regulations, especially in light of the current inadequacies of State review bodies in requiring and monitoring services.

This lack of sufficiently strong standards and no emphasis on monitoring takes on added importance for vulnerable people because the regulations oppose that proprietary agencies participate directly in the medicaid program. The National Council makes the following recommendations:

(1) Federal funds should be made available immediately to the States to help them strengthen their units responsible for the certification (monitoring) process under medicare and medicaid. Each State should be required to submit to and have approved by the Federal Government its plan for the use of these funds for monitoring the quality of home health services. In addition, Federal training programs should be established and conducted for the personnel undertaking this certification process as the Federal Government is doing now for similar personnel certifying nursing homes;

(2) Quality assurance procedures, utilization review, medical review, PSRO activities and fiscal accountability should not be limited to institutions but should also be applied to home health services.

(3) The Federal Government should utilize the quality assurance programs— standards and monitoring procedures of the national voluntary, nonprofit sector to complement the public role in monitoring home health care. There is a precedent for this in the use the Federal Government makes of the Joint Commission on the Accreditation of Hospitals. This precedent should be extended to the standard-setting and monitoring programs of national voluntary organizations, such as that of the National Council for Homemaker-Home Health Aide Services for agencies which provide any aspect of homemaker-home health aide services. It will require the voluntary and the public sectors working together to assure quality service in this rapidly expanding field. The national council's new national approval program has already approved close to 100 agencies providing homemaker-home health aide service. A like number are in process. We urge that approval by this national organization serve in lieu of State certification of homemaker-home health aide agencies for medicaid if the regulations proposed in the Federal Register on August 21, 1975, are adopted. The council's 14 basic national standards with an accompanying policy statement are attached.

(4) The Department of Health, Education, and Welfare should coordinate its units which have jurisdiction over any aspect of homemaker-home health aide services so that a common approach to a definition, to standards and to a monitoring system emerges. At least the following units of D/HEW are involved: Office of Human Development; Public Health Service; Social and Rehabilitation Service, and Social Security Administration.

(5) The health systems agencies to be established under Public Law 93-641 ought to be in place before the adoption of these regulations so that expansion of medicaid home health agencies will take place in a more orderly and coordinated fashion. Unless there is adequate planning in the health systems areas an unbalanced situation is likely to develop. For example, more home health agencies might be established, especially one-service agencies, than can be supported by a given area while next door there might be too few or none. Urban areas may see a proliferation of agencies while rural areas "go wanting." Health systems area planning should precede the rapid expansion that will take place if these proposed regulations are promulgated.

We note that some of the standards proposed in these regulations are at variance with those for medicare, such as the intervals between the physician's review of the plan of care. Under these regulations a review would be required every 90 days while under medicare a review is required every 60 days. This lack of uniformity will cause confusion and contribute to fragmentation in the delivery of home health services.

Other points we wish to make are:

249.10-We urge that the minimum services required by the State include nursing, home health aide, therapy services and medical supplies, equipment, and appliances;

249.150 (c) (3) (vi) (A) (B) (C).—In addition to identification of owners, part owners or partners, sufficient additional information should be obtained to reveal potential conflicts of interest. Action should be taken to prevent agency participation in the medicaid program when a conflict of interest does exist; (d) Advisory Committee.-We urge that the advisory committee include a social worker. We believe that none of the advisory committee members should be owners or staff members of an agency or their relatives;

(e)(1) and (f)(1).—Are inconsistent with respect to the initial evaluation visit being made by a nurse;

(i)(1). The wording "The home health aide shall be assigned to a particular patient by a registered nurse" should be changed so that when aide service is obtained through contract from another agency responsibility for assignment of the aide remains with the contractor. The outline of duties of a home health aide should include, in addition to those listed: assistance with meal preparation including special diets and helping with routine household duties such as shopping, laundry, budgeting, and light cleaning;

(i) (4) In-service education.-We recommend the following wording: "There shall be continuing in-service programs scheduled at least quarterly, in addition to on-the-job training which takes place during supervisory visits;" (j) (4) Clinical record review.-Wording of this section should be changed so that the selected sample of both active and closed clinical records to be reviewed include records closed within that quarter but with a reasonable upper limit on the number of cases to be reviewed because in larger agencies this would involve hundreds of cases;

Other. A statement should be added to prevent retroactive denial of payment for service already provided.

We respectfully urge that at least the above changes be made in these regulations before they are published in final form.

We understand that hearings may be called because of the importance of these regulations and we would support such a move.

