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""'i  HOME HEALTH AIDE SERVICES

FOR MEDICAR PATIENTS 
RICHAD P. 
KUSSEROW  1987 
INSPECTOR GENERAL  SEPTEMBER 
Control # OAI-02-86-00010
 : .  . .. .
TABLE OF CONTENTS

. i 
EXECUTIVE SUMYlARY . 
INTRODUCTION  . 1 
MEDICARE PATIENTS' NEEDS FOR SOME KEY 
HOME HEALTH AIDE SERVICES ARE NOT BEING MET 
STANDARDS NOT PROVIDED:  . 9 
PROBLEMS AND BEST PRACTICES 
IN PROVIDING HOME HEALTH AIDE SERVICES 
RECOMMENDATIONS  . 20 
4J. 
APPENDIX I:  HIGHLIGHTED HISTORY OF INTEREST 
IN HOME HEALTH ISSUES  . 22 
II: 
APPENDIX  PROFILE OF REVIEW AND METHODOLOGY  . 24 
APPENDIX III: EFFECTIVE STATE STANDARDS  . 25 
APPENDIX IV:  HCFA COMMENTS  . 27  EXECUTIVE SUMY

services. 
PURPOSE  This inspection was initiated to assess the 
strengths and weaknesses of existing Medicare standards for 
home health aide 
BACKGROUND  Covered health and personal care services 
provided to eligible patients at home are reimbursed under
Medicare. 
These services include skilled nursing, physical, 
speech and occupational therapy, medical social services and 
services provided by home health aides
care.  , including personal
They must be ordered by a physician and provided 
through a Medicare-certified home health agency. 
Coverage by
Medicare is also dependent upon a homebound patient'

s need

for the part-time or intermittent services of nurses and

other skilled professionals. 
The coverage of home health

aide services is contingent upon the need for skilled

professional services. 
Medicare reimbursement to nearly 6 
000 certified home health

agencies (HHA's) for all services in 1985 was about $2

billion. By 1990
, as many as 2. 2 million patients will be

receiving home health visits
, and as many as 30 percent of

those visits will be made by home health aides at a cost of 
000. 
about $750 000  Aides will continue to spend triple the
amount of time in a patient'
s home as skilled professionals. 
In order for an HHA to participate in the Medicare program

it must meet the Conditions of Participation. 
These

standards 
, set forth in 42 CFR 405. 120Iff 
, cover such areas

as organization, administrative accountability, financial

planning and budgeting, 
recordkeeping, the provision of

health services and quality assurance procedures.

Section 42 CFR 405. 1227 outlines the single Medicare

Condi tion of Participation and two standards that home care

agencies must meet concerning home health aide services.

Section 1861 (m) (4) of the Social Security Act requires home

heal th aide services provided to Medicare patients to be

part-time or intermittent" and also requires home health

aides to have "successfully completed a training program

approved by the Secretary.

The certification of 
HH' s is carried out by the Health Care

Financing Administration 
(HCFA) through the efforts of State

survey agencies. 
Home care agencies must be licensed in

States which require such licensure. 
METHODOLOGY  site visits were made to seven States 
throughout the country. 
In each State, discussions were held
wi th home health agency and vendor administrative personnel  State surveyors and licensure personnel
, supervisory visiting
nurses 
, home health aides, Medicare patients, physicians, and
representatives of labor unions, educational institutions and
home care industry agencies. A total of 62 Medicare patients
and 44 home health aides were visited in the patients
' homes.

A sample of medical records from each home health agency was

obtained and reviewed by skilled medical professionals on the

inspection team. 
Additional data were collected. (see
details). 
Appendix II for 
MAOR FINDINGS: 
MEDICARE PATIENTS' NEEDS FOR KEY HOME HEALTH AIDE

SERVICES AR NOT BEING MET

A review of patient records revealed that where 
the plans of care called for specialized services 
in support of the duties of skilled nurses or
physical therapists 
, the aides failed to
document , and perform, half of these tasks. The 
non-performance of these tasks deprives the 
Medicare patient of the full benefit of the home 
care program, and could result in a patient not 
realizing full rehabilitation potential
, or in a
patient' 
s condition worsening to the point where 
re-hospitalization is required. 
Since the Medicare program is already paying for

visi ts of sufficient 
length to accommodate more
specialized services of aides
, the Medicare
program is paying for aide services not rendered. 
We found that poor supervision of aides is the 
main reason for the failure to provide ordered
care. 
Substantial weaknesses were noted in the 
orientation of aides to the needs of patients by 
supervisory nurses and in the supervision given 
to the aides in the patients' homes. 
The review of patient records also revealed that 
home health aides always delivered prescribed 
personal care  services , such as helping patients
with baths, care of mouth, skin and hair 
assisting them to the bathroom or in use of bed 
pans and preparing meals for them. 
The aide is viewed as a personal care giver.

This perception contributes to the failure of

aides to provide specialized services.
 Serious problems were noted with agencies' use of 
home health aides under contract. These include: 
Medicare patien  vulnerability to substandard 
ssarily
practices and services which are unnec 
time consuming, frequent and costly. 
II. 
STANARS NOT PROVIDED 
The Medicare Condition of Participation for home 
heal th aides lacks standards for recruitment 
standards for 
hiring and training. The 
assignment of aides and supervision do not 
provide sufficiently objective criteria. As a 
result, state agencies responsible for surveying 
home health agencies for compliance with the 
Condi tion of Participation find the survey 
process difficult to perform effectively. Many 
States provide standards with specific criteria 
for the training of home health aides, although 
these standards vary with regard to training
curriculum length and content. 
Improvements in Medicare standards are needed to 
upgrade the quality of care provided by aides 
and to assure the cost-effectiveness of the 
estimated $650 million Medicare will pay for
aides 
' services in 1988. 
Low priority is placed by states on home health
surveys. 
This limits the size of survey staffs 
numer of 
as well as the  surveys performed. 
III. 
PROBLEMS NOTED WITH AGENCY PRACTICES IN EMPLOYING 
AIDES 
Recruitment 
, hiring and retention of home health 
aides are maj or problems for many agencies which 
offer low pay and limited benefits. These 
agencies do not attract the most reliable 
employees and experience a very high turnover
rate. 
other agencies, however, assure effective 
selection and retention of aides by offering many
incentives 
, including good pay, benefits and
paraprofessional status. 
MAOR RECOMMNDATIONS AN AGENCY COMMNTS 
The Health Care Financing Administration (HCFA) should

direct state survey agencies, through training

programs And written instructions, to review selected

iii  plans of care and the corresponding patient medical

records to assure that all prescribed tasks are

performed and documented by home health aides.

Training and instruction of state surveyors is

essential to assure that the Condition of

Participation for aides is satisfied.

The HCFA agrees with this recommendation and will take

steps to accomplish this.

II.

The HCFA should assure that required home visits are

made by state surveyors. The criteria for conducting

the home visit program should be reevaluated to assure

that the program can be effectively carried out within

existing budget I  tations. 
imi 
The HCFA indicates that all states have been provided 
wi th additional and adequate resources to conduct
required HH 
home visits. 
III.

The HCFA should encourage states without specific

state regulations on the training of home health

aides to develop a curriculum for training home health

aides , or adopt an existing curriculum. 
Completion of
an established training program should be a

prerequisi te of a home health aide position.

