oversight

Medicare Home Health Agencies: Certification Process Ineffective in Excluding Problem Agencies

Published by the Government Accountability Office on 1997-12-16.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                 United States General Accounting Office

GAO              Report to the Special Committee on
                 Aging, U.S. Senate



December 1997
                 MEDICARE HOME
                 HEALTH AGENCIES
                 Certification Process
                 Ineffective in
                 Excluding Problem
                 Agencies




GAO/HEHS-98-29
      United States
GAO   General Accounting Office
      Washington, D.C. 20548

      Health, Education, and
      Human Services Division

      B-277914

      December 16, 1997

      The Honorable Charles E. Grassley
      Chairman
      The Honorable John B. Breaux
      Ranking Minority Member
      Special Committee on Aging
      United States Senate

      As a result of changes in Medicare law, regulations, and policy, more
      Medicare beneficiaries are receiving more home health services and for
      longer periods of time. Home health care enables beneficiaries with
      short-term, acute-care needs, such as recovery from a hip replacement, as
      well as those with long-term, chronic conditions, such as congestive heart
      failure, to receive care in their homes. The use of home health care has
      grown because of the liberalization of the benefit as well as increases in
      the elderly population, longer life expectancy, and the ability to deliver
      services in the home that previously were provided only in hospitals or
      skilled nursing facilities (SNF). However, abusive billings for excessive care
      and visits for noncovered services have inflated this growth to some
      extent.

      The number of home health agencies (HHA) certified to care for Medicare
      beneficiaries has increased rapidly—from 5,700 in 1989 to nearly 10,000 at
      the beginning of 1997—and more than doubled in some states. During the
      same period, Medicare spending for home health care jumped from
      $2.7 billion to about $18 billion and is estimated to reach $21.9 billion in
      fiscal year 1998. Home health care has been, and continues to be, one of
      the fastest growing components of the Medicare program.

      Only HHAs that are surveyed and certified as meeting Medicare’s conditions
      of participation and associated standards can be reimbursed by Medicare
      for their services. This survey and certification process is administered by
      the Health Care Financing Administration (HCFA), in the Department of
      Health and Human Services (HHS), through state survey agencies, which
      are usually components of state health departments. These survey
      agencies assess whether HHAs have the appropriate staff, policies,
      procedures, medical records, and operational practices to deliver quality
      care. Surveyors conduct part of their work on site at HHAs and perform a
      variety of tasks, such as reviewing clinical records, interviewing HHA staff,
      and visiting patients in their homes.




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                   Because of your concerns about the rapid growth in the number of
                   certified HHAs and the effectiveness of the survey and certification process,
                   you asked us to determine how HCFA (1) controls the entry of HHAs into the
                   Medicare program and (2) ensures that certified HHAs continue to comply
                   with Medicare’s conditions of participation and associated standards. We
                   also looked at HCFA’s process for decertifying HHAs that are not complying
                   with Medicare’s requirements. This report expands on our July testimony
                   before your Committee, in which we presented the preliminary results of
                   our work.1

                   To address these issues, we interviewed officials and gathered pertinent
                   data about survey and certification activities at HCFA, state survey
                   agencies, Medicare claims processing contractors, the HHS Office of the
                   Inspector General, and trade groups representing the home health
                   industry. We concentrated our work in California, Illinois, and Texas,
                   which were among the original five states HCFA targeted under Operation
                   Restore Trust (ORT) for reviews addressing home health agencies.2 We
                   conducted our work between March 1996 and July 1997 in accordance
                   with generally accepted government auditing standards, with one
                   exception. We did not examine the internal and automatic data processing
                   controls related to the On-line Survey, Certification and Reporting
                   database (OSCAR), which HCFA and its state surveyors use to manage the
                   survey and certification process for HHAs. Further details on our scope and
                   methodology are provided in appendix I.


                   Becoming a Medicare-certified HHA is relatively easy—probably too easy,
Results in Brief   given the large number of problem agencies identified in various studies
                   over the past few years. If HHA owners have not been previously barred
                   from Medicare, they can obtain certification without having any health
                   care experience. Although such entrepreneurs can hire qualified health
                   care professionals, Medicare’s initial certification survey is so limited that
                   it does not provide a sound basis for judging an HHA’s ability to provide
                   quality care.




                   1
                    Medicare Home Health Agencies: Certification Process Is Ineffective in Excluding Problem Agencies
                   (GAO/T-HEHS-97-180, July 28, 1997).
                   2
                    ORT initially was a 2-year multiagency effort that targeted fraud and abuse in three areas of
                   Medicare—HHAs, SNFs, and durable medical equipment suppliers. This effort was conducted in the
                   five states (California, Florida, Illinois, New York, and Texas) that represented about 40 percent of all
                   Medicare and Medicaid beneficiaries. In May 1997, the HHS Secretary announced that the ORT effort
                   would continue for another 2 years and include projects in 12 additional states.



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             Although certified HHAs must be periodically recertified, serious
             deficiencies in the process allow problems to go undetected. HCFA
             recertifies HHAs by screening them against a subset of the conditions of
             participation, but when surveyors assessed 44 targeted HHAs against all
             applicable conditions of participation, almost half had problems serious
             enough to warrant decertification. Also, many HHAs operate branch offices,
             but these offices are not subject to the same oversight afforded the parent
             offices. HHAs are resurveyed every 12 to 36 months, depending on a variety
             of factors, but rapid growth and high utilization rates, which may indicate
             potential problem HHAs, are not included among those factors.

             Once certified, HHAs have little reason to fear that they will suffer serious
             consequences from failing to comply with Medicare’s conditions of
             participation and associated standards. Few problem HHAs are terminated
             from the program: Instead, they are provided repeated opportunities to
             correct their deficiencies, even if the same deficiencies recur from one
             survey to the next. Moreover, HCFA has not implemented a range of
             penalties to sanction problem HHAs, even though the Congress provided it
             the authority to do so over 10 years ago.


             Medicare, the nation’s largest health care payer, provides insurance
Background   coverage to more than 38 million elderly and disabled Americans. The
             program provides protection under two parts. Part A, the hospital
             insurance program, covers inpatient hospital care, posthospital care in
             skilled nursing homes, hospice care, and care in patients’ homes. Part B,
             the supplementary medical insurance program, primarily covers physician
             services but also covers home health care for beneficiaries not covered
             under part A. In 1996, Medicare paid approximately $17.7 billion for home
             health services under part A and $300 million under part B. HCFA uses six
             contractors (usually insurance companies) to process and pay home
             health claims.

             At the inception of the Medicare program, the home health benefit under
             part A provided limited posthospital care—up to 100 visits for 1 year,
             following a hospitalization of at least 3 days, and for the same illness that
             required the hospitalization. Similar requirements applied to SNFs. Part B
             had no prior hospitalization requirement and covered up to 100 visits per
             year that were not covered by part A. However, legislative and regulatory
             changes in the 1980s (1) dissolved the direct link to prior hospitalization
             under part A; (2) abolished limitations on the number of covered visits;
             and (3) in effect, expanded the home health care benefit to include



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long-term home care for the chronically ill. The Balanced Budget Act of
1997 (P.L. 105-33) defined the conditions under which part A or part B will
pay for home health care.3

To provide home health services to Medicare beneficiaries, an HHA must be
certified by HCFA and assigned a provider number for billing purposes. In
recent years, about 800 to 900 HHAs per year have been initially certified to
serve Medicare beneficiaries, and the demand for initial certification
continues. HHAs may be freestanding or hospital based, for-profit or
not-for-profit, public or private. Some are associated with regional or
national health care provider organizations. A growing number operate
branch offices as a way of expanding their operations. As defined by HCFA,
branch offices provide services within the geographic area served by the
parent office and share administration, supervision, and services with the
parent office.

Home health services covered by Medicare include part-time or
intermittent skilled nursing and home health aide services, physical and
occupational therapy, speech language pathology services, medical social
services, and the provision of certain medical supplies and equipment.
With the exception of providing medical supplies and equipment, no
copayments or deductibles are associated with these services. To qualify
for services, beneficiaries must be confined to their homes; have a plan of
care signed by a physician; and need intermittent skilled nursing care,
physical therapy, or speech language pathology services.

HCFA contracts with state health departments to survey HHAs and
determine if they comply with Medicare’s conditions of participation.4
There are 12 conditions of participation covering such topics as patient
rights, acceptance of patients and plans of care, skilled nursing services,
and clinical records. Most conditions are subdivided into more detailed


3
 Beginning in 1998, for individuals covered by both parts A and B of Medicare, part A will cover up to
100 home health care visits a beneficiary receives following a minimum 3-day hospital stay, with part B
paying for any other visits, including those without an associated hospitalization. For individuals
without part B coverage, all home health care visits will be covered under part A, and no prior
hospitalization requirement will apply.
4
 Alternatively, HHAs may elect to be surveyed and accredited by either the Joint Commission on the
Accreditation of Healthcare Organizations (JCAHO) or the Community Health Accreditation Program
(CHAP). A small number of HHAs that are surveyed according to HCFA’s prescribed survey frequency
by either of these accrediting bodies and that pass their surveys are “deemed” to meet Medicare’s
conditions of participation. JCAHO conducts more deeming surveys than CHAP. We previously
reviewed HCFA’s evaluation of these two accrediting bodies’ ability to ensure that HHAs adhere to
Medicare’s conditions. See Home Health Care: HCFA Properly Evaluated JCAHO’s Ability to Survey
Home Health Agencies (GAO/HRD-93-33, Oct. 26, 1992) and Home Health Care: HCFA Evaluation of
Community Health Accreditation Program Inadequate (GAO/HRD-92-93, Apr. 20, 1992).



