caregiver takes care of older woman
CHAP answers agencies' questions regarding post-PHE waivers and flexibilities

As of May 11, the nation is officially in a post-public health emergency (PHE) era according to the U.S. federal government. This means a new set of changes to waivers and flexibilities home health and hospice agencies have gotten used to.

To help agencies stay on course with the new standards, CHAP recently hosted a free webinar, titled "Return to Normal After the PHE—Are You on Track?" with CHAP Senior Program Manager Bobbie Warner answering questions from home health and hospice leaders who wondered if they were on the right path.

“Having said normal, we know that normal prior to March of 2020 has changed permanently in some ways,” Warner said.

Topics including expired waivers, extended waivers, use of telehealth, waiver to permanent regulation, tips for compliance and policy expirations and revisions were covered.

According to CHAP, the Centers for Medicare & Medicaid Services (CMS) made its decisions related to post-PHE waivers and flexibilities based on three different considerations:

  1. Community impact: Potential barriers and opportunities that the flexibilities may address
  2. Future PHE: Which flexibilities would be most useful to ensure a rapid response to future emergencies
  3. Collaboration: With federal partners and health care industry to ensure the health care system is prepared

“The health care industry definitely identified several potential barriers to care provision and safety of the patients with the start of the pandemic,” Warner said. “The flexibilities were able to address those key areas. In the consideration of the potential for future emergencies, particular flexibilities were identified to ensure a rapid response to future emergencies.”

Warner covered waivers that expired with the end of the PHE on May 11, including:

  • Home health waiver of requirements under §484.58(a).
  • The requirement for OASIS transmissions to be conducted within 30 days was waived during the PHE, but this waiver has expired.
  • Waived requirements under 42 CFR §484.80(h) regarding home health aide supervision have expired.
  • The extension of comprehensive assessment time for home health from five to 30 days has expired.
  • The extension for home health’s provision of clinical records (IM.4.I.M1) allowing for 10 days has expired.
  • The waiving of hospice requirements to use volunteers, including the provision of volunteer usage to meet at least five percent of patient care hours will end Dec. 31.
  • The waiver allowing for hospice providers to provide services to a Medicare patient receiving routine homecare through telecommunication technology if it was feasible and appropriate to do so expired in May.
  • Hospice onsite aide supervision waiver requirements under 42 CFR §418.76(h) has expired.
  • The extension of comprehensive assessment time for hospice from 15 to 21 days has expired.
  • During the PHE, the requirement for provision of non-core services (HCDT 14.I) including physical therapy, occupational therapy and speech pathology were waived—this has expired.

Extended waivers within the home health and hospice space included waivers introduced during the PHE that will become expired at a future date. This list includes:

  • Home health’s face-to-face encounter is expected to expire Dec. 31, 2024.
  • Home health’s annual onsite supervisory visit is expected to expire July 10, 2023.
  • Home health’s requirement for 12 hours of in-service training in a 12-month period was waived during the PHE, and this flexibility will be extended until Dec. 31, 2023.
  • Hospice’s face-to-face encounter is expected to expire Dec. 31, 2024.
  • Hospice’s annual onsite supervisory visit is expected to expire July 10, 2023.
  • Hospice’s requirement of 12 hours of in-service training in a 12-month period was waived during the PHE, this flexibility will be extended until Dec. 31, 2023.
  • The hospice requirement to annually assess the skills and competencies of all individuals furnishing care was waived. All postponed assessments must be completed by the end of the first full quarter following the conclusion of the PHE. This flexibility has been extended until Sept. 30, 2023

Warner also covered waivers introduced during the PHE that will shift to permanent regulation as they were deemed to be beneficial in regulation and practice. These now permanent regulations include:

  • In home health, occupational therapists are now allowed to complete initial and comprehensive assessments for patients who are receiving therapy services. 
  • If allowed by state law, Medicare-eligible home health patients can be under the care of a nurse practitioner, clinical nurse specialist or physician assistant. Know the scope of practice and state law for “allowed practitioners.”
  • The use of telehealth in patient care for home health. These visits are not to replace home visits but are an adjunct to those in-person visits. Key requirements include:
    • Telehealth visits be included in the plan of care
    • Not to replace in-person visits
    • Patient informed of mode of delivery
    • Are to be included on home health claim as of July 1
  • In hospice, the use of pseudo-patients is now appropriate as long as requirements are followed.

Before the conclusion of the webinar, Warner spent time answering participants' questions. Here are what some home health and hospice agencies wanted to know: 

Q: Is there any hope that Medicare will allow nursing or therapy to perform the SOC assessment when nursing and therapy are ordered? If SN/PT/OT are ordered can the occupational therapist do the SOC?
A: Per the requirements of the Home Health Conditions of Participation, if nursing is ordered, the comprehensive assessment is to be done by nursing.

Q: Occupational therapists may not determine eligibility—this is Medicare only, not Medicaid, correct?
A:  Although it is clearly stated that for Medicare, occupational therapy may not determine eligibility, this is a payment criterion. Medicaid in some states may allow occupational therapy as a qualifying service for payment purposes. Very similar to homebound status as an eligibility factor being state dependent.

Q: What is the implication of late OASIS transmission?
A: Timely OASIS transmission is a regulatory requirement under the Conditions of Participation. Consistent lack of timeliness could result in a citation at:

§484.45(a) Standard: Encoding and transmitting OASIS data.

An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the secretary), within 30 days of completing the assessment of the beneficiary.

Keep in mind that OASIS has an impact on publicly reported measures with the potential to impact payment. It is important to set up standardized operational processes to ensure compliance.

Q:  For annual on-site HHA competency do we just need to have recent competencies completed by July or do we need to make up for the years PHE was in effect?
A: Any employees with one or more postponed annual onsite visits will need to have an onsite visit completed by July 10, 2023. In addition, any onsite visits due in accordance with your agency policy after May 11, 2023 should be completed within compliance with the policy.

Q: What current reason would be placed in the Care Plan for continuing telehealth for hospice recertification?
A: Face-to-face encounters by use of telehealth are allowed through the extension of the waiver related to the PHE. Perhaps some verbiage like that. There is no specific verbiage to utilize.

Q:  Is the hospice 5% volunteer requirement per month or annually?
A: The broad answer is annually, however, an organization that does not track its volunteer hours ongoing puts itself at risk of not meeting the requirement.