The HCFA agrees with this proposal and 
is developing a
revision to the Medicare Conditions of Participation
which will strengthen requirements for 
home health
aide training and supervision. 
IV.  The HCFA should revise those sections in the Health

Insurance Manual for home health agencies and fiscal

intermediaries (FI' 
s) which deal with services

aides. 
provided by home health 
The revisions should 
distinguish between personal care services and those 
services representing extensions of skilled care 
indicating that all tasks in the plans of care
, are 
expected to be performed by aides during each
visit. 
The HCFA will consider including in the Home Health

Agency Manual and the State Operations Manual a

section which indicates that HCFA considers it to be a

significant health and safety breach if the HHA is not

insuring that the home health aide provides the

services ordered on the plan of treatment.
 The HCFA should revise the Home Health Agency Coverage 
FI' s. 
Compliance Review instructions to  Revised 
instructions should expand the points to be addressed
by the FI' 
s during onsite reviews to include 
comparison of aide tasks specified in plans of care 
with aide tasks performed, to assure that plans of 
care tasks for aides are fully implemented. 
The HCFA will consider including an instruction in the
Coverage Compliance Review Program 
(Part A' 
Intermediary Manual) which will address this concern. 
Full HCFA comments are included in Appendix IV.  INTRODUCTION 
Covered health and personal care services provided to

eligible patients at home are reimbursed under Medicare.

These services include skilled nursing, physical
, speech and

occupational therapy, medical social services and services

provided by home health aides, including personal care. They
must be ordered by a physician and provided through a

Medicare-certified home health agency. 
Coverage by Medicare
is also dependent upon a homebound patient'
s need for the

part-time or intermittent services of nurses and other

skilled professionals. 
The coverage of home health aide
services is contingent upon the need for skilled

professional services. 
Medicare reimbursement to nearly 6 
000 certified home health

agencies (HRA's) for all services in 1985 was about $2

billion. By 1990 , as many as 2. 2 million patients will be

receiving home health visits, and as many as 30 percent of

those visits will be made by home health aides at a cost of 
000. 
about $750 000  Aides will continue to spend triple the
amount of time in a patient's home as skilled professionals. 
In order for an HRA to participate in the Medicare Program 
it must meet the Conditions of Participation. These
standards 
, set forth in 42 CFR 405 . 1201ff , cover such areas
as organization, administrative accountability, financial 
planning and budgeting, record keeping, the provision of 
health services and quality assurance procedures. 
Section 42 CFR 405. 1227 outlines the single Medicare
Condi tion of Participation and two standards that home care 
agencies must meet concerning home health aide services. 
Outlined in summary form below
, they include the following

requirements: 
Hirinq 
- aides are able to read, write, and carry out
directions, and are mature and capable enough to deal

with sick patients. 
Training 
- aides are carefully trained in assisting 
patients to achieve maximum self-reliance.

Assiqnment of Duties - aides are assigned specific

duties by 
a registered nurse. 
Supervision 
- aides are closely supervised by a 
registered nurse or other professional staff every two

weeks.  The regulation also identifies tasks which home health aides 
are trained to perform and duties which they may be assigned
by a registered nurse. 
The regulation does not always define 
tasks and duties, such as "personal care" , but they may be

grouped into three categories and include the following:

Personal Care Services  Helping patient with bath, care

of mouth, skin and hair. Helping patient to bathroom or

in using bed pan. Changing patient's bed linen. 
Assisting with meal preparation and household services 
essential to health care at home to maintain a clean,
healthful and pleasant environment. 
Completing
appropriate records. 
Extension of Skilled Nursina Services  Assistance with
medications  that are ordinarily self-administered
simple exercises 
, specific treatments, clinical 
observations and nutrition. Reporting changes in the
patient' s condition to the supervising nurse. 
Completing appropriate records. 
Extension of Rehabilitation Services  Assistance with

ambulation and exercises as an extension of skilled

therapy services. Reporting changes in the patient' 

condition to the supervising nurse or therapist.

Completing appropriate records.

Section 1861 (m) (4) of the Social Security Act requires home

health aide services provided to Medicare patients to be

part-time or intermittent" and also requires home health

aides to have "successfully completed a training program

approved by the Secretary.

The certification of HRA' s is carried out by the Health Care

Financing Administration (HCFA) through the efforts of State

survey agencies. Home care agencies must be licensed in

States which require such licensure.  FINDINGS 
MEDICAR PATIENTS' NEEDS FOR SOME KEY 
HOME HEALTH AIDE SERVICES AR NOT BEING MET 
Plans of Care Not Being Followed

All 62 patient records reviewed contained plans of care 
which called for aides to perform tasks representing 
personal care services; 85 percent of the plans also 
called for aides to perform tasks which represented an 
extension of nursing or rehabilitation services. 
Examples of the tasks found in plans of care in support 
of nursing services included the following: -assisting
with dialysis; diabetic monitoring 
(urine testing);
catheter care; foot soaks; special skin care; 
observation and notation of changes in respiratory 
condi tion; encouraging intake of fluids; recording 
intake and output of fluids; taking of temperature 
pulse and respiration with readings noted. For
rehabilitation 
, it was noted that aides were often asked 
to help with exercises, transfers to and from bed and 
ambulation training as taught by the physical therapist 
and recording progress in activities of daily living. 
A comparison of the 62 aide plans of care with

corresponding aide activity sheets revealed that

prescribed personal care tasks were always documented as

having been performed. However
, in 48 , or 91 percent

of the 53 cases where extensions of skilled services

were prescribed, one or more tasks were  not documented

by the aides as having been performed. 
In half of these 
cases 
, one or more of those tasks were never 
documented; in the other hal f, one or more of those 
tasks were only occasionally documented. Overall 
half 
of the prescribed extension tasks expected 
nearly 
to have been performed during more than 1, 600 aide 
visits were not documented. 
Responses from both patients and aides support the 
conclusion that all personal care tasks were actually
performed. 
Responses also support the conclusion that a 
lack of documentation indicates that the extension tasks 
not  performed by the aides. 
were 
Since the services provided by home health aides as an

extension of nursing or rehabilitation services are

intended to be a continuum of skilled care
, failure to

provide the services deprives the patient of the full

benefit of the home care program. 
A patient who has a

therapy treatment twice a week without any aide-assisted
 practice" between skilled visits may not achieve

her/his full rehabilitation potential as 
quickly, if at

,all. When key obsexvations are not made by an aide or 
are not noted for the nurse, the patient's condition may
worsen , and skilled treatment essential to the patient'
recovery might not be started. 
Special treatments assigned to aides, such as 
foot soaks 
or special skin care, if not performed, could lead to 
deterioration. In 
serious skin  cases of this kind 
re-hospitalization. 
patients may require 
To gain an insight as to why so many aide tasks were not 
documented and apparently not performed, the inspection 
team made follow-up contacts with supervising' nurses and
administrati ve 
personnel of a number of HRA' s which had 
been previously visited. The consensus of these 
respondents was that the primary and continuing cause of 
the problem was the lack of orientation of aides by 
supervising nurses to patient cases and tasks as well as 
the lack of ongoing onsi te supervision of aides by

professionals. One respondent said: 
"The start-up visit is essential in every 
single case to introduce the aide
, give the
case plan and demonstration of tasks. The 
supervision every two weeks must be onsite
with the aide. 
Another respondent indicated that extension tasks were 
not performed by aides because they are usually alone 
with patients and lack confidence without the proper 
support of skilled professionals. She said: 
"The aide may be fearful of doing a procedure 
if they are not shown it specifically. They
are aware they might hurt a patient and get 
into trouble if they do it wrong 
... The 
therapist or nurse must meet with the aide in 
the home and show them what should be done. 
One respondent said that the assignment of multiple 
aides to the same patient precluded supervision. Nurses 
cannot orient and supervise multiple aides effectively,
nor assure uniformly effective performance of tasks. 
She also said that it was a good practice to have aides 
present at patient conferences with skilled
professionals 
, but that practice was discontinued at her 
agency.  other causes cited by respondents included deficiencies

in aide training, especially in the area of documenting

tasks performed. It was noted that since many aides

lack language skills to articulate tasks performed, many

agencies frequently have aides use a checklist to

identify those tasks.