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                         standards and requirements. For example, the “skilled nursing services”
                         condition of participation is divided into two broad standards that cover
                         the duties of a registered nurse and the duties of a licensed practical nurse.
                         These standards, in turn, are further defined by 15 requirements: 8 for a
                         registered nurse, 5 for a licensed practical nurse, and 2 overall general
                         requirements. (See app. II for a complete list of conditions of
                         participation.) Surveyors assess whether an HHA is meeting the
                         requirements and, ultimately, whether the HHA is in compliance with the
                         “skilled nursing services” condition of participation. Noncompliance with
                         an overall condition is considered a “condition-level” deficiency, and all
                         other deficiencies are considered “standard-level” deficiencies.

                         HCFA proposed significant revisions to the conditions of participation in
                         March 1997. The proposed new conditions emphasize improving patient
                         outcomes and establishing performance improvement programs within
                         HHAs. HCFA is now assessing comments received on its proposal.


                         During an initial HHA survey, the surveyor conducts a “standard survey” to
                         assess the HHA’s capacity to deliver quality care. Once an HHA passes its
                         initial survey and meets certain other requirements, HCFA certifies it as a
                         Medicare provider and issues it a provider number for billing purposes.
                         The HHA is then supposed to be recertified every 12 to 36 months following
                         the same survey process, with the exact frequency dependent upon factors
                         such as whether HHA ownership changed and the results of prior surveys.
                         But complaints about HHA services may trigger an earlier survey.

                         Certified HHAs can lose their certification if they are out of compliance
                         with one or more conditions; for example, an HHA providing substandard
                         skilled nursing care that threatens patient health and safety can be
                         terminated. If the deficiency jeopardizes patient health and safety and is
                         considered immediate and serious, the HHA is placed on an accelerated
                         termination timetable; otherwise, HCFA follows a 90-day termination
                         procedure. HHAs can avoid termination by implementing corrective actions
                         that bring them back into compliance with Medicare’s conditions of
                         participation. An HHA can continue to participate in Medicare even if
                         multiple standards are unmet, provided it has prepared an acceptable plan
                         of correction.


                         Medicare’s initial survey and certification process was not designed to
HHAs Easily Obtain       screen out potentially fraudulent or abusive billers, but rather to assess
Medicare Certification   whether an HHA is capable of delivering quality home health services.



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                         Therefore, it is not surprising that unscrupulous HHAs obtain certification.
                         But although the certification process was intended to screen out HHAs
                         that are unlikely to deliver quality care, it does not adequately do so. HHAs
                         do not need health care experience to be certified by Medicare. In
                         addition, the certification process covers fewer than half of Medicare’s
                         conditions of participation, is carried out too soon after an HHA has begun
                         providing services, and does not involve a complete review of HHA
                         operations. The overall result is that practically anyone who meets state or
                         local requirements for starting an HHA is virtually guaranteed Medicare
                         certification—a circumstance that probably contributes to Medicare fraud
                         and abuse. Moreover, although Medicare requires HHAs seeking
                         certification to complete a form detailing ownership and management
                         information, HCFA has only recently begun verifying the accuracy of that
                         information. It is unclear if or how the proposed new conditions of
                         participation would affect the initial certification process and the
                         problems we identified with this process.


Few Requirements Exist   Practically anyone who meets state and local requirements for starting an
for HHAs Seeking         HHA can be almost certain of obtaining Medicare certification. It is rare for

Medicare Certification   an HHA to not meet Medicare’s three fundamental certification
                         requirements: (1) being financially solvent; (2) complying with title VI of
                         the Civil Rights Act of 1964, which prohibits discrimination; and
                         (3) meeting Medicare’s conditions of participation. HHAs self-certify their
                         solvency, agree to comply with the law, and undergo an initial certification
                         survey that few fail. On September 15, 1997, the HHS Secretary announced
                         a moratorium on the entry of any new HHAs into Medicare while
                         regulations are written to address fraud in the home health industry.
                         Among the actions announced by the Secretary, HCFA will require HHAs to
                         demonstrate experience and expertise in home care by serving a minimum
                         number of patients before seeking Medicare certification. Before
                         September 1977, Medicare was certifying about 100 new HHAs each month.

                         HHAs  face few other obstacles to becoming certified. For example,
                         Medicare law does not require HHA owners to have health care experience.
                         We identified one owner whose most recent work experience was driving
                         a taxicab, another who owned and operated a pawn shop in addition to his
                         HHA, and a third who was a realtor specializing in ranch sales. None had
                         experience in the health care field. Further, until passage of the Balanced
                         Budget Act of 1997, a criminal background was not a deterrent to HHA
                         certification unless that criminal activity was related to Medicare, other
                         federal health programs, or illicit drugs. The law now allows HHS to refuse



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                          Medicare participation to HHA owners if they have a felony conviction
                          under federal or state law that is considered detrimental to the best
                          interests of the program or its beneficiaries.

                          Regarding service delivery, Medicare law requires only that HHAs provide
                          skilled nursing services plus one other covered service and that HHAs
                          deliver one of their covered services exclusively by their own staff. Except
                          for the one covered service that HHAs must provide directly, HHAs may
                          decide how to deliver their services—either directly or by another
                          individual or entity under contract with them. Such contractors do not
                          have to be Medicare certified; the certified HHA is responsible for
                          supervising their work. The one service delivered directly does not have to
                          be skilled nursing care, physical therapy, or speech language pathology
                          services—one of which individuals must need in order to qualify for the
                          home health benefit. In 1996, for example, Medicare certified a
                          Massachusetts HHA that delivered medical social services directly with one
                          social worker but relied upon 12 registered nurses from another entity to
                          deliver all of its skilled nursing services.

                          While contracting for services can give HHAs certain advantages, such as
                          the flexibility to manage staffing as patient populations fluctuate, it can
                          also lead to problems. For example, HHAs that rely heavily on contractors
                          may not exercise full control over the care they provide, and excessive
                          contracting may be an indication the HHA is exceeding its capacity to
                          effectively care for its patients. Further, heavy use of contractors may
                          indicate that the HHA is a “shell”—that is, little more than a fax machine
                          and a nurse used to bill Medicare for services. HCFA regional office
                          officials, for example, told us that HHAs that rely extensively on contractors
                          for skilled nursing services often cannot provide a list of patients with
                          their diagnoses or their clinical records because the HHAs have little
                          contact with the contract nurses. HCFA recognizes these problems and has
                          proposed under its new conditions of participation that HHAs deliver at
                          least half of their skilled services directly.


Initial Surveys Provide   Medicare’s initial certification process does not provide a sound basis for
Little Assurance That     judging whether an HHA does or will provide quality care in accordance
HHAs Are Capable of       with Medicare’s conditions of participation. Initial surveys often cover
                          fewer than half of Medicare’s conditions of participation, occur too soon
Furnishing Quality Care   after an HHA has begun providing services, and do not involve a complete
                          review of an HHA’s operations. As a result, state surveyors and HCFA do not
                          have sufficient, adequate information to verify that the HHA is capable of



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furnishing quality care for all its services or is in compliance with all of the
conditions of participation.

During the initial certification process, surveyors conduct a standard
survey that is required by statute to assess the quality of care and scope of
services the HHA provides, as measured by indicators of medical, nursing,
and rehabilitative care. The standard survey addresses the HHA’s
compliance with 5 of the 12 conditions of participation—and with one
standard associated with a sixth condition—that HCFA believes best
evaluate patient care. During the initial survey, according to HCFA officials,
reviewing HHA compliance with all of the conditions is often impractical
because some of them measure HHA activities over a period of time. For
example, the “group of professional personnel” condition calls for an
advisory panel to meet frequently and participate in evaluating the HHA’s
program; at the time of an HHA’s initial survey, the panel may not yet have
met. However, HCFA does not require HHAs to demonstrate compliance with
all conditions of participation at any point following their initial
certification, unless the surveyors find at least one condition-level
deficiency.5

Medicare sets no minimum standards for how long HHAs must be
operational before being surveyed, and these surveys typically occur soon
after HHAs begin providing services. As a result, surveyors have limited
information with which to judge the quality of care provided by HHAs. For
example, HCFA certified a Massachusetts HHA that had 1 month’s
operational experience at the time of its initial survey, and a Texas HHA
had been delivering care for 7 weeks when it was initially surveyed.
Because of the short time period between their opening and their initial
certification survey, many HHAs have treated few patients. California,
Massachusetts, and Texas surveyors told us that it is not uncommon for
HHAs to be caring for just one patient at the time of their initial survey.
Several HCFA regional offices recently issued guidance to their state survey
agencies suggesting that HHAs should have cared for at least 10 patients
before the initial survey. Such a criterion is not required at the national
level. HCFA central office officials said that imposing such a requirement in
rural states would create an access problem for some beneficiaries if their
HHA cared for only a few patients during the year.


We also found that, at the time of their initial survey, HHAs may not have
delivered all the services they will become certified to provide. For

5
 If they find one or more condition-level deficiencies, surveyors are required to conduct an extended
survey and review compliance with all conditions of participation.



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                                   example, an HHA certified to provide physical therapy services may not
                                   have cared for a patient that needed this service at the time of its initial
                                   certification. Further, surveyors do not always conduct home visits to
                                   patients receiving care from HHAs, although such visits are recognized by
                                   HCFA and state surveyors as the best indicator of an HHA’s performance.
                                   Surveyors told us that they prefer to conduct home visits when HHA staff
                                   are delivering services, but patients may not always be scheduled to
                                   receive care when the surveyors are on site at the HHA. Also, the patient
                                   may refuse a visit by the surveyor.

