been renamed and revised to clarify current CMS policy on branches. Survey policy sections that are no longer applicable have been deleted.

2 The sections on survey frequency have been revised to reflect current policy. The survey process information has been deleted from this Chapter and updated and moved to Appendix B. The OASIS requirements in sections have been updated to reflect current CMS policy and Federal regulations. NEW/REVISED MATERIAL - EFFECTIVE DATE: October 31, 2014 IMPLEMENTATION DATE: October 31, 2014 The revision date and transmittal number apply to the red italicized material only. Any other material was previously published and remains unchanged. II. CHANGES IN Manual INSTRUCTIONS: (N/A if Manual not updated.) (R = REVISED, N = NEW, D = DELETED) (Only One Per Row.)

3 R/N/D CHAPTER/SECTION/SUBSECTION/TITLE R 2/ Table of Contents R 2/2180A Citations R 2/2180B - Types of Agencies R 2/2180D - Services Provided R 2/2180E Application of Home Health Agency Conditions of Participation to Patients Receiving Chore Services Exclusively R 2/2182 - Organization of HHA R 2 - Characteristics Differentiating Branches From Subunits of HHAs R 2 Processing A Change From Branch to Subunit R 2 - CMS Approval Necessary for Non-Parent Locations R 2 - Notification by HHA to Add a Branch R 2 - SA Review of Request for Branch Determination R 2 - Onsite Monitoring of Approved Branches by the SA R 2.

4 Drop Sites R 2 - Branch Identification Numbers R 2/2183- Separate Entities (Separate Lines of Business) R 2 Staff Awareness R 2/2184 - Operation of HHAs Across State Lines N 2/2185 HHA Change of Address N 2 Move after Certification Survey and Before Final Medicare Approval R 2/2186 - Health Facility-Based HHAs R 2/2195 Guidelines for Determining Standard Survey Frequency D 2 - Tracking and Monitoring the Survey Cycles D 2/2196 - HHA Survey Process for Determining Quality of Care D 2 - Definitions D 2 Standard Survey D 2 Partial Extended D 2 Extended Survey D 2 - Home Health Functional Assessment Instrument (FAI) D 2 - Clinical Laboratory Improvement Amendments N 2/2197 Surveyor Worksheets D 2/2198 - Standard Survey - Structure D 2/2198A - Components D 2/2198B - Activities D 2/2198C - Applicability D 2/2200 - Survey Tasks D 2/2200A - Task 1 - Pre-Survey Preparation D 2/2200A1 - OBQM Adverse Event (AE)

5 Outcome Report and Patient Listing D 2/2200A2 - OBQI Outcome Report D 2/2200A3 - OBQI Case Mix Report D 2/2200A4 -Submission Statistics by Agency Report D 2/2200A5 -Error Summary Report by HHA D 2/2200B -Task 2 Entrance Interview D 2/2200C -Task 3-Information Gathering D 2/2200C1- Responsibilities D 2/2200C2 Request the following D 2/2200C3 When discussing observations D 2/2200C4 Clinical Record and Home Visit Selection for Standard Survey D 2/2200C5 - Selecting a Sample of Patients for Clinical Record Review with Home Visits D 2/2200C6 Selecting Sample of Clinical Records of Patients Who Will Not Receive Home Visit D 2/2200C7 - Recording Information D 2/2200C8 Conducting Home Visit D 2/2200D-Task 4-Information Analysis D 2/2200E-Task 5-Exit Conference D 2/2200F-Task 6-Formation of the Statement of Deficiencies R 2/2202 - Outcome and Assessment Information Set (OASIS) Requirements R 2 - OASIS Related Definitions R 2 - History of OASIS R 2 - Current Version of OASIS R 2 - OASIS as Part of the HHA s Comprehensive Assessment R 2 - Incorporation of OASIS Data Items Into the Comprehensive Assessment (Refer (e))