Maioritv of Undocumented Tasks Were Assianed to Vendor

Aides 
Medicare requires HH' s to meet all standards for home

health aide services, whether or not the services are 
provided directly or under contract. The HHs' must 
assure that vendors they contract with also meet the 
Medicare standards for aide services. 
Among the 44 home health aides providing services to the

62 patients, 15 were -emvloyees of vendors contracting

wi th six of the 16 HRA' s, and three were under direct

contract to a seventh HRA. 
Over one-half of the aides 
were employees of 12 HRA's (three also contracted for
some aide services and fall into both groups). The 
chart below summarizes the documentation of extension 
tasks by both groups of aides for the 48 patients
visi ted. 
Assigned Undocumented 
Aides  Patients  visits  Tasks  Tasks 
939  022  (tasks per  , 070 
Contract 
patient X visits) 
663  760  771 
Staff 
602  782  841  (49%) 
Visits 
Vendor Aide  Tend To Be Lon  Fre 
ent And Costl 
The average length of visit for the first group of 18
aides was 2. 
6 hours, while the second group of 26 aides
spent an average of 1. 
8 hours on each visit. Three
HH' s in one Eastern State, where contracting for aide 
service is prevalent, allow vendor aides to spend as 
much as 4 hours on each home visit. Staff aides of the
other HH' 
s spend under 2 hours per visit. Vendor
aides. also 
average more visits per week than staff
aides. 
Because of high turnover among aide staff 
vendors try to place aides on cases for longer periods 
of time with minimal travel. In addition, labor union  agreements affecting many vendor aides make it costlier

per hour to place those aides in a patient' 
s home for
less than three hours. 
For example, one union 
agreement with a vendor stipulates that aides will be

paid $1 more per hour on visits of under three hours. 
Lack Of Control Over Vendor Aides Makes HH Patients 
Vulnerable To Substandard Practices

In 1985, 6 of the 16 sample HH' s in three Eastern

States contracted with 18 vendors for all or part of the

nearly 150 000 home health aide visits provided to

Medicare patients. Of those total visits, 72 percent

were made by vendor aides the six HH's did not recruit, 
cases. 
hire, train or assign to patient  These HH' s 
assured vendor aides complied with standards in various

and often effective ways. 
In addition, it was found 
that vendors' deficiencies discovered by some HRA' s were 
not reported to Medicare authorities and were not always 
corrected. One HH conducted 1984 and 1985 annual 
audits of one of its vendors. Out of 165 aide personnel 
files audited, 211 deficiencies were found. Areas of 
deficiency included physical exams, health tests and
immunizations 
, references, and in-service training. 
Out of a small sample of 15 Medicare patients and vendor 
aides visited by the inspection team in three Eastern 
States, there was one case where the aide did not arrive 
at the patient's home when expected; the patient was a 
wheelchair-bound amputee on dialysis who lived alone. 
Another problem case involved a vendor aide who did not 
show up at the patient's home as scheduled for four
days. 
Nei ther the vendor nor the BR was aware of it 
until the patient complained. Some State surveyors and 
supervisory nurses said this occurs frequently. 
Supervision of Home Health Aides Is Found to be

Inconsistent And Ineffective. Especiallv When Multiple

Aides Visit The Same Patient

The previously noted comments on poor supervision were 
supported by the inspection team s observations during
the study. 
Weaknesses were noted in the areas of aide 
orientation and on-the-job training for individual 
patients by supervisory nurses. How supervision is to 
be carried out is not specified by Medicare regulations
al though registered 
nurses must make supervisory visits 
every 2 weeks, with or without the aide s presence.  Many supervising nurse and agency respondents believe

that aide orientation and on-the-j ob training for

specific patients, when conducted by supervising nurses

is the only effective way to assure that all prescribed

tasks are properly performed.

There was evidence that aides were given an orientation 
by the supervising nurse on the first aide visit in only 
22 percent of cases reviewed. This orientation 
introduces the aide to the patient and family, and
allows for discussing the home environment and reviewing 
care. 
the plan of  Demonstrations of tasks are given by 
the nurse followed by return demonstrations by the aide. 
orientation is considered more important when prescribed 
aide tasks include extensions of skilled services. 
When HRA's and vendors substitute aides on patient 
cases 
, the supervising nurse visits do not effectively 
intended. 
serve the purpose  Orientation to the patient
and on-the-j ob 
training should be repeated for each
aide 
, but often are not. One nurse supervising vendor
aides said: 
v"Iidseita ltloy  owrei ewinltl  hbeer  tthoe rteh eat t atshek sa.i des' first

cIfa nlolt.  I 
possible, I could make a telephone 
always make an effort to be onsi te the first 
time to teach the aide, but the aide changes 
time. It is
and I can't always go in every 
frustration! " 
A senior agency official of one of the HRA's advised
that "
rotation of aides" was based on assigning the more 
cases. 
experienced aides to new problem  However, a 
vendor official with more direct involvement in 
assignment of aide staff to the HH' s patients advised
that part-time vendor aides paid an hourly rate are 
usually taken off cases to give work to vendor full-time 
aides who are salaried. A common complaint from ex-
patients of this agency is "too many different aides. 
Documentation in two-thirds of the patient cases 
indicates supervising nurse visits were not made when 
the aide was present. Medicare regulations do not 
specify that the aide must be present. One nurse 
emphasized the importance of coordinating supervisory 
visits with aides when she said: 
"At least once a month there should be onsite 
supervision while the aide is in the home. 
Personally, I wouldn t want to be responsible 
for an aide if I didn't see her performance.  Although some nurses expressed difficulty coordinating

their visits with the aide in the home, many felt it was

essential to good care.

Aides Are Perceived As primaril v Personal 
Care Workers 
We learned from our discussions with patients
, aides and

supervising nurses, that home health aides are generally

perceived as "
caring companions" whose most important 
functions are to keep patients clean, lend emotional

support to patients and family and provide some

housekeeping services. Expectations for aides seldom

encompass duties to assist patients in achieving maximum

self-reliance. 
Eighty percent of all patient, aide and nurse

respondents identified personal care, especially

bathing, as the most important service aides provide.

Emotional support of patients and families ranked as the

second most important service provided by aides. Where 
family members lived with patients, aide visits were

seen as providing a needed respite from looking after

the patient. While the third-ranking service according

to patients and aides was housekeeping, the third-

ranking service in the view of nurses was the extension

of either nursing or rehabilitation services. 
One agency utilized aides primarily for providing

limited personal care services, regardless of the need

of its patients for other services aides are normally

expected to provide. All four patients from this agency

had plans of care calling for "personal care and bath"

only; two of the four patients had received physical

therapy, but the aides' plans of care in those cases

did not call for any tasks in support of the
rehabilitation services. 
The Registered Physical 
Therapist member of the inspection team felt that an 
extension of rehabilitation services by the aides in 
these cases was appropriate and would have been
beneficial to the patients. 
Aides indicated that this 
agency also does not allow them to do housekeeping, meal
preparati 
n or shopping. Such services may be covered
by Medicare and appropriate for specific patients. 
Where aides did not carry out the tasks considered 
extensions of skilled services, the length of visits did
or factor. In 
not appear to be a maj  those cases, aide
visits were as brief as 45 minutes and as long as 4
hours 
, averaging about 2 hours per visit, usually a
tasks. 
suff icient time to complete assigned  Medicare 
fiscal intermediaries routinely reimburse agencies for 
aide visits assuming all tasks were performed as 
prescribed in plans of care.  STANARS NOT PROVIDED 
Medicare Reaulations For Home Health Aides Are Not

