AHCA Home Health Regulatory Update

AHCA Home Health
Regulatory Update
Anne Menard
Home Care Unit
Bureau of Health Facility Regulation
Agency for Health Care Administration
July 23, 2013
Licensed as of July 10, 2013
2,217 home health agencies
County with largest #: Miami-Dade 669
Broward 256 Palm Beach 196
472 nurse registries
Broward 110 Palm Beach 108
1,704* homemaker companion services
Miami-Dade 191 Broward 179
*Decrease is due to 2012 law exempting businesses that only serve
developmentally disabled clients under contract with the Agency for
Persons with Disabilities.
2,217 Home Health Agencies
71% Certified for Medicare and/or Medicaid
1,016 Medicare only
62 Medicaid only
490 Medicare & Medicaid
649 not Medicare or Medicaid (29%) – 163 have applied for
Medicare and/or Medicaid
As of 7/10/2013
Home Health Agency Rules
Florida Administrative Code, Chapter 59A-8
Chapter 59A-8 was updated with some new items added that were required in
state law, some items removed for regulatory reduction, and some items
The rule revisions were effective July 11, 2013. Updated standards for
surveyors will not be in use until August.
Rules cannot repeat what is stated in the law. Thus, home health agencies
must follow both laws & rules: Florida Statutes and Florida Administrative
Home Health Agency Rules
Many of the rules and laws are enforced through on-site surveys.
State survey standards are verbatim quotes from rules and laws. Survey
standards are in the State Regulation Set used by surveyors at
http://ahca.myflorida.com/homecare - select “Home Health Agency” and select
the “Laws, Rules and Surveys” tab.
The revised State Regulation Set with the latest rule revisions will be at this
site by August. Accrediting organizations must include state requirements
when they survey your agency.
State Law Required AHCA to Write
Additional Director of Nursing Rules
Is every home health agency required to have a director of nursing? No
“A home health agency that is not Medicare or Medicaid certified and does not
provide skilled care or provides only physical, occupational, or speech therapy
is not required to have a director of nursing.” 400.476(2)(c), Florida Statutes
The state law 400.497(5),F.S., requires AHCA to write the rules for oversight by
the director of nursing. There are three parts to this law:
1. Standards for oversight:
400.497, Florida Statutes “Rules establishing minimum standards.—The
agency shall adopt, publish, and enforce rules ….which must provide
reasonable and fair minimum standards relating to: …
(5) Oversight by the director of nursing. The agency shall develop rules
related to:
(a) Standards that address oversight responsibilities by the director of nursing
of skilled nursing and personal care services provided by the home health
agency’s staff;”
New Director of Nursing Rule 59A-8.0095(2)(d), FAC
The new rule says:
“The director of nursing shall establish a process to verify that skilled
nursing and personal care services were provided.” 59A-8.0095(2)(d),
The process is not specified in the rule & is left up to each home health
agency to determine.
Your agency should have already have some way of verifying that, for
example, Nurse James went to the home of patient John Smith on
Tuesday to provide nursing care.
New Director of Nursing Rules
2. A certified daily report upon request
The state law requires:
400.497(5), F.S. states…. “The agency shall develop rules related to:
(b) Requirements for a director of nursing to provide to the agency [AHCA],
upon request, a certified daily report of the home health services provided by a
specified direct employee or contracted staff member on behalf of the home
health agency. The agency may request a certified daily report only for a period
not to exceed 2 years prior to the date of the request;”
New Director of Nursing Rule 59A-8.0095(2)(d), FAC
The new rule says:
When requested by an AHCA employee, the director of nursing shall provide a
certified report that lists the home health services provided by a specified direct
service staff person or contracted staff person for a specified time period.
What is meant by “home health services”? The law states:
‘Home health services’ means health and medical services and medical
supplies furnished by an organization to an individual in the individual’s home
or place of residence ……:
(a) Nursing care
(b) Physical, occupational, respiratory, or speech therapy
(c) Home health aide services
(d) Dietetics and nutrition practice and nutrition counseling
(e) Medical supplies, restricted to drugs and biologicals prescribed by a
400.462(14), F.S.
New definition in rule
59A-8.002(20), FAC
“Nursing care” means treatment of the patient’s illness or injury by a registered
registered nurse or a licensed practical nurse that is ordered as required in
required in 400.487(2), F.S.* and included in the plan of care.
*400.487(2), Florida Statutes, refers to treatment orders by a physician, physician’s
physician’s assistant or advanced registered nurse practitioner. (This state law
law applies to licensed agencies. Medicare & Medicaid agencies still are required
required to have orders by physicians per federal regulation 42 CFR 484.18(c).)