Limitations of Certification       The relative ease with which HHAs become certified has likely resulted in
Process Can Lead to Quality        certifying some HHAs that fail to provide high quality care and that abuse or
Problems and Fraudulent            defraud Medicare. For example:
Practices
                               •   An individual with no experience in health care started her Texas HHA in
                                   the pantry of her husband’s restaurant. Within 4 months of the HHA’s
                                   certification, state surveyors started receiving complaints that the HHA had
                                   been (1) enrolling patients who were either ineligible for the Medicare
                                   home health benefit or who had been referred for care without a
                                   physician’s order and (2) hiring home health aides on the condition that
                                   they first recruit a patient. Approximately 10 months after initial
                                   certification, state surveyors substantiated the complaints and also found
                                   that the HHA was not complying with four conditions of participation and
                                   multiple standards, including four standards that the HHA had been cited as
                                   not meeting during its initial survey. The surveyors also identified 13 cases
                                   in which they suspected the HHA provided unnecessary services or served
                                   ineligible beneficiaries; the surveyors referred these cases to HCFA’s claims
                                   processing contractor. One month later, the surveyors conducted a
                                   follow-up survey and found that the HHA had implemented corrective
                                   actions, as it had following its initial survey. No further surveys had been
                                   conducted at this HHA at the time of our review.
                               •   Another individual with no home health care experience started a
                                   California HHA, which was Medicare certified in 1992. Within 1 year of
                                   certification, state surveyors and HCFA’s contractor received numerous
                                   complaints alleging that the HHA had served patients ineligible for the
                                   Medicare benefit, falsified medical records, falsified the credentials of the
                                   director of nursing, and used staff inappropriately. A recertification survey
                                   about 15 months after initial certification found that the HHA was not
                                   complying with multiple conditions of participation and had endangered
                                   patient health and safety. By September 1993, after Medicare had paid the
                                   HHA over $6 million, the HHA had closed. The owner, who was a former




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                           drug felon, and an associate later pleaded guilty to defrauding Medicare of
                           over $2.5 million.

                           HCFA  regional office and state survey agency officials recognize that the
                           initial certification process provides little assurance that an HHA can and
                           will provide quality care to its patients in accordance with Medicare’s
                           conditions of participation. They believe that newly certified HHAs should
                           be resurveyed after several months of actual operation, when they have
                           treated a number of beneficiaries and demonstrated the quality of their
                           care. They also said that the HHAs should be assessed against all of
                           Medicare’s conditions of participation at this time, thus providing
                           assurance that an HHA is in total compliance with Medicare’s participation
                           requirements. HCFA central office officials told us that, while they have the
                           statutory authority to assess new HHAs against all of the conditions of
                           participation at any time and that it would be desirable to resurvey an HHA
                           several months after initial certification, these actions would require
                           additional funding for state survey agencies, which is currently
                           unavailable.


New Enrollment Process     HCFA  recently established an enrollment process for different types of
Requires Verification of   health care organizations, including HHAs, that are seeking initial entry into
HHA Information            the Medicare program or whose ownership has changed. Starting in
                           mid-1997, those owners of an HHA with a 5-percent or greater financial
                           interest in the HHA began to be required to supply HCFA with information,
                           such as their names and whether they had ever been excluded from
                           participating in Medicare, before an initial certification survey could be
                           carried out. The Medicare claims-processing contractors are responsible
                           for verifying this information within 21 days of receipt; in particular, they
                           verify that (1) the owners, managing employees, and subcontractors have
                           not been sanctioned or otherwise excluded from participating in the
                           program; (2) the HHA, if applicable, is appropriately licensed by the state;6
                           and (3) on the basis of a check with the current or prior Medicare
                           contractor that dealt with these individuals, there are no indications, or
                           proof, of fraud or abuse committed by the owners or managing employees.

                           The Balanced Budget Act of 1997 strengthened the HHA enrollment process
                           further by requiring HHA owners to supply HCFA with their Social Security
                           numbers; before this legislation, HCFA asked HHA owners for this
                           information but could not require it. Having owners’ Social Security
                           numbers, Medicare contractors should be better able to use various

                           6
                            As of 1996, nine states had no requirements for licensing HHAs.



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                            databases to determine if an owner has previously been sanctioned by, or
                            barred from, Medicare or other federal health programs.

                            If the enrollment process does not identify any problems, the Medicare
                            contractor notifies the state survey agency so that it can conduct an initial
                            certification survey of the HHA.


                            Medicare’s recertification process does not ensure that only those HHAs
Medicare’s                  that provide quality care throughout their operations and comply with all
Recertification             of Medicare’s conditions of participation retain certification. The process
Process Contains            does not require HHAs to periodically demonstrate compliance with all
                            conditions of participation, nor does it require a complete assessment of
Serious Weaknesses          an HHA’s branch operations. Thus, shortcomings with the recertification
                            process may cause quality of care issues to go undetected, to the potential
                            harm of beneficiaries.

                            Rapidly growing HHAs are surveyed as frequently as other HHAs, even
                            though rapid growth is an indicator of compliance deficiencies with
                            Medicare’s participation requirements. Also, most state survey agencies do
                            not routinely receive information from HCFA contractors, such as average
                            number of services per patient provided by an HHA and its average
                            Medicare payments per patient, that would be useful to them when
                            surveying HHAs; recent ORT studies have demonstrated that such
                            information sharing would be advantageous to Medicare.


HHAs Are Not Assessed       HCFA recertifies most HHAs without requiring them to demonstrate
Against All Conditions of   compliance with all the conditions of participation. As in the initial survey
Participation               process, state surveyors conduct a standard survey and assess HHAs
                            against 5 of the 12 conditions plus one standard associated with a sixth
                            condition; if they find an HHA out of compliance with one or more of these
                            conditions, they must expand the survey to check an HHA’s compliance
                            with all of the remaining conditions. Each year, on average, only about
                            3 percent of all certified HHAs are cited for having one or more conditions
                            out of compliance. Therefore, many HHAs function for years without ever
                            being assessed for compliance with all of Medicare’s conditions of
                            participation. As a result, neither HCFA nor beneficiaries know whether
                            HHAs are complying with the conditions not included in a standard survey.


                            HCFA believes that the standard survey effectively evaluates an HHA’s
                            patient care and its compliance with Medicare’s conditions of



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    participation. Evaluating HHAs against all of the conditions on each
    recertification survey would take additional resources that are not
    available, according to HCFA officials. However, legislation passed in 1996
    provides HCFA with increased flexibility, given existing resources, to
    periodically evaluate HHAs against all conditions of participation. This
    legislation increased the allowed intervals between recertification surveys
    to up to 36 months, from the previous requirement of approximately every
    12 months. Because fewer existing HHAs have to be recertified each year,
    the resources needed to assess some against all of the conditions of
    participation might become available.

    When selected HHAs were assessed against nearly all of Medicare’s
    conditions of participation in a recent ORT study in California, surveyors
    identified significant quality-of-care problems that led to terminating many
    of the HHAs. During this ORT study, HCFA targeted 44 HHAs that provided
    unusually high numbers of services to their patients and received high
    levels of Medicare payments, compared with their peers. HCFA and state
    surveyors evaluated these HHAs against 11 of the 12 conditions of
    participation7 rather than the 5 conditions and one standard reviewed
    during a standard survey. Approximately 80 percent of the targeted HHAs,
    when first surveyed, were out of compliance with at least one of the
    conditions not covered in a standard survey, and 21 of these targeted HHAs
    either voluntarily withdrew from Medicare or were terminated by HCFA
    from the program. The following examples describe some of the problems
    identified in the California ORT that relate to conditions of participation not
    covered in a standard survey.

•   Surveyors found an HHA out of compliance with all of the conditions they
    surveyed and identified the following quality of care issues: (1) The HHA
    could not provide the surveyors with a list of active patients, did not know
    which patients would receive care on a particular day, and did not
    exercise control over the services provided by contractor staff; (2) HHA
    staff provided patients with medication that had not been ordered by a
    physician; and (3) the HHA failed to ensure that therapists were qualified
    and prepared progress notes. HCFA subsequently terminated the HHA’s
    Medicare certification.
•   Another HHA was found out of compliance with seven conditions, including
    four not covered in a standard survey. Quality-of-care problems identified
    by the state surveyors included the following: (1) The HHA failed to monitor
    or control laboratory services and ensure that they were provided as

    7
     The study did not check HHA compliance with the condition regarding HHA qualifications to furnish
    outpatient physical or speech pathology services because none of the targeted HHAs provided these
    services.



    Page 12                                       GAO/HEHS-98-29 Medicare Home Health Agencies
                                    B-277914




                                    ordered, (2) nurses did not provide care as ordered and failed to initiate
                                    necessary revisions to patients’ plans of care, and (3) the HHA failed to
                                    verify that therapists hired under contract were qualified to deliver
                                    therapy services. HCFA terminated the certification of this HHA.


Medicare’s Recertification          Since the mid-1980s, more and more HHAs have created branch offices at
Process Does Not Fully              increasingly greater distances from the parent office, with many HHAs
Cover HHA Branch Office             operating multiple branches. In Texas, for example, we identified 106 HHAs
                                    as of January 1997 with 3 or more branch offices, including 1 HHA that had
Operations                          25 branch offices. Figure 1 shows that there were nearly 5,500 branch
                                    offices in January 1997—over four times the number that existed in
                                    November 1993.


Figure 1: Growth in the Number of
HHA Branch Offices, November        Number of Branch Offices
1993-January 1997                                           5484
                                    5500

                                    5000

                                    4500

                                    4000

                                    3500

                                    3000

                                    2500

                                    2000

                                    1500      1247

                                    1000

                                     500

                                       0
                                              93



                                                               97
                                             19



                                                           19
                                             er



                                                          ry
                                           mb




                                                        a
                                                     nu
                                       ve



                                                     Ja
                                      No




                                    Source: HCFA’s OSCAR.