Adequate 
Surveyors in 11 of the 12 States contacted view Medicare

regulations as barely adequate, or even inadequate, in

helping them do their job. A typical complaint was that

Medicare regulations "have too many gaps and are open to

too much interpretation.  others cited the lack of

training standards as a maj or weakness. "There' s a real 
void in the Medicare regulations there!" said a surveyor

in a Western State. Another deficiency noted was the

lack of a standard for the selection of aides. 
A review of the Medicare Condition of Participation for

home health aides and its two specific standards

indicates very few criteria. There are no specific

standards for the selection and training of home health

aides. 
For example, the Condition states that aides
should be "
carefully trained" , but it does not specify 
curriculum content or length, or required classroom and

clinical hours, or the need for continuing (in-service)
education or on-the-j 
ob training. 
In one of the two areas where the Condition does

establish a standard, which requires assignment of aides

to cases to be made only by a registered nurse
, there

are no criteria which provide a basis for the assignment 
such as patient needs and the abilities of specific
aides. 
The other Medicare standard deals with aide 
supervision. While it requires that a registered nurse 
aide, it
or other appropriate professional supervise the 
does not specify that the aide must be present during
supervision. 
Application Of Medicare Reaulations Is Subiective:

Guidelines Offer Limited Help

The decision by State surveyors as to whether agencies 
meet the overall Condition of Participation is largely 
left to the surveyor's subjective judgment. 
Consequently, while elements of the Condition (selection
or training of aides) or standards (assignment of duties 
and supervision of aides) may be out of compliance 
surveyors may still determine that the Condition is met. 
The only enforcement power to assure correction of 
specific deficiencies by non-compliant agencies is an 
involved decertification process which is rarely used.  Several surveyors indicated that HCFA's interpretive

guidelines for survey agencies offered them little help

in applying Medicare regulations during the survey
process. 
Some criteria are provided for the assignment 
of aides to patients and there is a reference to 
continuing staff education" being provided to aides. 
But HCFA guidelines say nothing about how many failures 
to comply with elements or standards are permitted 
before the Condition of Participation is judged "Not 
met.  One surveyor indicated that failure to meet 
either or both standards would always be cited as

deficiencies but would rarely be enough to find the

Condition not met.

3 .	 Most States Contacted Have Their Own Reaulations; Thev 
Contain More Specific criteria For Trainina Aides Than
Medicare Reaulations 
Of the 16 States queried, 11 said they had their own
regulations. Most said that their regulations give 
surveyors some specific and objective criteria 
primarily in the area of training, to determine an
agency' s compliance with Medicare regulations. (see
Appendix III for listing). The following elements are
significant: 
Course Curricula

Training course length is specified in nearly all the 
States which have their own regulations
, with the length
ranging from 42 to 230 total hours. 
Five of the States 
wi th regulations require supervised clinical training of 
from 15 to 30 hours as a prerequisite to successful
completion. Prior 
approval of home health aide training 
curricula is required by seven States. 
One State

requires training through a uniform curriculum offered

statewide by vocational-technical schools and regional

colleges. 
communi ty  Another State requires training 
programs to be equivalent in content and depth to the

National Homecaring Council's "Model Curriculum.

continuina Education

Of the 11 States with their own regulations
, the general

need for continuing education is cited in five States

while three other States specify that aides receive at

least 12 hours of in-service training a year.
 Certification of Successful Completion

A certificate attesting to successful completion of aide 
training is required in 6 of the 11 States with
regulations 
, with 3 States' certificates reflecting 
training. In 
State seals and approval of the  one State, 
certificates are issued by the licensing agency directly 
numer kept 
to the aide with a certificate  on permanent
registry. The application for the certificate must come 
from the trainer and attest to the aide's successful 
completion of a course approved by the State. 
Supervision 
with regard to supervision, most of thse.  State 
regulations are the same as Medicare' Only one State 
requires that a registered nurse provide direct
supervision, i. 
e., while the aide is present, to the 
home health aide in the patient's home at least every 2
weeks. 
Since Federal regulations offer few specific criteria 
surveyors in the five States which do not have any State 
regulations experience difficulty when agencies contest
findings of non-compliance. 
These States have developed 
internal procedures to compensate, e. g., recommending a 
particular training curriculum as one which meets the 
Medicare regulations. However, such recommendations do 
not carry the force of regulations and agencies are not 
compelled to comply with them. These surveyors
indicated they must also spend more time and resources 
tcor iatsesruriea .c oImtp liance without the benefit of objective
is much harder to assure that an aide is 
carefully trained" where States have no specific 
criteria mandating a curriculum, or where State 
regulations do not require prior approval of curricula. 
One surveyor in the East stated "It would make our job 
easier if we could simply verify that an agency uses 
aides that have been certified as passing a training 
program that is approved. 
4 .  Respondents Want More Specific Medicare Standards 
Virtually all the respondents 
queried, including all

surveyors, agreed that having a nationally mandated

training standard for home health aides would be useful. 
Several recommended wider use of the National Homecaring

Council' s "Model Curriculum" developed in 1978 and used 
extensively around the country as the basis for many
 . . . "
" . .. 
home health aide training programs. 
consultant said "It would  One survey nursing
make my job easier. 
It would
improve the qual i 
ty of work produced, and assure more
uniform practices from state to state. 
The Chief of another state s Home Health Survey Section

recommended "Revisions to include specific criteria for
training, i. e., numer of 
hours, curriculum content, 
composition of faculty and credential requirements.

She also suggested modifying the current Medicare

standards for assignment and supervision of aides by

the: 
addition of the requirement for
orientation 
of all Home Health Aides to the
patient 
, family and the written instructions
of duties. 
Verification of Home Health Aides' 
competency to carry out instructions should be

clearly documented in the patient'
s clinical

record 
This individual further recommended that patient and

family orientation "be added to the responsibilities of

the registered nurse 
(RN) in the Conditions of

Participation. " 
A State surveyor from a State without regulations 
indicated that former Medicare regulations are still 
used in that State as a guideline for compliance.
These former regulations established four Conditions of
Participation 
, including one each for home health aide
services 
, selection of home health aides
, assignment of
duties and supervision. All the 
Conditions contained 
some specific criteria to be met for compliance. 
Effective A plication Of Medicare And State Reaulations

Are Limited Bv Other Problems

Low prioritv for home health survevs limits survey

staff and number of survevs performed

We found that certified home health agencies are 
not usually resurveyed annually. Among the 16 
home health agencies visited by the inspection 
team in 1986, 1 was last resurveyed in early
1199868 ,1 .5  Iinn  f1a9c8t5, ,i n7  in 1984 , 1 in 1983 and 2 in
most sample States 
years.  , resurveys
are backlogged 1 to 4 
The reasons for the 
lack of resurveys are:  Federal/state budget restrictions limit survey 
resources allocated for home health agencies.
Most agencies are surveyed by one or two 
registered nurses, without other disciplines

represented. One state survey agency had only

three nurses available in 1985 to cover a

growing numer of certified agencies
nearly  , now

300. One state agency official
indicated: 
The principal problem is adaptation of the 
Federal budgetary process to state Agency
practices. In 
recent years, budget cuts and 
time lag in approval of Federal funding for

the program has all but eliminated 

national planning for maintaining necessary

staff and resources to carry out certification

activities. 
Horne health agency recertifications are given 
the lowest survey priority by state agencies.
The survey staff does give priority to 
agencies seeking Medicare reimbursement prior 
to certification. The dramatic increase in 
agencies seeking certification since 1981 
has heavily taxed state survey resources. 
Survevs performed are limited bv loaistical

factors 
Certified agencies' branch offices are not usually

visited on resurveys
, although a sample of some

branch office patients may be reviewed as part of 
a survey. 
This circumstance is due primarily to
two factors: 
The large size of some agencies. 
Some have as 
many as 20 branch offices. 
These branch 
offices sometimes fall wi thin the survey
jurisdiction of more than one of the State'
regional survey offices. 
Branch offices are sometimes located hundreds

of miles from the parent office
, making it

impractical and costly for a surveyor to visit

them. 
These branch off ices might be sub-units
and , as such, subj ect to independent
certification 
, if criteria for designating an
office as a sub-unit were stringently applied.  Trainina for state survevors has not emphasized

home health care

The HCFA training for new and experienced state 
surveyors has traditionally been built around
institutional activity, i. 
, hospitals, skilled
nursing facilities. Since the fall of 1985, HCFA
training has been geared more specifically to home 
care. 
heal th  Several survey agencies complained 
about training and suggested remedial action.