New Director of Nursing Rule 59A-8.0095(2)(d), FAC
The new rule also says:
“A certified report shall be in the form of a written or typed document or
computer printout and signed by the director of nursing.
The report must be provided to the surveyor within two hours of the request,
unless the time period requested is longer than one year, then the report must
be provided within three hours of the request.”
What do you already have in place at your agency that could be used to show
that the specified staff person provided the service (home health aide, nursing
care, physical therapy…etc.) on the requested days?
Your existing scheduling documents or computer scheduling type programs that
show the patient visits made by staff each day? Telephony reports for Medicaid
visits? A log or other document staff turn in that shows the patients that were
visited & the service (i.e. home health aide, nursing care, etc.)?
New Director of Nursing Rules 59A-8.0095(2)(d), FAC
When would a certified report be requested?
Here are some examples:
• A surveyor may ask for such a report when there is concern that
services were not provided by a staff person -- such as when
investigating complaints of patient neglect, false billing or
falsification of records.
• On a survey, 3 patient records have no notes to show that all the
nursing visits were made more than 2 months ago as specified in
each patient’s plan of care. The agency cannot provide any nurses
notes when requested, but says the nurses did make the visits.
New Director of Nursing Rules
3. A quality assurance program
The state law requires:
400.497(5), F.S. states….“The agency shall develop rules related to:
(c) A quality assurance program for home health services provided by the
home health agency.”
The state rule: A quality assurance program was already in rule. New items
have been added & are underlined below.
59A-8.0095(2)(e), FAC “The director of nursing shall establish and conduct an
ongoing quality assurance program. The program shall include at least
quarterly, documentation of the review of the care and services of a sample of
both active and closed clinical records by the director of nursing or his or her
delegate. The director of nursing assumes overall responsibility for the quality
assurance program.
How many records should the agency review in its sample? Your home health
agency decides how many.
New Director of Nursing Rules
Quality Assurance Program continued 59A-8.0095(2)(e)
“The quality assurance program is to assure that:
1. The home health agency accepts patients whose home health service needs can be
met by the home health agency;
2. Case assignment and management is appropriate, adequate, and consistent with the
plan of care, medical regimen and patient needs. Plans of care are individualized based
on the patient’s needs, strengths, limitations and goals.;
3. Nursing and other services provided to the patient are coordinated, appropriate,
adequate, and consistent with plans of care.
4. All services and outcomes are completely and legibly documented, dated and signed
in the clinical service record;
5. The home health agency’s policies and procedures are followed;
6. Confidentiality of patient data is maintained; and
7. Findings of the quality assurance program are used to improve services.”
New Director of Nursing Rules
Quality Assurance Program continued
Are all patient records required to be sampled for quality
No. Quality assurance is required only for clinical records of
patients receiving skilled services (nursing care, physical,
occupational, respiratory and speech therapy, dietetics and nutrition
practice and nutrition counseling, social work).
The therapy-only home health agencies are not required to have a
director of nursing in state law and thus, are not included.
Patients that are only receiving home health aide services
(including services provided by certified nursing assistants),
homemaker, and companion services are not included.
Director of Nursing Rules
Rule on biomedical waste has been updated
• Policies and procedures may now be developed by the administrator or
alternate administrator, not just the direct of nursing.
• The revision clarifies that rule only apply to agencies that provide nursing
and physical therapy
• The requirement to comply with specific Department of Health rules has
been removed, referring instead to the Department’s web site.
59A-8.0095(2)(b), FAC “The director of nursing, the administrator, or alternate
administrator shall establish policies and procedures on biomedical waste for home
home health agencies providing nursing and physical therapy services. The Department
Department of Health website has information on biomedical waste handling and the
and the requirements at www.doh.state.fl.us/Environment/Community/biomedical .”
Home Health Agency Rules Updated
Regulatory reduction changes
Removes the 1-year experience requirement for physical therapist, occupational
therapists, and therapists assistants; 59A-8.0095(6)(8)
Permits training of home health agency staff to be done at drop-off sites to save
costs; 59A-8.003(8)
Chapter 59A-8 is shorter since items that are now in 408, Part II, F.S. and 59A-35
have been removed.
