§484.55 Condition of participation: Comprehensive assessment of patients.

Interpretive Guidelines §484.55

A comprehensive assessment of the patient, in which patient needs are identified, is a crucial step in the establishment of a plan of care. In addition, a comprehensive assessment identifies patient progress toward desired outcomes or goals of the care plan.

The manner and degree of noncompliance identified in relation to the standard level tags for §484.55 may result in substantial noncompliance with this CoP, requiring citation at the condition level.

Interpretive Guidelines §484.55(a)(1)

For patients receiving only nursing services or both nursing and rehabilitation therapy services, a registered nurse must conduct the initial assessment visit. For patients receiving rehabilitation therapy services only, the initial assessment may be made by the applicable rehabilitation skilled professional rather than the registered nurse. See §484.55(a)(2).

The initial assessment bridges the gap between when the first patient encounter occurs and when a plan of care can be implemented. “Immediate care and support needs” are those items and services that will maintain the patient’s health and safety through this interim period, i.e., until the HHA can complete the comprehensive assessment and implement the plan of care. “Immediate care and support needs” may include medication, mobility aids for safety, skilled nursing treatments, and items to address fall risks and nutritional needs.

The clinical record must demonstrate that homebound status/eligibility for the Medicare home health benefit was determined and documented during the initial visit.

An HHA that is unable to complete the initial assessment within 48 hours of referral or the patient’s return home, shall not request a different start of care date from the ordering physician to ensure compliance with the regulation or to accommodate the convenience of the agency.

In instances where the patient requests a delay in the start of care date, the HHA would need to contact the physician to request a change in the start of care date and such change would need to be documented in the medical record.

Interpretive Guidelines §484.55(b)(1)

The start of care date is the first visit where the HHA provides hands on, direct care services or treatments to the patient. If an initial assessment is completed without any direct care services being provided by the HHA during the assessment visit, the date of that initial assessment visit would not be the start of care date. The comprehensive assessment must be completed within 5 calendar days of the first visit where the HHA provides hands on, direct care services/treatments to the patient.

Interpretive Guidelines §484.55(b)(2)

The requirements for conducting the initial assessment visit and the comprehensive assessment for home health services are based on sections 1814(a)(2)(c) and 1835(a)(2)(A) of the Act regarding eligibility and payment for home health services. The requirements for these assessments are based on the professional disciplines that will be involved in, and coordinating, care for the patient. When nursing is assigned to the case, it is likely the patient will have a greater need for nursing services than other services and therefore skilled nurses should conduct the initial assessment visit and initiate the comprehensive assessment (86 FR 62240, 62351 (Nov. 9, 2021)).

Survey Procedures §484.55(b)(2)

• Through clinical record review, verify the initial assessment was conducted by a registered nurse unless the patient is receiving therapy services only.

• Through home visit observation, verify if the current comprehensive assessment and plan of care were completed and accurately reflect the patient’s status.

Interpretive Guidelines §484.55(b)(3)

In therapy-only cases, a qualified therapist (registered and/or licensed by the State in which they practice) may conduct the comprehensive assessment for therapy services ordered.

Interpretive Guidelines §484.55(c)(1)

Completion of the comprehensive assessment should provide the HHA with a complete picture of the patient’s status to assist the HHA in developing the patient’s plan of care.

Assessment of the patient’s current health status includes relevant past medical history as well as all active health and medical problems.

Assessment of a patient’s psychosocial status and his/her functional capacity within the community is intended to be a screening of the patient’s relationships, living environment, impact on the delivery of services and ability to participate in his/her own care. Assessment of a patient’s functional status includes the patient’s level of ability to function independently in the home such as activities of daily living.

Assessment of a patient’s cognitive status refers to an evaluation of the degree of his or her ability to understand, remember, and participate in developing and implementing the plan of care.

Interpretive Guidelines §484.55(c)(2)

Consistent with the principles of patient-centered care, the intent in identifying patient strengths is to empower the patient to take an active role in his or her care. The HHA must ask the patient to identify her or his own strengths and must also independently identify the patient’s strengths to inform the plan of care and to set patient goals and measurable outcomes. Examples of patient strengths identified by HHAs through observation and by patient self-identification may include: awareness of disease status, knowledge of medications, motivation and readiness for change, motivation/ability to perform self-care and/or implement a therapeutic exercise program, understanding of a dietary regimen for disease management, vocational interests/hobbies, interpersonal relationships and supports, and financial stability.

The intent of assessing patient care preferences is to engage the patient to the greatest degree possible to take an active role in their home care rather than placing the patient in a passive recipient role by informing the patient what will be done for them and when.

“Patient goal” is defined as a patient-specific objective, adapted to each patient based on the medical diagnosis, physician’s or allowed practitioner’s orders, comprehensive assessment, patient input, and the specific treatments provided by the agency.

“Measurable outcome” is a change in health status, functional status, or knowledge, which occurs over time in response to a health care intervention. Measurable outcomes may include end-result functional and physical health improvement/stabilization, health care utilization measures (hospitalization and emergency department use), and potentially avoidable events. Because the nature of the change can be positive, negative, or neutral, the actual change in patient health status can vary from patient to patient, ranging from decline, no change, to improvement in patient condition or functioning.

Interpretive Guidelines §484.55(c)(3)

Medicare does not limit the number of continuous 60-day episode recertifications for beneficiaries who continue to be eligible for the home health benefit. Therefore, the comprehensive assessment must clearly demonstrate the continuing need, i.e., eligibility, for the home health benefit.

Survey Procedures §484.55(c)(4)

Verify if the current comprehensive assessment accurately reflects the patient’s current status.

Interpretive Guidelines §484.55(c)(5)

The patient’s clinical record should identify all medications that the patient is taking, both prescription and non-prescription (e.g., over-the-counter drugs, herbal remedies, and other alternative treatments that could affect drug therapy), as well as the dose, route, frequency, or time of administration when indicated on the prescription or order. The skilled professional performing the comprehensive assessment should consider, and the clinical record should document, that the skilled professional considered each medication the patient is currently taking for possible side effects and the list of medications in its entirety for possible drug interactions. Each agency must determine the capabilities of current staff members to perform comprehensive assessments, considering professional standards or practice acts specific to the State. No specific discipline is identified as exclusively able to perform the medication review. However, only Registered Nurses (RNs), Physical Therapists (PTs), Occupational Therapists (OTs) and Speech-Language Pathologists (SLPs) are qualified to perform comprehensive assessments (see also §484.55(b)). While only the assessing clinician is responsible for accurately completing and signing a comprehensive assessment, the agency may develop a policy where clinicians may collaborate to collect data for all OASIS items. For example, to assess potential side effects and drug interactions, the agency may wish to have RNs or practical (vocational) nurses, as defined in §484.115, review the mediation lists.

HHA should have policies that guide staff in the event there is a concern identified with a patient’s medication that should be reported to the physician or allowed practitioner.

Survey Procedures §484.55(c)(5)

Through home visit observation and record review, confirm the medications the patient identifies they are taking against the medical record documentation to verify that the HHA identified all medications, both prescription and non-prescription.

Interpretive Guidelines §484.55(d)

A marked improvement or worsening of a patient’s condition, which changes, and was not anticipated in, the patient’s plan of care would be considered a “major decline or improvement in the patient’s health status” that would warrant update and revision of the comprehensive assessment.

Interpretive Guidelines § 484.55(d)(3)

The update of the comprehensive assessment at discharge would include a summary of the patient’s progress in meeting the care plan goals.