6 D 2 Copyright Release R 2 - OASIS and the Medicare Home Health Benefit R 2 - Non-Medicare/Non-Medicaid Patients R 2 Patients Turning 18 R 2 - Comprehensive Assessment and OASIS Reporting (Refer to and ) R 2 - Comprehensive Assessment and OASIS Collection R 2 - OASIS Encoding R 2 - OASIS Reporting (Refer to ) R 2 - Outcome-Based Quality Improvement (OBQI) R 2 - Using Outcome Based Quality Monitoring (OBQM) and Risk Adjusted OBQI Reports in the Survey Process R 2 - Privacy Act Requirements R 2 Accessing the OBQM, OBQI and Process Based Quality Improvement (PBQI) Reports R 2 - OASIS Guidance Manual R 2 - Other Manuals R 2 - Other Teaching Tools R 2 - OASIS and the Medicare Home Health Prospective Payment System (PPS) R 2 - Condition of Participation: Comprehensive Assessment of Patients (See ) R 2 - Record Keeping R 2 - Condition of Participation: Reporting OASIS Information R 2 - Condition of Participation.

7 Release of Patient Identifiable OASIS Information R 2 - OASIS and HHAs Seeking Initial Certification R 2 - Determining Compliance with the OASIS Transmission Requirements R 2 - HHAs Seeking Initial Certification Through an AO with Deeming Authority R 2 - Exceptions to Demonstrating Compliance with OASIS Submission Requirements Prior to Approval R 2 - Compliance Dates and PPS R 2 - Instructions for Handling Medicare Patients in HHAs Seeking Initial Certification R 2 - Instructions to New HHAs Concerning all Other Patients R 2 - Correction Policy R 2 - Determining When to Inactivate an Assessment R 2 - Deleting Assessments R 2 - Types of Corrections an HHA Can Make in HAVEN R 2 - Timeliness of Corrections R 2 - OASIS State System R 2 - System Description R 2 - Administration Requirements R 2 - Validation and Editing Process R 2 Reports R 2 - Replication to the CMS Repository R 2 - System Security R 2 - Security of Transmission R 2 - OASIS System of Records R 2 - Protection of Confidentiality Under the Privacy Act of 1974 R 2 - Regional Office R 2 State R 2 RO R 2 HHAs R 2 - Fax Transmission of OASIS or Other Patient Identifiable Information R 2 - Change of Ownership (CHOW)

8 , Merger, and Termination Procedures Affecting HHAs and OASIS Requirements R 2 - Wound Ostomy Continence Nurses Society (WOCN) and the National Pressure Ulcer Advisory Panel (NPUAP) OASIS Guidance III. FUNDING: No additional funding will be provided by CMS; contractor activities are to be carried out within their FY 2014 operating budgets. IV. ATTACHMENTS: Business Requirements X Manual Instruction Confidential Requirements One-Time Notification Recurring Update Notification *Unless otherwise specified, the effective date is the date of service. State Operations Manual Chapter 2 The Certification Process Table of Contents (Rev.)

9 125, Issued: 10-31-14) Home Health Agencies (HHAs) Processing A Change From Branch to Subunit SA Review of Requirement for Branch Determination - Onsite Monitoring of Approved Branches by the SA 2183 - Separate Entities (Separate Lines of Business) 2185 - HHA Change of Address - Move after Certification Survey and Before Final Medicare Approval 2195 Guidelines for Determining Standard Survey Frequency 2197 Surveyor Worksheets - Incorporation of OASIS Data Items Into the Comprehensive Assessment (See (e)) - Comprehensive Assessment and OASIS Reporting (Refer to and ) - OASIS Reporting (Refer to )

10 OASIS and the Medicare Home Health Prospective Payment System (PPS) - Condition of Participation: Comprehensive Assessment of Patients (See ) - Determining Compliance with the OASIS Transmission Requirements - HHAs Seeking Initial Certification Through an AO with Deeming Authority - Exceptions to Demonstrating Compliance with OASIS Submission Requirements Prior to Approval - Compliance Dates and PPS - Instructions for Handling Medicare Patients in HHAs Seeking Initial Certification - Instructions to New HHAs Concerning all Other Patients Change of Ownership (CHOW), Merger, and Termination Procedures Affecting HHAs and OASIS Requirements Wound Ostomy Continence Nurses Society (WOCN)