Rather than specify tasks that can be performed in the rules, the RN, LPN, PT,
PT, PTA, OT and OTA rules refer to the scope of practice authorized by the license
Home Health Agency Rules Updated
Regulatory reduction changes
5. Change of administrator or alternate:
• Removes requirement to submit a resume and affidavit of good moral
character when there is a change in the administrator or alternate
• Still requires notification of new administrator (not alternates) and a
statement that the person meets the requirements in law.
59A-8.0095(1)(b) “If an agency changes administrator the agency shall notify
the AHCA Home Care Unit office in Tallahassee as required in subsection
59A-35.100(1), F.A.C. Notification shall consist of submission of the person’s
name and a statement that the person meets the qualifications in Sections
400.476(1) and 400.462(1), F.S. Send the notification by email, fax or mail
…The administrator also must submit level 2 screening…or inform the Home
Care Unit that level 2 screening was previously submitted.”
Home Health Agency Rules Updated
Regulatory Reduction
6. Home health aides & certified nursing assistants
Removes the requirement for certified nursing assistants to have training on
specific items (59A-8.0095(5)(i)). The rule used to say:
(i) A home health agency shall ensure that a certified nursing assistant
has competency in the home health core curriculum listed in
subparagraphs 59A-8.0095(5)(d)2. and 13. through 16., F.A.C.
The requirement in the law is sufficient without the training that was specified in
400.476(3) “TRAINING.—A home health agency shall ensure that each
certified nursing assistant employed by or under contract with the home
health agency and each home health aide employed by or under contract
with the home health agency is adequately trained to perform the tasks of a
home health aide in the home setting.”
Home Health Agency Rules Updated
Home health aides & certified nursing assistants (continued)
It is up to the home health agency to determine if the CNA is “adequately
trained to perform the tasks of a home health aide” or not as the law requires.
Here are some possible ways --• Check references for any home health agency or individual patient
• Give the AHCA home health aide competency test. [Note – Medicare and
Medicaid home health agencies have more competency evaluation
requirements in federal survey standards from federal regulations 42 CFR
484.4 and 484.36(b)(3) to (5)]
• Have an RN or LPN accompany the CNA on a home visit.
• The CNA may already have home health aide training…
Rules Updated
Home Health Aides & Certified Nursing Assistants
59A-8.0095(5)(l)3 adds the tasks associated with elimination that
a home health aide and certified nursing assistant may do as
requested by home health agencies.
3. b. Assisting with tasks associated with elimination:
i. Toileting
ii. Assisting with the use of the bedpan and urinal
iii. Providing catheter care including changing the urinary
catheter bag
iv. Collecting specimens
v. Emptying ostomy bags, or changing bags that do not
adhere to the skin”
Rule Revisions
Homemakers 59A-8.0095(12)(a)
Here are the paragraphs that are revised:
(12)(a) The homemaker shall:…
“2. Perform the functions generally undertaken by the customary
homemaker, including such duties as preparation of meals, laundry,
shopping, household chores, and care of children;”
“8. If requested by the client or his responsible party, the homemaker
may verbally remind the client that it is time to for the client to take his
or her medicine.”
Rule Revisions
Companions 59A-8.0095(12)(b)
Here are the paragraphs that are revised:
(12)(b) The companion shall:….
“2. Accompany the client to doctor appointments, recreational outings,
or shopping;”
“8. If requested by the client or his responsible party, the companion
may verbally remind the client that it is time for the client to take his or
her medicine.”
Rule Revisions
Clinical Records – 59A-8.022(6)(b)
Rubber stamp signatures for physicians are no longer permitted.
Advanced Directives 59A-8.0245(2)(a)
Use the April 2006 version of the “Health Care Advanced Directives – The
Patient’s Right to Decide” rather than the 2004 for new patients. Still available
at www.FloridaHealthFinder.gov.
Rule revisions 59A-8.027
Comprehensive Emergency Management Plans
Changes to the Comprehensive Emergency Management Plan (CEMP) form:
• The one-page “Information for Home Health Agency Patients” (Appendix B
of the CEMP form) to the patient has one important sentence changed:
“(1) If the patient has a caregiver*, the caregiver must accompany the
patient and must remain with the patient at the special needs shelter.”
*Caregivers can be relatives, household members, guardians, friends,
neighbors and volunteers.
The title “safety liaison” is used for the person in charge during an
emergency as required in 408.821(1), F.S.
The law on the cover page has been changed to use “State Surgeon
General” instead of the Secretary of the Department of Health.
HHAs do not have to re-do their CEMP Plans because of these changes, but
please use the updated Information for HHA patients that may go to the special
needs shelter.