                                    Page 13                            GAO/HEHS-98-29 Medicare Home Health Agencies
B-277914




HCFA considers branch offices integral parts of an HHA and, therefore, does
not require them to be surveyed and certified. Without such an
investigation, however, HCFA has no way of knowing whether a new site
actually meets Medicare’s definition of a branch office or should more
appropriately be classified as an independent HHA, which must be surveyed
and certified. As a result, HHAs can expand their operations by creating
new branch offices and avoid the scrutiny of the survey and certification
process. Further, HHAs may open new branches before demonstrating their
own capability for providing quality care. For example, a Massachusetts
HHA planned to open three branch offices in different parts of the state
immediately following its initial certification, which was based on care
provided to two patients.

Significantly, Medicare does not require surveyors to conduct home visits
with patients served by any of the branch offices at the time of an HHA’s
recertification. This means that quality-of-care issues within an HHA’s
overall operations may be missed, especially if the branch offices care for
a significant percentage of the HHA’s patients. For example, as of
October 1996, one Texas HHA cared for 49 patients at its parent office and
160 patients at a total of 10 branch offices; two of the branches each cared
for more patients than the parent office. While HCFA’s regulations
recognize that surveyors should visit patients served by a branch office
when recertifying an HHA, they do not actually require it or establish
criteria for defining which branches and their patients should be included
in the survey. As a practical matter, surveyors told us that they sometimes
do not have time to conduct home visits with branch office patients and
still finish the survey within their allotted time and resources.

According to HCFA officials, visiting patients treated by some or all HHA
branch offices is a resource issue and conducting home visits with patients
treated by each branch office would be impractical when recertifying HHAs.
However, now that the time frame for recertification has been relaxed,
HCFA should have greater flexibility to have surveyors conduct more home
visits with branch office patients. Moreover, developing targeting criteria
for surveyors to follow in selecting which branch offices or patients to
visit would allow a more efficient use of HCFA’s survey and certification
budget.

By not surveying branch operations, significant problems can go
undetected. This became evident when branch offices were surveyed
because the HHAs wanted to convert them into independent HHAs.
Examples follow.



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                              B-277914




                          •   In California, surveyors found that one branch of an HHA cared for 581
                              patients over the 12 months ending September 1996—more than the
                              average number of patients cared for by an entire HHA in the state during
                              that time. The branch was not complying with one condition of
                              participation, and the surveyors recommended the branch office be denied
                              certification as an independent HHA. Among its problems was the fact that
                              the branch office had no system in place to ensure that its contractor staff
                              had the appropriate qualifications and licenses.
                          •   Similarly, a branch office of a Massachusetts HHA had cared for 69 patients
                              since the HHA’s last survey. The branch was denied initial certification as
                              an independent HHA because it failed to meet nine standards associated
                              with several conditions of participation. For example, the surveyors found
                              that the branch office, in 10 of 12 cases examined, did not follow the plan
                              of care and provide services as frequently as ordered by a physician. At the
                              time of our review, the HHA had not yet submitted its correction plan, and
                              the branch office had not been certified as an independent HHA.

                              We also found that it is common for HHAs to have branch offices located
                              hundreds of miles from the parent office, which may result in branch
                              office staff receiving less direct supervision from their parent office than is
                              required by Medicare. For example, one Texas HHA has branch offices
                              located over 300 miles from the parent office. A California HHA located
                              near Sacramento operates four branch offices in other parts of the state as
                              far as 200 miles away. HCFA does not define how far a branch office can be
                              located from the parent office because, according to HCFA officials, a fair
                              definition that applies on a national basis would be difficult to develop
                              because of variations in geography and population throughout the country.
                              However, some states have set limits. For example, one state requires that
                              a branch office be located no more than 100 miles from its parent office,
                              while another restricts a branch to being no more than 1 hour’s drive from
                              the parent office. In 1996, an administrative law judge addressed the issue
                              in a California case about whether an entity should be designated as a
                              branch or an independent HHA. The judge ruled that parent offices must be
                              capable of sharing required functions on a daily basis with their branches
                              and that a branch office located approximately 50 miles from the parent
                              office, which could, in heavy traffic, be up to 2-1/2 hours’ driving time
                              away, did not meet this criterion.


HCFA’s Survey Frequency       Under HCFA’s recertification criteria, HHAs are to be resurveyed every 12 to
Criteria Need to Be           36 months, depending upon such factors as how long they have been
Expanded                      certified, results of prior surveys, and changes in ownership. Excluded



                              Page 15                             GAO/HEHS-98-29 Medicare Home Health Agencies
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from consideration are factors such as whether an HHA is quickly
increasing its patient population, receiving large increases in Medicare
payments, or experiencing high utilization rates—factors that can affect an
HHA’s compliance with Medicare’s conditions of participation.


Our work in California and Texas, in fact, suggests that HHAs that have
grown rapidly often have difficulty complying with Medicare’s
participation requirements. Nearly one-fourth of the HHAs initially certified
in 1993 in California and Texas received Medicare payments exceeding
$1 million in 1994—their first full year of Medicare certification. By their
second year of operation, these HHAs averaged about $3 million in
Medicare payments, and the average number of patients they treated more
than tripled between 1993 and 1995. Accompanying that growth, however,
was noncompliance with the conditions of participation. Forty percent of
the high-growth HHAs in California did not meet one or more conditions of
participation in their latest survey—almost double the percentage of the
other HHAs certified that same year. In Texas, about 11 percent of the
high-growth HHAs failed to comply with one or more conditions in their
latest survey, compared with about 6 percent of the other HHAs certified in
1993.

Without input from Medicare contractors, state surveyors must generally
wait until they survey the HHAs to obtain information about the number of
patients HHAs have and how much they are receiving in Medicare
payments. In 1989, we recommended that HCFA establish a procedure for
its contractors to use in providing state surveyors with information that
could be useful in their assessments of HHA compliance with the conditions
of participation.8 Until the advent in 1995 of ORT activities, this
information, which would help surveyors better target their efforts toward
problem HHAs, had not been routinely shared by the contractors.

The HHS Office of the Inspector General (OIG) recently reported that HHAs
that have abused or defrauded Medicare or misappropriated Medicare
funds tend to exceed national and state averages for the number of visits
and reimbursements per patient.9 We found that HHAs that exceed such
state averages are also likely to experience problems complying with
Medicare’s conditions of participation. In California, HCFA targeted 44 HHAs
for inclusion in its ORT project, largely on the basis of information supplied
by the two contractors processing home health claims for HHAs in the

8
 Medicare: Assuring the Quality of Home Health Services (GAO/HRD-90-7, Oct. 10, 1989).
9
 HHS, OIG, Home Health: Problem Providers and Their Impact on Medicare
(OEI-09-96-00110) (Washington, D.C.: HHS, July 1997).



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                          B-277914




                          state. Specifically, the contractors developed a rank-order list of HHAs that
                          had the highest average number of visits per patient and Medicare
                          payments per patient. In 1995, California HHAs averaged 45 visits per
                          patient and received approximately $4,000 per patient from Medicare. In
                          contrast, one of the 44 targeted HHAs provided an average of 174 visits per
                          patient that year and received an average Medicare payment per patient of
                          $15,700. Another targeted HHA provided an average of 148 visits per patient
                          and received an average of $12,700 per patient from Medicare. With this
                          targeted approach, surveyors found most of the 44 targeted HHAs out of
                          compliance with multiple conditions of participation, and almost half are
                          no longer in the program. Had the HHAs in the following examples not been
                          targeted for the ORT survey, they would likely have continued providing
                          substandard care for as long as 3 years before they were resurveyed under
                          HCFA’s survey frequency criteria.


                      •   A California HHA initially certified in 1988 more than doubled its Medicare
                          payments between 1993 and 1994 to $7 million while increasing the
                          number of patients it treated from 715 to 1,034. This HHA’s average
                          Medicare reimbursement per patient in 1995 was $7,613. When surveyed
                          under the ORT project, this HHA terminated its participation after being
                          found out of compliance with six conditions of participation.
                      •   Another California HHA, initially certified in 1990, approximately doubled
                          its Medicare payments to $6 million and increased its patient population
                          almost 20 percent from 1993 to 1994. Its average Medicare reimbursement
                          per patient in 1995 was $5,867. ORT surveyors initially found this HHA out of
                          compliance with three conditions, but after a third follow-up survey, it was
                          found to be in compliance with all conditions and therefore its
                          certification was not terminated.


                          Once an HHA has been certified as a Medicare provider, it is virtually
Once Certified, Few       assured of remaining in the program, with no penalty, even if found to be
HHAs Lose Their           repeatedly deficient in complying with Medicare’s conditions of
Certification             participation. An HHA’s participation in the Medicare program is not
                          terminated on the basis of volume of deficiencies or repeat deficiencies,
                          but rather on the basis of surveyors’ finding lack of compliance with at
                          least one condition of participation that the HHA does not subsequently
                          correct. Even when an HHA is cited for serious deficiencies and threatened
                          with termination, termination rarely occurs. As explained by HCFA central
                          office officials, once the HHA takes corrective action to remove any
                          immediate threat and is thereby moved from the accelerated termination




                          Page 17                            GAO/HEHS-98-29 Medicare Home Health Agencies
                         B-277914




                         track to the 90-day termination track, the HHA is virtually assured of
                         remaining in the Medicare program.

                         Until the advent of ORT, a project that in 1995 began targeting “high-risk”
                         HHAs in several states on the basis of suspected aberrant billing practices,
                         the likelihood that an HHA’s Medicare participation would be terminated by
                         HCFA was remote. In fiscal years 1994, 1995, and 1996, about 3 percent of
                         all certified HHAs nationwide discontinued Medicare participation—most
                         of them voluntarily, as a result of either mergers or closures. Terminations
                         initiated by HCFA as a result of uncorrected deficiencies identified during
                         the survey process were even more rare—ranging from about 0.1 percent
                         of HHAs nationwide in 1994 to 0.3 percent in 1996. In 1996, however, as a
                         result of its participation in ORT, California accounted for almost one-half
                         of the 32 HCFA-initiated terminations nationwide, with 8 of its 15
                         terminations that year stemming from the ORT project.


