Administrative hearing before the Department of Consumer and Regulatory Affairs shall be held within 15 calendar days before an appropriate hearing officer. Client/patient shall have the right to be represented by a The home care agency, the client/patient and his or her The burden of proof shall be on the client/patient, and no After due consideration of all oral and documentary evidence The hearing officer shall issue a final written decision If a violation has been established, the Department may For example, remedies may include, but are not limited to: The The procedures and standards for issuing and determining The agency or the client/patient may request review of the The Director of the Department, or his or her designee, Except as specified above, all administrative appeals under Ombudsman The Task Force strongly recommends the creation of a Home Care Ombudsman Office, and has referred to the ombudsman throughout this section. Patient rights and grievance procedures, as defined in this section, are premised upon the creation of this office, which should be outside the Department of Consumer and Regulatory Affairs (DCRA). The Home Care Ombudsman shall be responsible for looking into complaints, seeking resolution of complaints and helping clients with grievance procedures in any appropriate agency. For example, a complaint about an agency which contracts with DHS should go to DHS as well as DCRA; within DHS, a contract monitor, the Office of Fair Hearings, and adult or child protective services may all need to be told about a complaint which alleges abuse, neglect, or exploitation. A client should not have to keep track of all of these different processes--an Ombudsman should be able to channel complaints to all appropriate bodies and see that they respond. The ombudsman could also assist in educating consumers about their rights. 1. Questions for Hadley Hall from House Select Committee on Aging Hearing on the "Black Box" of Home Care Quality, July 29, 1986 for home health The Medicare Standards of Participation A. At present, the most important uniform quality controls for home health agencies are the federal "Medicare Conditions of Participation". These standards, which apply to some 6,000 home health agencies certified for participation in the Medicare program, set forth basic requirements for organization, services, administration, professional personnel, acceptance of patients, plans of treatment, medical supervision, skilled nursing services, therapy services, medical social services, home health aide services, clinical records, and evaluation, among others. These standards are the minimum with which Medicare-certified home health agencies must comply; several states require higher standards in some areas. We believe that the Medicare standards are appropriate and reasonable for that program. basically structural and These standards are process standards, however, which measure the capacity to deliver services (that is, the procedures followed in delivering the services) rather than the actual quality of the services rendered. We believe that the current Medicare requirements could be improved by study of outcome measures which would be indicative of high quality of care, and inclusion of those outcome measures in the conditions of participation. For example, the Homecare Association of Washington has recently received a grant from the Health Care Financing Administration (HCFA) to develop, pilot, test, and refine a total of seven reliable and valid outcome scales for the home care industry. Several other states are currently experimenting with outcome-oriented quality assurance measures, and we believe that such experiments should be continued and expanded. One should always remember that for home care patients, total recovery is not always the realistic outcome to be expected. Acceptable patient outcomes in home care depend on the patient's diagnosis and condition, and include rehabilitation, maintenance of the patient in his or her home, slow deterioration, and death. 2. Even if quality standards are in place, how can compliance with these standards be monitored on a day to day basis? Compliance is difficult to monitor on a day to day basis, but there are several monitoring methods which appear to function adequately. or Compliance could be monitored through processes similar to the Medicare survey process, in which regulatory personnel periodically visit the agency, either announced unannounced, and audit compliance with program requirements. The Medicare conditions of participation already require home health agencies to use plans of care and periodic review of We those plans as well as an evaluation of the agency. home care recommend expanding those requirements to all services receiving federal funds. (Other Medicare requirements which relate to patients in need of skilled nursing care should not be expanded to other programs.) An accreditation process which would result in deemed status for all federally funded home care programs could also be considered. Some states, such as Iowa, have established monitoring systems for paraprofessional services receiving state funds, and a similar system could be considered as a state solution. The concept of peer review of home care is a good one, however if the current Peer Review Organizations (PROs) are used, much work would have to be done with them to educate . them regarding the role and use of home care services. PROS currently have an institutional perspective and focus solely services. They would need to become more on "medical" sensitized to the care services. We would recommend that if PROS are to be used to review home care quality, that representative home care providers be added to the group. We would also want to assure that PRO review did not result in duplication of current review efforts, or that funds were taken from current patient care activities to fund peer review. In addition to these review mechanisms, there should be an adequate system for prompt, effective means of responding to consumer or family complaints regarding the quality of home care. We support the idea of toll-free hotlines to receive questions and complaints from beneficiaries, providers, and others concerning home care quality issues, as is being considered by your Committee in "the Homecare Quality Assurance Act of 1986". We believe such a hotline could function be st office with state-based investigators who could also act as ombudsmen. on a state-wide basis, or through a national feel We support the concept of home care ombudsmen, but we that such a program would have to operate somewhat 3. differently from the current ombudsman program for nursing homes. A home care ombudsman on the state level could be available to receive complaints and assure that appropriate investigation and follow-up is performed. The ombudsman should be separate from state and local againg prorams, however, because those programs are often providers of home care services, and it would be a conflict of interest for an ombudsman affiliated with an organization to pursue complaints against that organization. Medicare An additional means of monitoring quality of care in the program would be to have the fiscal intermediary send a copy of the bill for services to the beneficiary, together with an easily understandable explanation of the benefits for which the bill was submitted, (in a form that is "in English" rather than in codes or numbers) and to request the beneficiary to advise the intermediary, the peer review entity or the ombudsman if the patient has questions about the bill or the quality of services rendered. A similar concept should be considered for other programs on a state by state basis. What impact has cost containment and the move to DRGs had on the quality of home care services? Where do providers make cuts when the budget axe falls and what will happen to quality if additional cuts are made? A. care after a The implementation of the hospital prospective payment system has had a dramatic impact on the home industry, both in terms of the number of patients needing home care hospital discharge and the acuity of the care those patients require. on Several studies (by the General Accounting Office, the DRGS. since the implementation of |