Sincerely,

[Enclosures]

(Mrs.) FLORENCE MOORE.

POLICY STATEMENT BY THE BOARD OF DIRECTORS OF THE NATIONAL COUNCIL FOR HOMEMAKER-HOME HEALTH AIDE SERVICES ON SAFEGUARDS FOR DELIVERY OF HOMEMAKER-HOME HEALTH AIDE SERVICES

Homemaker-home health aide services should be efficient, effective, and given with safeguards to protect the people served. Therefore, any agency-government, voluntary nonprofit, or proprietary-which provides homemaker-home health aide services should meet basic standards, established by a national voluntary not-for-profit standard-setting body. The standard-setting body determines through objective review whether an agency meets basic standards.

Adherence to basic standards requires that homemaker-home health aide services, under whatever auspices:

(1) Be provided by a team composed of both professionals and homemakerhome health aides. The homemaker-home health aides are to be employed and paid by the agency; the agency must provide training, and professional supervision;

(2) Be soundly administered, including maintenance of sound statistical and cost data;

(3) Insure that appropriate services are given as needed, but only for the period required, as determined by professional evaluation and continuing reassessment of the individual's or family's needs;

(4) Be described accurately and adequately to the public. Information as to the availability and quality of service shall be readily accessible to those to be served.

The above principles are equally essential when the services are delivered directly to an individual or family and when the services are purchased on their behalf from another agency.

Communities provide homemaker-home health aide service in various ways. Whatever the system, the interests of those served must be protected. Government, voluntary nonprofit, and proprietary agencies all have responsibility to work actively toward comprehensive, quality homemaker-home health aide services in each community.

BASIC NATIONAL STANDARDS FOR HOMEMAKER-HOME HEALTH AIDE SERVICES

I. The agency shall have legal authorization to operate.

II. There shall be an appropriate duly constituted authority in which ultimate responsibility and accountability are lodged.

III. There shall be no discriminatory practices based on race, color or national origin and the agency either must have or be working toward an integrated

board, advisory committee, homemaker-home health aide services staff, and clientele.

IV. There shall be designated responsibility for the planning and provision of financial support to at least maintain the current level of service on a continuing basis.

V. The Service shall have written personnel policies; a wage scale shall be established for each job category.

VI. There shall be a written job description for each job category for all staff and volunteer positions which are part of the service.

VII. Every individual and/or family served shall be provided with these two essential components of the service:

A. Service of a homemaker-home health aide and supervisor.

B. Service of a professional person responsible for assessment and implementation of a plan of care.

VIII. There shall be an appropriate process utilized in the selection of homemaker-home health aides.

IX. There shall be: A) initial generic training for homemaker-home health aides such as outlined in the National Council for Homemaker Services' Training Manual; B) an on-going in-service training program for homemaker-home health aides.

X. There shall be a written statement of eligibility criteria for the service. XI. The service, as an integral part of the Community Health and Welfare Delivery System, shall work toward assuming an active role in an on-going assessment of community needs and in planning to meet these needs including making appropriate adaptations in the service.

XII. There shall be an on-going agency program of interpreting the service to the public, both lay and professional.

XIII. The governing authority shall evaluate through regular systematic review all aspects of its organization and activities in relation to the service's purpose (s) and to the community needs

XIV. Reports shall be made to the community, and to the National Council for Homemaker-Home Health Aide Services, as requested.

ITEM 7. LETTER FROM EVA M. REESE,* EXECUTIVE DIRECTOR, VISITING NURSE SERVICE OF NEW YORK; TO THE ADMINISTRATOR, SOCIAL AND REHABILITATION SERVICE, HEW, DATED OCTOBER 6, 1975

DEAR SIR: We wish to submit the following comments concerning regulations dealing with home health services in the medical assistance program published in the Federal Register, Vol. 40, No. 163, August 21, 1975.

We strongly commend the stated purpose of removing certain ambiguities in the current regulations which have prevented full realization of the benefits of home health services in State medicaid programs. The clarification that the “skilled" nursing and prior hospitalization requirements of medicare A do not apply to medicaid coverage will extend home health services in many States where coverage has been interpreted inappropriately.

We are in agreement with section 249.10 which describes very clearly the minimum services which must be provided by States, and the population eligible for such services. Based on our experience with chronically ill homebound patients, we believe that consideration should be given to adding physical and speech therapy to the basic services rather than including them only at the option of the State.