Corrective Actions Are   For HCFA to terminate an HHA’s Medicare certification, the surveyors must
Often Temporary          find that it did not comply with one or more of the conditions of
                         participation and remained out of compliance 90 days after a survey first
                         identified the noncompliance.10 If an HHA threatened with termination
                         takes corrective action and state surveyors verify through site visits that
                         this action has brought the HHA back into compliance, HCFA will cancel the
                         termination process. An HHA, however, can subvert the termination
                         process by taking corrective action for a short time, reverting to
                         noncompliance by the next survey, taking corrective action again, and so
                         on and still remain certified almost indefinitely—or at least until a patient
                         is seriously harmed.

                         While surveyors return to an HHA to verify that noncompliance with
                         conditions has been corrected, this is not always the case when the
                         noncompliance is limited to standards. For standard-level deficiencies,
                         just submitting an acceptable plan of correction may be enough. For
                         example, Illinois surveyors did not revisit 13 of 21 HHAs included in its ORT
                         project because they had submitted plans to correct their violations of
                         Medicare’s standards. Moreover, surveyors do not always review prior
                         survey reports to better focus on problematic areas before beginning a
                         new survey. In one state, for example, we found one group of surveyors
                         that always prepared for a survey by reviewing previous survey reports in
                         order to identify the types of deficiencies previously found and the extent

                         10
                          If the deficiency jeopardizes patient health and safety and is considered immediate and serious,
                         HCFA places the HHA on an accelerated termination timetable of 23 days.



                         Page 18                                        GAO/HEHS-98-29 Medicare Home Health Agencies
    B-277914




    of complaints received involving the HHA or its branch operations. In that
    same state, however, another group of surveyors intentionally did not
    review prior reports in order to avoid biasing the current survey.

    Even when surveyors visit HHAs and verify that corrective actions have
    been taken, HHAs may not sustain their corrective efforts over time. For
    example, after a Massachusetts HHA was initially certified in 1989,
    surveyors found it out of compliance with one or more conditions in 1991,
    1993, 1994, and 1996.

    To some extent, HCFA has relied on HHAs to police themselves between
    surveys, with questionable results. For example, one condition of
    participation requires a group of professional personnel to establish and
    annually review HHA policies and operations. This group is to meet
    frequently to advise the HHA on professional issues, program evaluation,
    and liaison with other health care providers. Another condition requires an
    overall evaluation of the HHA’s program at least once a year by the group of
    professional personnel, HHA staff, and consumers. This evaluation must
    assess the extent to which the HHA’s program is appropriate, adequate,
    effective, and efficient. Also, health professionals must review a sample of
    active and closed clinical records at least quarterly to determine whether
    established policies are followed. Neither of these conditions, however, is
    reviewed as part of the standard survey process. In fact, when HHAs were
    actually surveyed against these conditions in the California ORT project,
    most were found not in compliance with these two conditions.

    Given multiple opportunities to correct their deficiencies, it is not unusual
    for HHAs to have conditions and standards out of compliance from one
    survey to another and remain in the program, as the following examples
    illustrate:

•   A California HHA’s second recertification survey revealed that the HHA had
    deficiencies in meeting five standards and that three of the deficiencies
    had been identified in the previous year’s survey and supposedly
    corrected. Several months later, at this same HHA, an ORT survey team
    found eight conditions and numerous standards not met. When the HHA
    was resurveyed 5 months later, it was found to be back in compliance with
    all conditions, but it had yet to meet seven standards. Most of these
    deficiencies in meeting standards had been cited in the preceding surveys,
    and some had existed for a long time. For example, for the three most
    recent surveys, this HHA had been cited for not following physicians’ orders




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    B-277914




    in the written plan of care. The HHA was still certified at the time of our
    work.
•   On a Texas HHA’s first recertification survey, 1 year after initial
    certification, the state surveyor found four standards not met and referred
    several cases of possible fraud to the Medicare contractor. Within 10
    months of that survey, state surveyors resurveyed the HHA and found it was
    not in compliance with seven conditions of participation and the
    previously cited deficiencies in meeting standards had not been corrected.
    HCFA issued a termination letter, but within 2 months of the last survey, the
    HHA had corrected its deficiencies, and the termination process was halted.
    On a complaint investigation 6 months after the deficiencies had been
    corrected, the surveyors found the HHA was again out of compliance with
    three of the same seven conditions. On this most recent survey, the
    surveyors attributed the death of one patient directly to this HHA. At the
    time her attorney advised her to surrender her state license and Medicare
    certification, the owner/operator of this HHA had already hired a nurse
    consultant to bring the HHA back into compliance so that it could remain
    certified.
•   State surveyors found deficiencies in 12 standards when conducting a
    California HHA’s first recertification survey in 1993. At its next survey in
    1995, the surveyors found nine standards out of compliance, three of
    which had been identified in the preceding survey. In 1996, the ORT survey
    team found 10 conditions and multiple standards out of compliance,
    including most of the standards cited in previous surveys. The surveyor’s
    report documented a case in which the HHA accepted a patient who had a
    surgical wound on the knee that had not healed properly. Over a 5-week
    period, the HHA never reported the deteriorating condition of the patient’s
    wound to the attending physician. The patient was ultimately admitted to
    an acute-care hospital, where his leg was amputated. As a result of this
    latest survey, HCFA notified the HHA that it would be terminated. Before the
    effective date of termination, the HHA voluntarily surrendered its state
    license and Medicare provider number.

    Because of circumstances such as these, the threat of termination has
    little, if any, deterrent value, and problem HHAs seem to operate with
    impunity. The Congress, recognizing that HCFA should have more
    enforcement options than that of terminating an HHA, enacted provisions in
    the Omnibus Budget Reconciliation Act of 1987 to address this issue. The
    act authorized the Secretary of HHS to impose intermediate sanctions for a
    period not to exceed 6 months on those HHAs found deficient, in lieu of
    terminating their certification. If the HHA was still found deficient after that
    6-month period, it was to be terminated from the program. The act



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              B-277914




              required the Secretary of HHS to develop and implement, not later than
              April 1, 1989, a range of intermediate sanctions that was to include civil
              monetary penalties for each day of noncompliance, suspension of
              Medicare payments, and assumption of management of the HHA. The act
              also required that these regulations provide for progressively more severe
              sanctions for repeated or uncorrected deficiencies.

              HCFA proposed alternative sanctions for HHAs in August 1991 but never
              finalized its implementing regulations. HCFA officials told us that they
              wanted experience with the SNF intermediate sanctions, which became
              effective in July 1995, before implementing intermediate sanctions against
              HHAs.



              HHAs  provide important needed services to an increasing number of
Conclusions   beneficiaries where they most desire to receive their care—in their homes.
              However, HCFA grants certification to HHAs without adequate assurance
              that they provide quality care or meet Medicare’s conditions of
              participation. There are few barriers to certification once an HHA has been
              licensed by the state; and not all states license their HHAs. As a result, few
              HHAs are denied entry to the program. While most HHAs seek entry to
              Medicare with the intent of providing quality care, some are drawn to
              Medicare because of the relative ease with which they can become
              certified and partake in this lucrative, fast-growing industry.

              There has been little use of targeting to focus surveys on potential problem
              HHAs  or those more likely to have difficulty meeting Medicare’s conditions
              of participation. Targeting would lend itself to identifying branch offices
              for survey, particularly when those branches are serving more patients
              than the parent office. By considering such factors as growth, high costs
              per patient, and high numbers of visits per patient, specific HHAs could be
              targeted for more frequent or more comprehensive surveys. HCFA
              contractors develop information during their claims processing efforts that
              could be used to flag potential quality-of-care problems at HHAs, but this
              information is not routinely shared with state survey agencies.

              Once certified, there is little likelihood that an HHA will be terminated from
              the program for not meeting Medicare’s conditions of participation.
              Furthermore, because surveys do not always consider an HHA’s survey
              history, HHAs can have the same problems over and over again and still
              remain in the program, provided they take temporary corrective action.
              HCFA has not implemented intermediate sanctions and thus has no way to




              Page 21                             GAO/HEHS-98-29 Medicare Home Health Agencies
                         B-277914




                         penalize deficient HHAs other than threatening termination, a threat that
                         can be defused through corrective action plans.


                         We recommend that the Administrator of HCFA take the following actions:
Recommendations
                     •   Establish minimal requirements for how long an HHA must be operational
                         and how many patients it must have treated before it is eligible to be
                         surveyed and certified. HCFA could grant exceptions to such a national
                         policy for those situations in which HHAs treat few patients and access to
                         home care is an issue.
                     •   Require that HHAs be certified to provide only those services for which
                         they have been surveyed; the addition of a new service should prompt a
                         recertification survey.
                     •   Establish targeting criteria to select HHAs for survey against all conditions
                         of participation. These criteria should ensure that all HHAs are periodically
                         assessed against all conditions of participation.
                     •   Require that branch offices be periodically surveyed to ensure that they
                         meet Medicare’s definition of a branch office and provide quality care in
                         accordance with the conditions of participation. HCFA should develop
                         criteria, such as the number of patients served by a branch office relative
                         to the number served by the parent office, that would help surveyors
                         select which branch offices should be surveyed as part of an HHA’s
                         recertification.
                     •   Monitor state surveyors to ensure that they conduct home visits with
                         patients treated by HHA branch offices. Additionally, HCFA should develop
                         criteria defining how surveyors are to select branch office patients to visit.
                     •   Revise the survey frequency criteria to include consideration of other
                         factors that may indicate problem HHAs, such as rapid growth and high
                         utilization patterns. As part of this effort, HCFA should establish procedures
                         for contractors to routinely provide state survey agencies with information
                         that would help them assess compliance with the conditions of
                         participation.
                     •   Issue implementing regulations regarding the intermediate sanctions
                         authorized by the Congress that allow for penalizing and terminating HHAs
                         that are repeatedly out of compliance with Medicare’s conditions of
                         participation.