One survey agency representative said:

"Basic Training sessions for surveyors do

not address the Home Health agency survey

process. Training sessions for newly

hired surveyors, to accommodate changes

in state Agency personnel, are not 
readily available. Advanced training
for home health agency surveyors is 
existent. 
limited or non-
Another surveyor said: 
"I recommend specific training in home

heal th by HCFA centrally and through

regional offices. There has not been

enough emphasis on home care in past

training. 
There are currently 200

certified home health agencies in this 
state and the number is growing. We need 
more staff and training. 
Mandated home visits during survevs are not being

made 
Home visits during state surveys, required by a
recent HCFA directive (November 1985), are not
routinely made to Medicare patients in 11 of the
12 States contacted. 
Some limited experimentation 
has been tried in several States, but generally

implementation is lagging because:

The HCFA has not provided any additional

funding for this activity.

The HCFA criteria for implementation are 
extensive and scheduling visits could add 
more than a day to the survey process. For
example , patient consent for the visit is
required 
, and surveyor sample patients served 
by branch offices may be located far from the 
parent office of the agency. 
Many states are skeptical about the efficacy

of home visits.
 AN 
PROBLEMS  BEST PRACTICES IN PROVIDING 
HOME HEALTH AIDE SERVICES

Recruitment of Aides Is Costly To Many Aaencies;

Competi tion for Desirable Workers Is Keen And Employee

Turnover Is Hiah

Forty percent of the home health agencies and aide 
vendor agencies contacted during the inspection have had 
maj or problems recruiting, hiring and retaining aides. 
The 10 agencies serve primarily urban and suburban areas 
in three Eastern states and one Southern State. 
six of 
the 10 agencies train the aides they recruit and hire 
while 4 agencies recruit aides already train 
d or 
utilize aides provided by vendors under contract. 
All 10 agencies recruit aides through the use of daily

and/or weekly newspaper advertising, flyers distributed
in local communities, church and merchant bulletin 
boards and word-of-mouth. Several agencies offer cash
bonuses to aide staff for referring 
candidates. The

cost of advertising is high and the number of

respondents screened is much higher than those actually

interviewed, trained or hired. 
One agency
administrator 
s statement is typical: "We have 
suspended recruiting because it was too 
expensive. Too
many people didn't show up for employment interviews. 
came. It 
One in twenty  was too costly to do screening.
Nonetheless 
, this agency has since returned to 
recrui ting aides for its staff because of great 
dissatisfaction with the performance of the aides 
prov ided by vendors. 
One vendor, which recruits and trains aides in a
suburban area 
, screened nearly 1, 000 applicants over
the last 3 years. 
After an extensive and costly 
interviewing process, only 411 people were selected for
: training; of that 
hired.  number, 324 aides were graduated and
The maj or concern expressed by respondents 
about aides trained under these circumstances was the

pressure agencies are often under to assign aides to

patients when the aide's ability and reliability are

questionable.  An agency administrator summarized the predominant view

of respondents about the hiring and training of aides: 
"If the future will continue to see paraprofessionals

doing more and more for patients
, there must be higher

standards for training and pay.

. One phenomenon affecting many of the agencies is the 
movement of a segment of the workforce
, made up of

mature women, to local employers such as fast food

chains. Many of these women are filling jobs previously

held by teenagers. Many of the people responding to

agency recruitment efforts tend to be looking for

transient employment. One vendor indicated that half

the aides they train and hire are single parents, some

on public assistance, whose reliability is affected by

day care and school schedules. Aide turnover rates of 
from 20 percent to 50 percent annually have perpetuated

the recruitment problems of the 10 agencies
, making

recrui tment a constant 
and costly process. 
Agencies with Staffina problems Offer Few Incentives to

Assure Effective Selection And Retention Of Aides

Eleven agencies reported problems retaining aides

including the 10 agencies with recruiting problems. 
One 
maj or characteristic of these agencies is that they

offer prospective aides the lowest wages and benefits

among all the 25 agencies contacted. Agency
administrators agreed this was the maj 
or reason for
hiring and turnover problems. 
A typical response was: 
"Its hard to keep good aides because of poor pay and

lack of benefits.  In suburban and rural areas
, the
aides must provide their own transportation
, usually a
car, because public transportation is poor or
nonexistent. In 
these cases, a valid license and fully-
insured car is also required. 
One vendor does not 
reimburse its aides for transportation costs
, while
others provide reimbursement for mileage between 
patients' homes only. 
Other disincentives, include:

generally no pay during classroom training which may

last up to 4 weeks.

up to 6 months work for the agency or vendor before

a certificate attesting to the aide's successful

completion of the required training is awarded. 
no upward mobility opportunities and extremely

I imi ted hourly wage increases.  work assignments in some urban areas which are 
considered dangerous with no additional compensation 
made for these assignments. 
little or no allowance for uniforms.

agency treatment of aides as "second-class" 
employees rather than paraprofessional members of a 
home care team. 
Other Aaencies Assure Effective Selection And Retention

Of Aides Throuah Best Practices

The practices of most of the remaining 14 agencies in 
the sample group have resulted in effective hiring and 
retention of aides  Incentives offered to prospective 
employees have assured stable individuals and low or no
turnover. 
Consequently, recruitment has rarely been a
problem. 
Several agencies have waiting lists of
prospective employees. 
Most of the agencies can afford 
to be selective in filling occasional vacancies.

The practices of these agencies include: 
hiring aides, already trained, who have up to 2

years of patient care experience.

offering wages or salaries which provide annual 
earnings of from $12, 000 to $18 000. 
providing extensive health insurance and sick and

vacation leave benefits. 
reimbursing travel expenses at rates of $0. 18 to 
$0. 28 per mile, or the full cost of public 
transportation used. 
providing advancement opportunity through

significant incremental wage increases for both

length of service and effective performance.

providing opportunities for positions of greater 
responsibility within the agency, and offering other
incentives 
, such as tuition assistance programs to 
encourage continuing education in related health 
careers. 
acknowledging aides as important members of the

interdisciplinary home ,health care team.
 Aaencv practices Limit Efficient Use Of Aide Staff

Agency and vendor administrators agreed that many 
factors influence the assignment of aides to patients.
Al though a patient' s condition 
was frequently cited as a 
main consideration, in practice most assignments appear 
to have been made based on the availability of the
aide, the patient' 
s location and the aide's access to 
transportation. This was particularly true where
vendors provided aides under contract. 
Most of the 25 agencies and vendors indicate they try to

assign the same aide to a patient for the duration of

the plan of care. However, a review of medical records

showed 42 percent of the patients had three or more

aides assigned to them over a period from 1 to 6

months. 
Vendors frequently substitute aides on cases 
because of turnover and unreliability of their aide

staff. 
Aaencv Policies and Practices Influence Lenath Of Aide

visi ts 
Aides in six agencies indicated that the amount of time

spent with each patient was influenced by the agencies

policies. A proprietary agency in one Western state

requires all home health aide visits to Medicare

patients to be 2 hours, regardless of whether the needs

of individual patientss areiqdu:i re more or less time. One 
aide from this agency  "Two hours is not enough 
for certain patients.