We would like to draw your attention to an apparent contradiction in the standards of agencies qualified to provide home health services in section 249.150. The regulations make clear that nursing is the basic service in care at home, with home health aides receiving their assignments, duties, and supervision from nurses. It seems to us essential that agencies responsible for providing home health services must have both nursing and home health aide services, not nursing or home health aide services as stated in paragraph 2 in section 249.150.

*See statement, p. 111.

While agencies providing only home health aide service or primarily home health aide service may contract for the required nursing evaluation and supervision, our concern is that this arrangement will be less effective than the present one which permits nursing agencies to contract for home health aide and homemaker service. Patients in need of home health aide service require periodic professional assessment and intermittently need professional nursing care. This care can be provided without the delays of a referral procedure and with better continuity of care when the nursing and other services such as therapies and equipment and supplies are provided by the primary agency.

Voluntary home health agencies have acquired experience in caring for the chronically ill at home over many years. The medicare legislation stimulated the expansion of the model in which the nurse from a certified home health agency supervised the home health aide who was often obtained through a contractual arrangement. Proprietary agencies, on the other hand, have actively promoted the use of home health aides with minimal or token nursing supervision.

We therefore are strongly opposed to the removal of the current limitation which restricts proprietary home health agencies from qualifying as providers except where the State licenses such agencies. This action seems to us to be very short-sighted means of expanding home health services.

By definition, profitmaking health care agencies do not make quality patient care their primary concern. This point has been made over and over again in the current New York State medicaid scandals. Medicaid "mills" and proprietary nursing homes have siphoned off millions of tax dollars for marginal and sometimes no services. Under the present circumstances, enabling profit-making enterprises to provide home health services under tax-supported programs invites similar abuse. It should also be pointed out that the possibilities for abuse in the home are enormous, because of the difficulty in monitoring patient care in such dispersed settings.

We do not feel that certifying such agencies under the proposed conditions and standards will suffice to protect the public. Rules and regulations are only as effective as the surveillance and enforcement procedures to back them up. This proposed change comes, unfortunately, at a time when many State health departments, including our own in New York, are being forced by financial pressure to cut staff.

A wiser solution, we think, would be to encourage, through funding of expansion programs, the growth of public and voluntary agencies. Expanding this solid foundation is the most reliable route to achieving wider availability of in-home health services. Enabling proprietary home health services seriously undermines existing agencies and threatens the future development of home care as an alternative to unnecessary institutional care in hospitals, nursing homes, and health-related facilities.

It must also be remembered that the existing nonprofit and public agencies are the only resource for those of limited income who need home health care, but do not qualify for third-party reimbursement such as medicare. These agencies would be seriously jeopardized if their caseloads involved a higher proportion of "free" service than they now do.

Home health services are too important a modality of care to jeopardize their effectiveness through premature changes in their delivery.

Sincerely,

(MRS.) EVA M. REESE.

ITEM 8. LETTER FROM FLORENCE MOORE, EXECUTIVE DIRECTOR, NATIONAL COUNCIL FOR HOMEMAKER-HOME HEALTH AIDE SERVICES, INC., NEW YORK; TO SENATOR FRANK E. MOSS, DATED OCTOBER 29, 1975

DEAR SENATOR Moss: At the October 28, 1975, hearing on the August 21, 1975, proposed regulations on medicaid, the National Council for Homemaker-Home Aide Services, Inc., was asked to write confirming our verbal reply to a question about our participation in the development of these regulations. The National Council was not invited to review these proposed regulations in draft form. The first time that we had an opportunity to comment on them in any form was when they appeared in the Federal Register on August 21, 1975.

We would like to reaffirm the point we made during our testimony that the national council appreciated the opportunity this hearing afforded not only for commenting on the regulations but also on other issues of vital importance to homemaker-home health aide services.

Sincerely,

MRS. FLORENCE MOORE.

ITEM 9. LETTER FROM CONSTANCE HOLLERAN, DEPUTY EXECUTIVE DIRECTOR, AMERICAN NURSES' ASSOCIATION, INC., KANSAS CITY, MO.; TO SENATOR FRANK E. MOSS, DATED NOVEMBER 3, 1975

DEAR SENATOR Moss: At the hearings of October 28, 1975, on "Proprietary Home Health Care," information was requested to whether the American Nurses' Association had any opportunity for advanced review of the proposed regulations for home health services under the medical assistance program published on August 21, 1975.

In response, there was no such opportunity. The Social and Rehabilitation Service did not offer a draft nor ask review or advice on the proposed regulations.

Sincerely,

CONSTANCE HOLLERAN.