                         We provided the Administrator of HCFA a draft of this report for comment.
Agency Comments          With one exception, HCFA concurred with our recommendations but also
and Our Evaluation       noted that implementing some of the recommendations could require



                         Page 22                             GAO/HEHS-98-29 Medicare Home Health Agencies
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additional funding for certification surveys. We recognize that requiring
more surveys is a resource issue, but options do exist to provide additional
funding for such activities. Both the HHS OIG and HCFA have supported
charging fees for certification surveys. We also recently suggested that the
Congress may wish to consider enacting legislation directing HCFA to carry
out a pilot demonstration to address the issue of abusive billing practices
by HHAs.11 Under such a demonstration, once improper billing that
identified an HHA as an abusive biller had been detected, follow-up audit
work would be conducted, the cost of which could be assessed against the
HHA. Under a similar approach, HCFA could charge HHAs for all surveys,
except for those HHAs on the 36-month survey frequency cycle. Being
placed on such a survey cycle would mean that the HHA had been in
compliance with the Medicare conditions of participation for at least the
past 3 years.

HCFA  did not agree with our recommendation that the addition of a new
service by an HHA should prompt a recertification survey. HCFA believes
that if an HHA is in compliance with the conditions of participation, it is
responsible for ensuring that all services provided to the patients are
monitored and appropriately supervised. HCFA stated that our
recommendation would place an unnecessary burden on the survey
process and budget and could result in patients’ having to wait for needed
services.

We disagree, for several reasons. First, when state surveyors conduct
standard surveys of HHAs, they select a case-mix stratified sample of
records to review and patients to visit. Using this sample, the surveyors
assess compliance with conditions of participation for the services the
agency actually provides—not services the HHA may provide in the future.
Second, Medicare law already provides that a change in HHA ownership,
management, or administration is sufficient reason to conduct a new
survey to determine whether such changes have resulted in any decline in
the quality of care furnished by the HHA, thereby potentially affecting the
HHA’s compliance with Medicare’s conditions of participation. Similarly,
adding a new type of service should raise questions about whether the HHA
has the structure, resources, and qualified staff needed to deliver that
service. Finally, although the large number of HHAs already certified makes
it unlikely that a patient would have to wait for needed services, HCFA
could allow agencies in areas in which the needed services are not



11
 See Medicare: Need to Hold Home Health Agencies More Accountable for Inappropriate Billings
(GAO/HEHS-97-108, June 13, 1997).



Page 23                                     GAO/HEHS-98-29 Medicare Home Health Agencies
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otherwise available to provide new services until a recertification survey
could be arranged.

HCFA concurred with our recommendation that regulations on interim
sanctions be issued and stated that a final regulation was being developed.
HCFA has had the authority to establish interim sanctions for nearly 10
years, and it still has not indicated when it expects to finalize this
regulation.

HCFA   also made several technical comments, which we have addressed.
HCFA’s   comments are included in their entirety as appendix III.


As arranged with your office, unless you release its contents earlier, we
plan no further distribution of this letter for 30 days. At that time, we will
make copies available to other congressional committees and Members of
Congress with an interest in these matters, and the Secretary of Health and
Human Services.

This report was prepared by Robert Dee and Donald Hunter, under the
direction of William Reis, Assistant Director. Please call me at
(202) 512-7114 or Mr. Reis at (617) 565-7488 if you or your staffs have any
questions about this information.




William J. Scanlon
Director, Health Financing and
  Systems Issues




Page 24                             GAO/HEHS-98-29 Medicare Home Health Agencies
Page 25   GAO/HEHS-98-29 Medicare Home Health Agencies
Contents



Letter                                                                                            1


Appendix I                                                                                       28

Scope and
Methodology
Appendix II                                                                                      30

Conditions of
Participation,
Standards, and
Underlying
Requirements for
HHAs
Appendix III                                                                                     40

Comments From the
Health Care Financing
Administration
Related GAO Products                                                                             48


Figure                  Figure 1: Growth in the Number of HHA Branch Offices,                    13
                          November 1993-January 1997




                        Page 26                         GAO/HEHS-98-29 Medicare Home Health Agencies
Contents




Abbreviations

CHAP       Community Health Accreditation Program
HCFA       Health Care Financing Administration
HHA        home health agency
HHS        Department of Health and Human Services
JCAHO      Joint Commission on the Accreditation of Healthcare
                 Organizations
LPN        licensed practical nurse
OIG        Office of the Inspector General
ORT        Operation Restore Trust
OSCAR      On-line Survey, Certification and Reporting database
OT         occupational therapy
PT         physical therapy
RN         registered nurse
SNF        skilled nursing facility


Page 27                          GAO/HEHS-98-29 Medicare Home Health Agencies
Appendix I

Scope and Methodology


             In developing information for this report, we interviewed officials at the
             Health Care Financing Administration’s (HCFA) central office in Baltimore
             as well as at its regional offices in Boston, Chicago, Dallas, and San
             Francisco; the Department of Health and Human Services’ (HHS) Office of
             the Inspector General (OIG); five contractors that process and pay home
             health claims for HCFA: Blue Cross of California, the Associated Hospital
             Service of Maine, the Health Care Service Corporation, Palmetto
             Government Benefits Administrators, and IASD Health Services
             Corporation; state survey agencies in California, Illinois, Maine,
             Massachusetts, and Texas; and the National Association for Home Care,
             the California Association of Health Services at Home, and the Home and
             Hospice Association of California, which are home health agency (HHA)
             trade associations. We concentrated our work in California, Illinois, and
             Texas—three states that have been actively involved in conducting
             Operation Restore Trust (ORT) studies directly related to the HHA survey
             and certification process. Additionally, these states are among the 10
             states with the highest numbers of certified HHAs. We also performed
             limited work in Maine and Massachusetts—two states that use the
             traditional survey and certification process and were not part of the
             original ORT effort.

             To determine how HCFA controls the entry of HHAs into Medicare, we met
             with HCFA central office and regional officials to determine HCFA’s roles and
             responsibilities, reviewed legislation and pertinent regulations, reviewed
             and analyzed Medicare’s conditions of participation, interviewed state
             survey agency officials, determined the roles and responsibilities of HCFA’s
             contractors, interviewed HHS OIG officials, interviewed trade association
             representatives, reviewed related reports and the literature, and kept
             abreast of pending changes to the conditions of participation and provider
             enrollment processes.

             To determine how HCFA ensures that certified HHAs continue to comply
             with Medicare’s conditions of participation and provide quality care, we
             reviewed HCFA’s On-line Survey, Certification and Reporting (OSCAR)
             database to determine the extent to which HHAs (1) do not meet Medicare’s
             conditions of participation during surveys, (2) have repeated violations of
             Medicare’s conditions and associated standards over time, and (3) create
             branch offices.12 Through meetings with HCFA and state survey agency
             officials and a review of survey reports, we determined the type of
             problems that the survey and certification process identifies. Further, we

             12
              OSCAR contains such information about certified HHAs as names, addresses, provider numbers,
             survey results, and terminations.



             Page 28                                     GAO/HEHS-98-29 Medicare Home Health Agencies
Appendix I
Scope and Methodology




reviewed survey reports and other documents prepared for the ORT studies
in California, Illinois, and Texas and determined HCFA’s process for
targeting HHAs during these studies. We met with HCFA contractor officials
to discuss their involvement in the ORT studies and the processes they have
in place to identify HHAs suspected of fraud and abuse.

To examine HCFA’s process for decertifying HHAs, we analyzed HCFA
information related to the number of HHA terminations and the reasons for
them. We also met with a representative of the HHS Office of the General
Counsel to determine Medicare’s termination process and reviewed
Medicare’s termination regulations. We also discussed issues related to
this objective with trade association representatives and obtained related
reports.




Page 29                           GAO/HEHS-98-29 Medicare Home Health Agencies
Appendix II

Conditions of Participation, Standards, and
Underlying Requirements for HHAs


Conditions of participation       Standards                                         Underlying requirements
Patient rights                    Notice of rights                                  HHA provides patient written notice of rights.

                                                                                    HHA maintains documentation of compliance
                                                                                    with patient rights.
                                  Exercise of rights and respect for property and   Patient has right to exercise rights as a patient of
                                  person                                            HHA.

                                                                                    Patient has right to have property treated with
                                                                                    respect.

                                                                                    Patient has right to voice grievances regarding
                                                                                    treatment or care without reprisal.

                                                                                    HHA must investigate complaints regarding
                                                                                    treatment or care.
                                  Right to be informed and to participate in        Patient has right to be informed in advance
                                  planning care and treatment                       about care and changes in care.

                                                                                    Patient has right to participate in planning care.

                                                                                    HHA maintains policies and procedures
                                                                                    regarding advance directives.
                                  Confidentiality of medical records                Patient has right to confidentiality of clinical
                                                                                    records.

                                                                                    HHA must advise patient of record disclosure
                                                                                    policies and procedures.
                                  Patient liability for payment                     Patient has right to be advised of cost of care
                                                                                    before care is initiated.

                                                                                    HHA must inform patient orally and in writing of
                                                                                    who will pay for services.