A proprietary agency in another Western State contracts

directly with individual aides and pays them on a per

visit basis. The aides stated that they spend about 30

to 45 minutes with each patient and see six to eight
patients per day. 
Al though they 
provided personal care
services to their patients, including bathing, the

taking of temperature, pulse and respiration readings

and transferring the patient from bed, one aide said

that an hour was needed just to properly bathe patients.

Medicare Fiscal Intermediarv Policies Affect Agencv

Practices 
Although HCFA policy directives are used by all fiscal
intermediaries (FI), 
respondents in seven States 
indicated that FI application of policies varied both 
wi thin States and from State-to-State. These policies
which have become more restrictive in recent years
, have
influenced the length and frequency of aide visits 
agencies. 
provided by most of the 16  Respondents  indicated that services which will be reimbursed will 
always be provided. Aide services that are frequently 
denied, based on experience with FI decisions, will be 
all. 
limited or not provided at  RECOMMENDATIONS 
The Health Care Financing Administration (HCFA) should 
direct State survey agencies, through training 
programs 
and written instructions, to review selected 
plans of care and corresponding patient medical 
records to assure that all prescribed tasks are 
performed and documented by home health aides. 
Training and instruction of state surveyors is 
essential to assure that the Condition of
Participation for aides is satisfied. 
II.

The HCFA should provide state survey agencies with

administrative guidelines for assisting home health

agencies in the selection, training, assignment and

supervision of aides. This will prepare surveyors to

hdelup rhoimne ghe atlthh eag ensciuesr vcorereyct  pdefriociceneciess sfo.u nd

III.

The HCFA should assure that required home visits are

made by state surveyors. The criteria for conducting

the home visit program should be reevaluated to assure

that the program can be effectively carried out within

existing budget limitations. 
IV.  The HCFA should encourage:

states without specific state regulations on the 
training of home health aides to develop a 
curriculum for training home health aides, or
adopt an existing curriculum. 
Completion of an 
established training program should be a 
prerequisite for a home health aide position. 
Organizations such as the National Homecaring
Council 
, National Association For Home Care and 
the Joint Commission on the Accreditation of 
Hospi tals to work with their members to improve 
home health aide services through more effective 
training and supervision. 
The HCFA should revise those sections in the Health 
Insurance Manual for home health agencies and fiscal
intermediaries (FI' 
s) which deal with services 
aides. 
provided by home health  The revisions should 
distinguish between personal care services and those 
services representing extensions of skilled care 
indicating that all tasks in the plans of care are 
visit. 
expected to be performed by aides during each  VI.	 The HCFA should revise the Home Healths .A gency Coverage 
Compliance Review instructions to FI' Revised 
instructions should expand the points to be addressed
by FI' 
s during onsite reviews to include comparison of 
aide tasks specified in plans of care with aide tasks
performed , to assure that plans of care tasks for 
aides are fully implemented. 
VII.	
The HCFA should review home health aide services 
provided under a contract to determine whether a 
limitation on such services would be appropriate, in 
view of the findings that aides under contract: 
did not perform the majority of extensions of

skilled care tasks assigned to them; 
subj ected Medicare patients to substandard 
practices; and 
made visits which were unnecessarily time 
costly. 
consuming, frequent and  APPENDIX I 
HIGHLIGHTED HISTORY OF INTEREST IN HOME HEALTH ISSUES

In 1981, studies of home health services under Medicare by 
The General Accounting Office (GAO) and HCFA included 
findings and recommendations related to home health aide 
services. The GAO found that the use of aide services to 
assist beneficiaries with personal care could be reduced 
because either the beneficiary or family and friends often 
could and would have provided the care required. The HCFA 
identified overutilization of home health aide services 
resul ting from Medicare fiscal intermediary misinterpretation 
of utilization policy. 
Legislative changes in Section 1861 (m) (4) of the Social

Security Act in 1980 required home health aides to have

successfully completed a training program approved by the

Secretary. " The HCFA drafted a regulation which established

law. 
a training curriculum to meet the intent of  That 
regulation was never finalized and no training standard was

establ ished. 
On October 19, 1981, the Senate Permanent Subcommittee of 
Investigations, chaired by Senator William Roth
, followed an
investigation into home health services with a report.
Responding to concerns about home health agencies' practices 
in providing many services under contractual arrangements the 
Subcommittee recommended that nursing services and one other 
agencies. 
service be provided only by employees of the  This 
recommendation was made to alleviate questionable 
circumstances under which many agencies, characterized as 
"brokerage houses" by the Subcommittee, had been providing
services. 
In 1982 , HCFA advised the Subcommittee that its

recommendation would be reviewed. At the request of then
HCFA Administrator Davis, regulations were drafted addressing 
the Subcommittee's concerns as well as others HCFA had about 
the Conditions of Participation for home health agencies.
Those regulations were never finalized, and home health 
agencies are still permitted to provide many skilled and home 
aide services under contract. 
heal th 
At recent hearings on "Home Care Quality" held by the House 
Select Committee on Aging, testimony was presented which 
report. 
highlighted a number of issues addressed in this 
The 
Committee also released a report prepared by the American Bar
Association 
, entitled "The Black Box of Home Care Quality" 
which addresses quality standards and systems for monitoring
 the quality of care provided under Federal and state
Programs. 
The Chairman of the House Select Committee on 
Aging, Representative Edward R. Roybal, sponsored a bill to 
address home care quality problems the Committee has 
identified. Among the reforms in the bill are

administrative and judicial sanctions" for quality assurance 
violations; the establishment by HHS of "training 
requirements for all individuals delivering home care
services"  certification 
; and the development of "
requirements for homemakers, home health aides and personal 
care attendants. 
In April 
1987, the Senate Special Committee on Aging, Senator 
Care: 
John Melcher, Chairman, held a hearing on "Home  The 
Agony of Indifference, the Role of the Older Americans Act in 
Assuring Access to Quality Home Care.  Senator Melcher noted 
in his opening remarks at the hearing his intention to find a 
way to "insure quality home care to the millions of Americans 
who need it.  APPENDIX II

PROFILE OF REVIEW AND METHODOLOGY

The inspection included onsite visits in seven states

(California, Connecticut, Illinois, New York, Pennsylvania 
Tennessee and Texas) tso) 1.6  selected Medicare certified home 
health agencies (BR' Visits were also made in three of 
those states to nine aide vendor agencies with whom six of 
services. 
the 16 HH' s contract for aide  Discussions were 
held with 194 respondents in these states and in five other
states 
(Colorado, Iowa, Michigan, Minnesota and Ohio). 
Information on state standards was also provided by Florida,
Iowa , Louisiana, Oregon and Virginia. 
The 16 HH' 
s consisted of 12 voluntary agencies, including
thre 
hospital-based, and 4 proprietary organizations. Three 
agencies primarily serve urban areas, while two serve
suburban areas; seven serve urbani 
suburban areas; three serve
urbani suburban/ rural areas; and 1 a rural area. The nine 
vendors are primarily located in urban/suburban areas of 
state. 
three eastern states and one southern 
Respondents included HHA and vendor administrative personnel,
state surveyors and licensure personnel, supervisory visiting 
nurses, home health aides, Medicare patients, physicians, and 
representatives of labor unions, educational institutions and 
home care industry agencies. A total of 62 Medicare patients 
and 44 home health aides were visited in the patients' homes. 
Medical records from each HRA were,obtained and reviewed by 
team. 
skilled medical professionals on the inspection  The 
records corresponded to active and discharged Medicare cases 
selected onsite. Three active patients per agency were 
selected for a home visit at a time when their home health

aide was present. A discharged patient from each agency was

also visited at home, where possible.