Comprehensive Emergency Management Plan Updates
Review your plan annually & update procedures
Submit changes in telephone #s & names of staff who lead
your agency’s emergency response (your “Safety Liaison” )
to the county emergency management office & to the
county health department.
– Home Health agencies licensed for multiple counties
report changes to each county health department &
each county emergency management office.
– Must include phone #s where staff can be contacted
outside of the HHA’s regular office hours.
Home Health Agency Quarterly Report
• 2013 law changes reduced the fine for failure to report within the required
time frame to:
$200 a day for each day late up to a maximum of $5,000
• Some home health agencies no longer have to report.
“A home health agency is exempt from submission of the report and the imposition of
Home Health Agency Quarterly Report
As you know, Single Sign On is used to submit your quarterly report through the
AHCA web portal. Single Sign on is not an organization account for your agency, it
is an individual account. The User name and password that is created belongs to
the individual and should not be shared.
There are two systems that use Single Sign On now and soon there will be a third:
• Background Screening
• Home Health Quarterly Report
• On-Line Home Health Agency Licensure
Providers access the AHCA Portal through Single Sign On to use one of the three
systems or all three if a single user requests access to each system.
Many HHAs have staff that have forgotten their password. There are instructions
on the steps for getting a new password. When the staff person who had the
password leaves, a new user agreement must be completed. Call the AHCA Home
Care Unit if you need help, (850) 412-4403.
Background Screening
Care Provider Background Screening Clearinghouse
Provides a single data source for background screening results of persons required to be
screened by law for employment in positions that provide services to children, the elderly, and
disabled individuals.
Allows the results of criminal history checks to be shared among specified agencies when a
person has applied to volunteer, be employed, be licensed, or enter into a contract that
requires a state and national fingerprint-based criminal history check.
Seven total state agencies will participate in the Clearinghouse—
1. Department of Health (DOH)
2. Department of Children and Families (DCF)
3. Department of Juvenile Justice (DJJ)
4. Department of Elder Affairs (DOEA)
5. Agency for Persons with Disabilities, and (APD)
6. Vocational Rehabilitation (DOE-VR)
To be entered into the Clearinghouse, a person screened must:
• Undergo Level 2 screening and have fingerprints retained by FDLE, and
• Have a photograph taken at the time of screening, and
• Sign a privacy policy
Current Clearinghouse functionality
Initiating a Clearinghouse Screening:
It is very important for all screenings to be initiated through the Clearinghouse
website prior to sending an applicant for fingerprinting. Initiating the original
screening online will provide the privacy policy required for the employee to be
included in the Clearinghouse and will also supply a view of the Florida Public
Rap Sheet. Also, initiating the screening allows the ability to track a screening
through the process and email updates when an employee’s status has been
changed or updated.
To register and begin initiating screenings please visit the website at
Your agency can initiate a screening and have the employee schedule and pay
their own LiveScan appointment. (This is not available for all LiveScan
vendors. Please contact the vendor and ask.) Print the LiveScan Request
form for the applicant, employee or contractor to take to the vendor.
Current Clearinghouse Functionality
Privacy Policy:
Applicants must sign a privacy policy in order for their screening to be
entered into the Clearinghouse. The privacy policy is available during the
‘Initiate New Screening’ process on the website. Employers must retain a
copy of the privacy policy in the employee’s personnel file.
Initiating an Agency Review:
If an individual has been screened by another specified agency (i.e. Dept.
of Health) and entered into the Clearinghouse, an AHCA provider must
request an agency review on the Clearinghouse website. This will allow
AHCA to make an eligibility determination for employment purposes without
the provider having to pay for a completely new screening.
Current Clearinghouse functionality
Initiating a Resubmission:
The retention of fingerprints (effective for screenings on or after January 1, 2013) provides
a cost savings for applicants that are in the Clearinghouse but have had a lapse in
employment greater than 90 days. If there has been a 90 day lapse in employment, these
applicants would only require a new national criminal history check – a resubmission of
the retained fingerprints. A new state criminal history search will also be conducted, at no
additional charge. A resubmission can be requested and paid for directly through the
Clearinghouse website.
• Arrest and Criminal Registration Notifications:
The retention of fingerprints will allow the Florida Department of Law Enforcement (FDLE)
to report any new arrest/registration information to the specified state agencies. At this
time the Agency is receiving arrest/registration notifications from FDLE and manually
updating the employee’s eligibility as necessary.
• Bulletin Messages:
Important updates will be displayed on the Home Page of the Clearinghouse results
website. Providers should regularly check the home page for notifications regarding
system outages, new regulations, etc.