                                                                                    Patient has right to be informed of changes in
                                                                                    the cost of care or in who pays for the care no
                                                                                    later than 30 days after the change.
                                  Home health hot line                              Patient has right to be advised of availability of
                                                                                    toll-free HHA hot line.
Compliance with federal, state,   Compliance with federal, state, and local laws    HHA and staff must comply with federal, state,
and local laws; disclosure and    and regulations                                   and local laws and regulations.
ownership information; and
accepted professional standards
and principles
                                  Disclosure of ownership and management            HHA must comply with disclosure of ownership
                                  information                                       and management information requirements.

                                                                                    HHA must disclose ownership and management
                                                                                    information for each survey and whenever
                                                                                    changes are made.
                                                                                                                              (continued)



                                             Page 30                                 GAO/HEHS-98-29 Medicare Home Health Agencies
                                        Appendix II
                                        Conditions of Participation, Standards, and
                                        Underlying Requirements for HHAs




Conditions of participation   Standards                                          Underlying requirements
                              Compliance with accepted professional              HHA and staff must comply with accepted
                              standards and principles                           professional standards and principles.
                              a
Organization, services, and                                                      Delegation of responsibility is clearly set forth in
administration                                                                   writing.

                                                                                 Administrative and supervisory functions are not
                                                                                 delegated to another HHA.

                                                                                 All services not provided directly are monitored
                                                                                 and controlled by the parent HHA.

                                                                                 Administrative records for each subunit are
                                                                                 maintained by the parent HHA.
                              Services furnished                                 HHA must provide skilled nursing services and
                                                                                 at least one other therapeutic service, one of
                                                                                 which the HHA must provide with its own staff.
                              Governing body                                     Governing body assumes full legal authority and
                                                                                 responsibility for the HHA.

                                                                                 Governing body appoints qualified administrator.

                                                                                 Governing body arranges for professional advice.

                                                                                 Governing body adopts and periodically reviews
                                                                                 written by-laws.

                                                                                 Governing body oversees management and
                                                                                 fiscal affairs of HHA.
                              Administrator                                      Administrator organizes and directs HHA
                                                                                 functions.

                                                                                 Administrator employs qualified personnel and
                                                                                 ensures adequate staff education and evaluation.

                                                                                 Administrator ensures accuracy of public
                                                                                 information materials and activities.

                                                                                 Administrator implements an effective budgeting
                                                                                 and accounting system.

                                                                                 Qualified person is authorized in writing to act in
                                                                                 absence of administrator.
                              Supervising physician or registered nurse (RN)     Services furnished are under the supervision of a
                                                                                 physician or RN.

                                                                                 Supervisor or alternate is available during
                                                                                 operating hours.

                                                                                 Supervisor participates in activities relevant to
                                                                                 furnished services.
                                                                                                                          (continued)




                                        Page 31                                   GAO/HEHS-98-29 Medicare Home Health Agencies
                                            Appendix II
                                            Conditions of Participation, Standards, and
                                            Underlying Requirements for HHAs




Conditions of participation       Standards                                          Underlying requirements
                                  Personnel policies                                 HHA has written personnel policies, and
                                                                                     personnel records include staff’s current
                                                                                     licenses and qualifications.
                                  Personnel under hourly or per-visit contracts      Hourly and per-visit personnel have written
                                                                                     contracts.
                                  Coordination of patient services                   Personnel providing services coordinate
                                                                                     effectively.

                                                                                     Coordination of patient services is documented
                                                                                     in the clinical records or minutes of case
                                                                                     conferences.

                                                                                     Written summary report for each patient is sent
                                                                                     to attending physician every 62 days.
                                  Services under arrangements                        Services for which the HHA contracts are subject
                                                                                     to a written contract.
                                  Instructional planning                             Annual operating budget and capital
                                                                                     expenditure plan are prepared.

                                                                                     Plan and budget are prepared under direction of
                                                                                     governing body.

                                                                                     Plan and budget are reviewed and updated at
                                                                                     least annually.
                                  Laboratory services                                If HHA provides laboratory testing or refers
                                                                                     specimens elsewhere, it must comply with the
                                                                                     requirements of the Clinical Laboratory
                                                                                     Improvement Amendments of 1988.
                                  a
Group of professional personnel                                                      Group includes physician, RN, and professionals
                                                                                     from other appropriate disciplines.

                                                                                     Group establishes and annually reviews HHA
                                                                                     policies.
                                  Advisory and evaluation function                   Group meets frequently to advise agency on
                                                                                     professional issues.

                                                                                     Meetings are documented by dated minutes.
                                  a
Acceptance of patients, plan of                                                      Patients are accepted on basis of reasonable
care, and medical supervision                                                        expectation that needs can be met at home.

                                                                                     Written plan of care is established and
                                                                                     periodically reviewed by physician.
                                                                                                                           (continued)




                                            Page 32                                   GAO/HEHS-98-29 Medicare Home Health Agencies
                                        Appendix II
                                        Conditions of Participation, Standards, and
                                        Underlying Requirements for HHAs




Conditions of participation   Standards                                          Underlying requirements
                              Plan of care                                       Plan of care covers all diagnoses, required
                                                                                 services, visits, and so on.

                                                                                 Physician is consulted to approve modifications
                                                                                 to plan.

                                                                                 Orders for therapy services specify procedures
                                                                                 and modalities to be used and their amount,
                                                                                 frequency, and duration.

                                                                                 Therapist and other personnel participate in
                                                                                 developing plan.
                              Periodic review of plan of care                    Plan is reviewed by attending physician and
                                                                                 HHA personnel as necessary, but at least every
                                                                                 62 days.

                                                                                 HHA staff promptly alert physician to changes
                                                                                 that suggest need to alter plan.
                              Conformance with physician’s orders                Drugs and treatment are administered only as
                                                                                 ordered by physician.

                                                                                 RN or therapist records and signs oral orders
                                                                                 and obtains physician countersignature.

                                                                                 Staff check all medicines to identify ineffective
                                                                                 drug therapy, adverse reactions, drug allergies,
                                                                                 and so on and report problems to physician.
                              a
Skilled nursing services                                                         Skilled nursing services are furnished by or
                                                                                 under supervision of an RN.

                                                                                 Skilled nursing services are furnished in
                                                                                 accordance with plan of care.
                                                                                                                       (continued)




                                        Page 33                                   GAO/HEHS-98-29 Medicare Home Health Agencies
                                        Appendix II
                                        Conditions of Participation, Standards, and
                                        Underlying Requirements for HHAs




Conditions of participation   Standards                                          Underlying requirements
                              Duties of the RN                                   RN makes initial evaluation visit.

                                                                                 RN regularly reevaluates patient nursing needs.

                                                                                 RN initiates plan of care and necessary revisions.

                                                                                 RN furnishes services requiring substantial or
                                                                                 specialized nursing care.

                                                                                 RN initiates appropriate preventive or
                                                                                 rehabilitative procedures.

                                                                                 RN prepares notes, coordinates with physician
                                                                                 and other staff, and informs physician and other
                                                                                 staff of changes.

                                                                                 RN counsels patient and family in meeting
                                                                                 nursing and related needs.

                                                                                 RN participates in in-service program and
                                                                                 supervises and teaches staff.
                              Duties of the licensed practical nurse (LPN)       LPN furnishes services in accordance with HHA
                                                                                 policy.

                                                                                 LPN prepares clinical and progress notes.

                                                                                 LPN assists physician and RN in performing
                                                                                 specialized procedures.

                                                                                 LPN prepares equipment and materials
                                                                                 observing aseptic techniques.

                                                                                 LPN assists patient in learning self-care
                                                                                 techniques.
                              a
Therapy services                                                                 Therapy services are given by a qualified
                                                                                 therapist, or qualified therapist assistant under
                                                                                 supervision of qualified therapist, in accordance
                                                                                 with the plan of care.

                                                                                 Therapist helps physician evaluate functional
                                                                                 level and helps develop plan of care.

                                                                                 Therapist prepares clinical and progress notes.

                                                                                 Therapist advises and consults with family and
                                                                                 other HHA personnel.

                                                                                 Therapist participates in in-service programs.
                                                                                                                          (continued)




                                        Page 34                                   GAO/HEHS-98-29 Medicare Home Health Agencies
                                        Appendix II
                                        Conditions of Participation, Standards, and
                                        Underlying Requirements for HHAs




Conditions of participation   Standards                                          Underlying requirements
                              Supervision of physical therapy (PT) assistant     Services provided by a PT or OT assistant must
                              and occupational therapy (OT) assistant            be supervised by a qualified PT or OT.

                                                                                 PT and OT assistants help prepare clinical notes
                                                                                 and progress reports.

                                                                                 PT and OT assistants participate in educating
                                                                                 patient and family and in in-service programs.
                              Supervision of speech therapy services             Speech therapy is furnished only by, or under
                                                                                 the supervision of, a speech pathologist or
                                                                                 audiologist.
                              a
Medical social services                                                          Services are provided by a qualified social
                                                                                 worker or social worker assistant.

                                                                                 Social worker participates in developing the plan
                                                                                 of care.

                                                                                 Social worker prepares clinical and progress
                                                                                 notes.

                                                                                 Social worker works with family.

                                                                                 Social worker uses appropriate community
                                                                                 resources.

                                                                                 Social worker participates in discharge planning
                                                                                 and in-service programs.

                                                                                 Social worker consults with other HHA personnel.
                              a
Home health aide services                                                        Home health aides are selected according to
                                                                                 personnel qualifications specified in regulations.
                                                                                                                        (continued)




                                        Page 35                                   GAO/HEHS-98-29 Medicare Home Health Agencies
                                        Appendix II
                                        Conditions of Participation, Standards, and
                                        Underlying Requirements for HHAs




Conditions of participation   Standards                                          Underlying requirements
                              Home health aide training                          Aides must have at least 75 hours of training in
                                                                                 specific subject areas; 16 hours must be
                                                                                 supervised practical training.