The remaining data included agency policies and procedures 
concerning home health aides; personnel records of aides 
interviewed; contracts with vendors providing aide services; 
labor union agreements; state laws and regulations and other 
standards concerning aides; and training curricula from state 
institutions. 
agencies and public and private educational  " ..
APPENDIX III

EFFECTIVE STATE STANDARDS

The following State standards are drawn from the 11 States in

the inspection sample which have regulations for home health

aide services. These standards are recognized by the

inspection team as being effective in helping to assure that

home health aides are capable of providing the highest

quality services to Medicare patients.

Recrui tment and Hiring 
Trainees receive pav

The State of Connecticut requires agencies to hire

prospective home health aides before classroom training

begins. 
The agencies must provide aides with 10 hours of 
agency. 
orientation to the  During the orientation and 60 
hours of classroom training, agencies must pay the

prospective aides minimum wage.

Trainina 
Prior approval of training proarams

Seven States require prior approval of training programs for

home health aides: California, Connecticut, Illinois, Iowa

New York , Oregon and Texas. 
Cl inical experience required in trainina proarams 
Five States' training standards require a minimum of from 15

to 30 hours clinical experience before training is considered

complete: California, Iowa, New York, Texas and Virginia.

In New York, a graduate of classroom training is not deemed

qualified to practice as a home health aide until clinical

experience is completed. In California, home health aides do

not qualify for state certification (attesting to successful

completion of training) until all training requirements

including clinical experience, have been met.

Uniform statewide svstem for trainina

The State of Connecticut requires that all approved training

programs for home health aides are conducted by the State

Department of Education, Bureau of Vocational Technical

Schools or the Regional Community College program coordinated 
by the Matatuck Community College.  Recoanition of successful completion of training

Three states provide official state certificates attesting to 
the successful completion of training by the home health
aide: 
California, Connecticut and Illinois. In the two 
latter states, certificates are issued by trainers/employers 
but a record of certification is not maintained on any 
permanent state registry. 
In California, the Licensing and Certification Division of

the Department of Health Services issues certificates

aides. 
directly to the home health  Each aide receives a 
certification number permanently assigned to the aide
, and a

record of certification is maintained on a registry by the

icensing agency.

Continuina (in-service) education 
Three States require employing agencies to provide a minimum 
amount of annual in-service training for home health aides:
Connecticut 
, New York and Oregon. 
Supervision 
periodic and direct supervision of aides

The state of California, alone, requires that a registered

nurse provide direct supervision of the home health aide,
i. e. 
, while the aide is present, at least once every 2
weeks. 
Ratio of supervisory nurses to home health aides

Three States mandate that a specific ratio exist between

supervising nurse and home health aide staff: California

Connecticut and Florida.  .) .

APPENDIX IV

HCFA COMMNTS
 .. 
&;.: .  '.".  - "-;  :"' - - . j -
",t"III-
Heeltn C.re 
DEPARTTtE  T Of HEALTH  HVMAI' SERVICES,  Financing Adminis tra ' n 
Memorandu 
:t 
-i 2 3 S87  "','I ' "',- r:S
f. ' J. 
Dale 
William L. Roper, M.

VJtA 
Adinistrator 
rlo.r, 
Drft  Meca Patients 
Ole  Report "Hom Health Aide Services for 
Subject  (OA -02-86-00010 ) 
The Inspetor General 
Office of the Seretay 
drft 
qulity of hom health aide 
We have reviewed the Mecrae pporatt ioenn tthae.  \Ie appreiate the anlyais 
services provided to  in the 
Ole report an are pleaed to report tht HCA is in the press of
_jor coma cotain 
respoin. to  the 
ne  two of the  in the 010 report: 
for bet ter traini  of han heal th aidea: an imoved an IDre 
freuet han visits by State 8ureYOr&. 
conts  apeific recmndtiona ar oattaahte d for 
CA  on Ttheh    your
coideration.  yo for the opprtunity to 
on this report. 
t.nt 
At 
. Ie 
DIG 
ADM 
OGCIJG 
EX SEC 
7/;, 
DATE SENT  ' , 
Finainl Adinistration 
of the Health Care 
on thE' OIG Draft Report. "Hom Heal t. Aide Service 
" (Q,-
for Meicare Patients 02-86-00010) 
Reomndation  tJro 
OIG  diret  encies.  trinina prra an 
HCA should 
intrutionsSta.te  tsuorey  review selecte plan of ca an the 
wcroir rtslepno ndng patient meca rerd to assur tht all prescribe taks 
t. aides. Trininl an 
are perform an doc\.nte by ahro m heal  ..su tht  cotion 
the 
lrution of State sureyors 
essential to 
of paticipation for 
aides is &atisfied. 
Conts 
HCFA 
HCA aares tht tratinhitn l an instrution of State aaency sureyors 
Plticipation for hom health 
essential to IUsure  the ConcH tion of 
aides is satished. HCA will send a counication to all relional 
notify State ueniea to review aelecte hem 
offices reuestmineii ctahla tr ethredy  an plan of treatmnt to usur tht all 
heal tn aaency 
aides ' prescribe tak. ar perfonn an dol.nted: U ordere by the 
patients ' physician. 
rerd 
ad88 clinical 
review at all of its 
HCFA will also continue to  aureyors an will emphizer aecrsuttieni zation of 
traininl aessions for State  relpet to aervicea  of, an 
aderence to 
physicians ordrii wilh 
provide by, hom heal t. aidea. 
Reomndtion 
OIO  .uey  adinist 
HCFA should provide Stat  &8encies with  tive auidelines

(HH)  t.raininl, 
1n t.e selection, 
afso8r i assinstti naan h soumpee hrevailsti.o n8 .oefn caiiedse s. 'nilif woiull  prepare aureyors ptor oheslsp.  
correl deficiencies  durina the surey 
hom health agencies 
Conts 
HCA 
th  an enforce Federal relUlation 
The role of the surveyor is to ...ess 
rather  serve as a cosul t.t toM ae pircoavi daenr  1n correctina its
deficienies. HH, 
as with other  HecHcaid providers.
expte  s health an aafety reuiremts an 
to be aware of the prtra 
to oaply wi th them. 
th 
The interpreti ve auidelines uaed by sureyor. to usi8t them in conduclina 
sureys of HH caot  1"5t.rictive reui  nta  the
cotion  impoae aore 
of participation. 
at.rd 
It is tnl  cotion or  tho\C 
that a .tard  -.y be !lt even  there is a 
Hover, this 
or elemnt level.  applies only 
deficiency at the 

if the deficiency:  -. 
. -... -. .
- --- ....-......-..
Pae 2

requiremnt; 
Is not inconsistent with a 8tatutory 
cae; 
does not interfere wi t. adequate patient 
haza to patient. ' health an _fet:;; 
does not represent a 
correte within a reonble  tim; 
is capable of beina  period of 
tht  efforts 
the in.U tulion is mainJ reuonble plan an 
is one 
to corret.; Ul.d t. 
lemnt& or the
is not out of ,eneral confonn ty with the 8peific 
state at  iM1n. of each section of
the be 
condi lion or 

rent8 

the reui 
HH also mut 8ubnit an aceptable plan of 
If there i8 a deficiency, the 
o-rti fied or continue to be oert1 tied. 
corretion befo 
1 t. Q& 
ndti( 
OIG Re 
h..l re u.iNd h  vil1H.8 1U8  by State 8ureyora.
HCFA 8hould 
 vi.it pre.ra should be revaluated
Tthoe  acsrsituerr ita.  ft.o rth ct"o npdlu"eltIiln' cC lah 
 bi liff  u ve'1y euried out wi thin exi8tina 
buet 
limi tat1oru. 
Conts 
HCFA 
As evidence of HC'F'A I 5 b
 caUd  Hf h1n  t.h. .f."(fJ ulre:vii8 ntoes cso onfd u8cUtn -M'  H"S  hI oamll  vSitsaittses. 
have ben prO\'lct  , wi t)'  N:l  ' &h  -.qute 
et.ed am .&lt$ for FYIi l  &G, HU  1988 ar  for the