Employee Roster
“Employee” means any person required by law to be screened pursuant to this chapter,
including, but not limited to, persons who are contractors, licensees, or volunteers.
435.02(2), F.S.
According to section 435.12(2)(c), F.S., an employer of persons subject to screening
by a specified agency must register with the Clearinghouse and maintain the
employment status of all employees within the Clearinghouse. Initial employment
status and any changes in status must be reported within 10 business days.
• Current employees screened since January 1, 2013, who have a photo, retained prints,
and a signed privacy policy must be added to the employee roster immediately or their
status will change to “Resubmission Required-90-day lapse in employment” and
payment will be required for a resubmission.
• You must add an employee to your employee roster to receive arrest and criminal
registration notifications. Please remember, per section 435.06(2)(b), F.S., if an
employer becomes aware that an employee has been arrested for a disqualifying
offense, the employer must remove the employee from contact with any vulnerable
person that places the employee in a role that requires background screening.
*We are aware and currently working on the glitch in the system that won’t allow for
licensed employees to be added to the employee roster. Please add them as an
“Employee/Staff Person” until this situation is resolved.
Benefits of the Clearinghouse
Allows the results of criminal history checks to be shared among specified state
agencies, thereby reducing duplicative screenings for individuals requiring
screening across multiple state agencies.
Applicants will now have their fingerprints retained for a period of 5 years.
• The retention of fingerprints enables a provider to be notified of an
arrest of their employee as soon as the information is reported to the
Agency by FDLE.
• The retention of fingerprints will also provide a cost savings for those
employees that are in the Clearinghouse but have had a lapse in
employment greater than 90 days. After a 90 day lapse in employment,
these applicants would only be required to pay for a new national
criminal history check (currently $16.50).
Provides a photo of the applicant taken at the time of screening.
– The provider can verify that the person who applied for the position is
the same person that had their background screening done.
Clearinghouse Statistics
• From January 1, 2013 to June 30, 2013:
– 421 individuals arrested AFTER they were
screened (rap backs)
 149 individuals went from Eligible to Not Eligible for
offenses including:
 Grand Theft
 Battery and Assault
 Sex Offenses
 Exploitation of the Elderly
Agency for Health Care Administration
Background Screening Resources
Agency for Health Care Administration Web Site
-- See the Background Screening Clearinghouse Instruction Guide at
the home page.
[email protected]
CMS Temporary Moratorium on New Medicare
Home Health Agencies in 2 Counties
• Miami-Dade and Monroe counties
• Beginning July 30
• Denies the enrollment of new Medicare home health
• Federal Register announcement is coming – watch the
Home Health Agency Center at the CMS web site for the
If your email has changed since your
last application
• Please let AHCA Home Care Unit know – send an email to
[email protected] with your correct
email address.
• So you can get emails including email blasts sent by AHCA
If you don’t agree with the surveyor
1. Ask the surveyor to show you the survey standard or
law, rule
2. Discuss with surveyor at Exit Interview
3. Contact the AHCA Field Office Manager
4. If still not resolved, contact AHCA Chief of Field
Operations, Polly Weaver (850) 412-4301
Contacting AHCA
When you have questions about your survey or any standard that
was cited as not met
- Call the Field Office Manager or Supervisor
When you have questions about laws, rules, the application form
or requirements
– 1st check http://ahca.myflorida.com/homecare - click on “Home
Health Agency” or “Nurse Registry” - See Frequently Asked
– Then call the Home Care Unit (850) 412-4403
or, send an email to
[email protected]
See “Locate” “Facilities and Providers”
“Search by Facility Type/Location”
Now “Advanced Search” has “Service Area”
Select county & get all licensed for that county – includes
those that may not be located in county
Updated nightly from licensing data
Can now get Excel listings by county & statewide
Get the AHCA Smartphone Facility Locator
For information on facilities or agencies & driving
See www.FloridaHealthFinder.gov, select “Find
Facilities or Providers” and see “Smartphone Apps”
Contact information – Home Health Agencies &
Nurse Registries
Anne Menard – Supervisor
Home Care Unit – 6 programs
[email protected]
Medicare & Medicaid HHA initial
certification & branch approvals
-Cynthia Thomas
(850) 412-4403
Jan Benesh – HHA & NR
licensing manager
• Ed Barnes - Change of
ownership & licensing
• Lenora Lowry – HHA
• Pat Guilford – NR
• Natarsha Humphries – HHA
& NR
• Susan Glass - HHA
[email protected]

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