                                                                                 Aides must have at least 16 hours of classroom
                                                                                 training before beginning practical training.

                                                                                 Aides must have good communication skills;
                                                                                 ability to observe, report, and document care;
                                                                                 and ability to recognize emergency situations
                                                                                 and needs of patients.

                                                                                 Any organization may conduct training except an
                                                                                 HHA that, within the past 2 years, has not
                                                                                 complied with Medicare requirements, has been
                                                                                 penalized by Medicare, or has had Medicare
                                                                                 payments suspended.

                                                                                 The practical portion of training must be
                                                                                 supervised by, or carried out under the
                                                                                 supervision of, an RN with at least 2 years’
                                                                                 experience, 1 of which is in home health.

                                                                                 Other individuals may provide instruction under
                                                                                 the supervision of a qualified RN.

                                                                                 Aide training must be documented.
                              Competency evaluation and in-service training      Aides may furnish services only after
                                                                                 successfully completing a competency
                                                                                 evaluation program.

                                                                                 HHA is responsible for ensuring its aides meet
                                                                                 the competency evaluation requirements.

                                                                                 Competency evaluations must meet specific
                                                                                 requirements specified in the regulations.

                                                                                 HHA must complete a competency evaluation of
                                                                                 each aide at least every 12 months.

                                                                                 Aides must receive at least 12 hours of in-service
                                                                                 training each year.

                                                                                 Competency evaluations may be provided by
                                                                                 any organization except an HHA that, within the
                                                                                 past 2 years, has not complied with Medicare
                                                                                 requirements, has been penalized by Medicare,
                                                                                 or has had Medicare payments suspended.

                                                                                 Competency evaluation must be performed by
                                                                                 an RN, and in-services must be supervised by
                                                                                 an RN.

                                                                                                                        (continued)


                                        Page 36                                   GAO/HEHS-98-29 Medicare Home Health Agencies
                                       Appendix II
                                       Conditions of Participation, Standards, and
                                       Underlying Requirements for HHAs




Conditions of participation   Standards                                         Underlying requirements
                                                                                Performance in specified subject areas must be
                                                                                evaluated by observation; for others, evaluation
                                                                                may be by observation or oral or written
                                                                                examination.

                                                                                Aides may not continue to perform tasks
                                                                                evaluated as unsatisfactorily carried out.

                                                                                An aide has not passed the competency
                                                                                evaluation if performance in more than one
                                                                                required area is considered unsatisfactory.

                                                                                Competency evaluation must be documented.

                                                                                HHA may use only aides who meet competency
                                                                                requirements.
                              Assignment and duties of the home health aide     Aides are assigned to a specific patient by an
                                                                                RN.

                                                                                Written instructions for patient care are prepared
                                                                                by an RN or a therapist.

                                                                                Duties of an aide include performing simple
                                                                                procedures as an extension of therapy,
                                                                                providing personal care, assisting in exercise,
                                                                                carrying out household services, and assisting
                                                                                with self-administered medications.

                                                                                Aides report changes in patient care and needs.

                                                                                Aides complete appropriate records.
                              Supervision                                       Aides must be supervised.

                                                                                When only aide services are being provided, an
                                                                                RN must make a supervisory visit to patient’s
                                                                                home at least once every 60 days.

                                                                                Supervisory visit must occur when aide is
                                                                                furnishing care.

                                                                                When skilled nursing or therapy services are also
                                                                                being provided, an RN must make a supervisory
                                                                                visit to patient’s home at least every 2 weeks
                                                                                whether the aide is present or not.

                                                                                When therapy services are being
                                                                                provided—without aide or skilled nursing
                                                                                services—a skilled therapist may make the
                                                                                supervisory visits.

                              Personal care attendant—evaluation                Individuals hired only to provide personal care
                              requirements                                      services under Medicaid must be found
                                                                                competent by the state.
                                                                                                                       (continued)


                                       Page 37                                   GAO/HEHS-98-29 Medicare Home Health Agencies
                                             Appendix II
                                             Conditions of Participation, Standards, and
                                             Underlying Requirements for HHAs




Conditions of participation        Standards                                          Underlying requirements
                                   a
Qualifying to furnish outpatient                                                      HHA providing outpatient therapy services on its
physical therapy or speech                                                            own premises must meet all pertinent conditions
pathology services                                                                    for an HHA as well as additional specified health
                                                                                      and safety requirements.
                                   a
Clinical records                                                                      Clinical records containing past and current
                                                                                      findings must be maintained for each patient in
                                                                                      accordance with accepted professional
                                                                                      standards.
                                   Retention of records                               Clinical records must be retained for at least 5
                                                                                      years after the applicable cost report is filed with
                                                                                      the contractor.

                                                                                      A copy of the clinical record or abstract is sent
                                                                                      with patient when transferred to another health
                                                                                      facility.
                                   Protection of records                              Clinical records are safeguarded against loss or
                                                                                      unauthorized use.

                                                                                      Written procedures govern the use and removal
                                                                                      of records and conditions for release of
                                                                                      information.

                                                                                      Patient’s written consent is required for release
                                                                                      of information not authorized by law.
                                   a
Evaluation of the HHA’s program                                                       Written policies require an annual evaluation of
                                                                                      the HHA’s total program.

                                                                                      Evaluation consists of an overall policy and
                                                                                      administrative review and a clinical record
                                                                                      review.

                                                                                      Evaluation assesses the appropriateness,
                                                                                      adequacy, effectiveness, and efficiency of the
                                                                                      HHA’s program.

                                                                                      Results of the evaluation are reported to and
                                                                                      acted upon by those responsible for operating
                                                                                      the HHA.

                                                                                      Results of the evaluation are maintained
                                                                                      separately as administrative records.
                                   Policy and administrative review                   Evaluation includes a review of policies and
                                                                                      administrative practices of the HHA.

                                                                                      Mechanisms are established in writing to collect
                                                                                      data for the evaluation.
                                                                                                                              (continued)




                                             Page 38                                   GAO/HEHS-98-29 Medicare Home Health Agencies
                                        Appendix II
                                        Conditions of Participation, Standards, and
                                        Underlying Requirements for HHAs




Conditions of participation   Standards                                              Underlying requirements
                              Clinical record review                                 Appropriate health professionals must review a
                                                                                     sample of active and closed clinical records
                                                                                     quarterly to ensure policies are being followed.

                                                                                     Active clinical records must be reviewed every
                                                                                     62 days to assess adequacy of plan of care and
                                                                                     appropriateness of continuing care.

                                        a
                                          No standard was specified for these requirements.

                                        Source: HCFA.




                                        Page 39                                       GAO/HEHS-98-29 Medicare Home Health Agencies
Appendix III

Comments From the Health Care Financing
Administration




               Page 40    GAO/HEHS-98-29 Medicare Home Health Agencies
Appendix III
Comments From the Health Care Financing
Administration




Page 41                               GAO/HEHS-98-29 Medicare Home Health Agencies
Appendix III
Comments From the Health Care Financing
Administration




Page 42                               GAO/HEHS-98-29 Medicare Home Health Agencies
Appendix III
Comments From the Health Care Financing
Administration




Page 43                               GAO/HEHS-98-29 Medicare Home Health Agencies
               Appendix III
               Comments From the Health Care Financing
               Administration




Now on p. 4.




Now on p. 7.




               Page 44                               GAO/HEHS-98-29 Medicare Home Health Agencies
Page 45   GAO/HEHS-98-29 Medicare Home Health Agencies
Page 46   GAO/HEHS-98-29 Medicare Home Health Agencies
Page 47   GAO/HEHS-98-29 Medicare Home Health Agencies
Related GAO Products


              Medicare Home Health Agencies: Certification Process Is Ineffective in
              Excluding Problem Agencies (GAO/T-HEHS-97-180, July 28, 1997).

              Medicare: Home Health Utilization Expands While Program Controls
              Deteriorate (GAO/HEHS-96-16, Mar. 27, 1996).

              Medicare: Allegations Against ABC Home Health Care (GAO/OSI-95-17,
              July 19, 1995).

              Home Health Care: HCFA Properly Evaluated JCAHO’s Ability to Survey
              Home Health Agencies (GAO/HRD-93-33, Oct. 26, 1992).

              Home Health Care: HCFA Evaluation of Community Health Accreditation
              Program Inadequate (GAO/HRD-92-93, Apr. 20, 1992).

              Medicare: Increased Denials of Home Health Claims During 1986 and 1987
              (GAO/HRD-90-14BR, Jan. 24, 1990).

              Medicare: Assuring the Quality of Home Health Services (GAO/HRD-90-7,
              Oct. 10, 1989).

              Medicare: Need to Strengthen Home Health Care Payment Controls and
              Address Unmet Needs (GAO/HRD-87-9, Dec. 2, 1986).

              Savings Possible by Modifying Medicare’s Waiver of Liability Rules
              (GAO/HRD-83-38, Mar. 4, 1983).

              The Elderly Should Benefit From Expanded Home Health Care But
              Increasing These Services Will Not Insure Cost Reductions (GAO/IPE-83-1,
              Dec. 7, 1982).

              Medicare Home Health Services: A Difficult Program to Control
              (GAO/HRD-81-155, Sept. 25, 1981).

              Response to the Senate Permanent Subcommittee on Investigations’
              Queries on Abuses in the Home Health Care Industry (GAO/HRD-81-84,
              Apr. 24, 1981).

              Home Health Care Services—Tighter Fiscal Controls Needed
              (GAO/HRD-79-17, May 15, 1979).




(101576)      Page 48                           GAO/HEHS-98-29 Medicare Home Health Agencies
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