Tcheo  ntinue  uri;)'f'S.

visi t 
req'.i  by lute 
Prara  worklea aopUahed, indcate tht in 

data. withI" qreuliaNrdd  ttoJ  in.  161 HA (53 percnt cover&e).

1986 States weN:  HIl  3. 
States actually sur\'  yt' 5,001  (84t .peertcn. t coverae). a 58 percnt 
increed the 
increase over the minimally aceptable  We have 
minimally aceptable cove  e level fran 53 percnt to 75 percnt as 
buet. 
refl  re80urB ar provided 
ea  ted in the Fi 1988  Adequate Federal 
ooverae level.. 
State to conduct reuire surey 
Mr. 
t..,  ouca tl'  ap  OIid8e,
i.tea our 111. 
deop  orien1: tAbe
   to 
an 
ptsaa\.tta. pat of the contrat, atrhe  current surey praons s an form (inccloutdrnai t 
home xvitsiet  procedures)  to be reevaluated  revised. ThiB 
is  coplete in abut 12 8Oth. 
to be 
Reonnd ti 
01 G 
reJUatioh on the 
HCA shoud encoure States without speific State 
hom health aides to develop a curiculum for traininl hom 
trainini of 
aides, or adopt an exiatina curriculum. Copletion of 
heal th  proar  prereisite of a han health 
established trainina  should be a 
i tion.
aide  ..,
 - -
\. 
.: 
u't-t 
Conts 
HCFA  i&  a..d 
''. Jed  ua"C 
HCFA is developing B  &4\o'
Participation whicPhA"1'1 s't  en 'ruiremnlsIornome"he!'talde 
trainini an  ma..e.r .t..- dresses this  ndtion 
supervision in a 
an  Cfte M.DA.  which  tor 
lrainwhiincih  hwoimll h eal th aides or to adopt an establishelcpd.  curicuum. 
ReOlndtion 
OICi 
shoud  Nationl Homina 
HCFA  encourage Orlanizations suchC aaa  athne  
Hom  tne Joint Caiaaion 
Council, National Association for 
the Acrei taUon of Hospi tala to work wi t. their meabenr a to imrove 
auprviaion.
health aide aervices throuah more effective traini

Ccnts 
HCFA 
HCA routinely dissemnates informtion to nationl or,anizationf \fsotr use 
of a.Nioes. HCA atafr have appared .. 
in trainina provider

sipnefaokerrtsi oant  laDnet .i  s of Uie Amrica Health CainN!l& Ain8 sao wciaoUrkoinn l1 r0e .lhaatiroe nhip 
data. We 
with these or,anizationli Awilln o otwinuie ltlo  encoure thsm to work witi their 
mebers to imrove hom health Aide aervice.. 
Reocnd ti
OI  Ci  th Insure Maual for HH 
HCFA ahould revise those aections in the Heal 
an fiacl intenn ari ea (iiI' a) whi oh deal wi lh aervioea provide by baD 
heal th aides. The revi8ion ahould diatinluiah between personcl aca,e
sinecrvciacteins aa nth thto sael ls tearvkisce isn r ethpvree speilnatnian oa fie cxtaer nes iatornes  .eoxf  taekidll etdo  be 
perform by aides during eah 
ex Calian 
Also, HCA should revise the Hom Health A,ency Coverae  Review 
instrotion to FI' 8. 
Revised instrutions should caisothne  points to be
adessed by FI' s durin onsic tae  review to include  of aide 
taks specifaie d in plan of  arw ith aide taks perform, to assur tht
plan of  taks for aides 
fully implemnted. 
rena 
Conts 
HCFA 
HIta nia H neoatl tch lAe,aen tcoy  Husr uwhaelt dhaenre   t0h1e0  Ciosv e  e Coplitahnt  RHevCiAe wr Pevris&e rth e 
require intermiaries to  paycmat ,fo r hom health aide services when 
the aide provides ordere personl  but does not pro\'ide the
exteion  nurin 
of skilled  services which are ordere on the plan of
treatmt. If  caot suprt  ndtion beuse 
so, we  we do not 
statutry kais fothre  denyina Mecare p8)'mnt for a hom 
believe there is a  ar 
health aide visit where all cove  e criteria  met, even if the aide 
did not provide som of the aervices which were ordere on the plan of 
treatmnt. 
However, we would coider includna in the Hom Health Aaency Maual
the State Oprations Maual, a section which indicates tht HCA coiders 
an 
HH is not ensurin 
it to be a sianificat health  safety breach if the 
that the bCl  aide prvides the services ordere 
tretmt.  beal th  on the plan of , , 
II , 
pae 4

Coplian  PrJra 
the Coverae  Review 
We a150 would consider including  sint atent  tht
(Pat A Intermiary Maual), a  which indcates 
intennaries who beom aware of si tuationa in which the han health 
reuired t.o be proided by the 
aide is not providinj all of the services 
aide in the plan of treatmnt,  tuaUon to the at.tention 
ahould bri  the s1 
relionl  relional office wold be resposible for 
of the HCA  office. The  intermiary, forwina 
re\'iewi  the informtion provided by the  it to 
the State ..ency, aM detennir'i  the natur of the action to be taen 
the Stat. aaenc)'

Renda t 
010  i on hc. health aide 8ervio.a provide wder a cotrat 
HCA should review 
ser\'iceil wold be approriate. 
det.raine whet.er a limitation on luch 
Ccnts 
HCA 
will  ,..01 ve the findna& of the 
We believe that the prposed reJUlati  ar 
010 st\d  apet to .  rvi8ion of aidM .arv1oea t4ich  provide 
wi th 
uner cotrat. 
Con 
General  tht 
idehtitied in the rel  rt (pae 18) 18 
One of the probl  an fro 
intermary applicaUan of pa!iey vuie!i boO. w1t.hln Stiatnesf lue 
State t.o State.  th.t. lhvlit: poliCl.. have  the 
lt is alht.ed 
lenth an freuency of aide viii ls provide. 
freeeri 
han 
In October 1986, HCA bClCM Ulii""i7\/et"feal8 silni  trahfeael rtsh 
int; 
aaencies (HH
 ) to 10
 S1ent.  *:i  iarie8.h Tah ese 
will be capleted b ' Septlt  r I. 1987. A provoaed rule  a180 ben 
baed HH to the deaianted
piunbtleisrhmedi ator iaesss.i sInt/ riaea assniteinc ippraotveidde trh.a
 t the reuction in the n\Dber of 
intermaries procssi  HH bills will lead to areter consistency. 
Since the desiintion of the 10 reJional intermiaries, HCFA ha ben 
worki  with them to identify aras where incnsistent dettehnnt nation have 
ben mde. to arrive at proper determinations, an to ae  in the 
futur the auidelinea will be applied uniformy.