Department of Health and Human Services
 
OFFICE OF 

    
INSPECTOR GENERAL 

 
 
 
 
 
 
 
 
DEFI CIENCY HISTORY AND 

 
R M
ECERTIFICATION OF  EDICARE 

 
 
H H A  
OME  EALTH  GENCIES 

 
 
 
 
Daniel R. Levinson 
  
Inspector General 

 
August 2008 
 
OEI-09-06-00040 
   
 
Office of Inspector General

http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components:  
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections  
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving  program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The  Office of Counsel to the Inspector General (OCIG)  provides  general legal services  to  
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.    
   
I N T R O D U C T I O N  
  E X E C U T I V E   S U M M A R Y  
OBJECTIVE 
 
To determine: 
1. 	  the extent to which Medicare home  health agencies (HHA) 
repeated the same deficiency citations across three consecutive 
surveys, and 
2. 	  whether the Centers for Medicare &  Medicaid Services (CMS) 
uses deficiency history in its oversight of HHAs. 
BACKGROUND 
Medicares home health benefit provides treatment for beneficiaries who 
have short- or long-term illnesses or  injuries and who are confined to 
their homes. Services provided by a Medicare HHA include skilled 
nursing services, therapeutic services (physical and occupational 
therapy and speech-language pathology), home health aide services, 
medical social services, and certain medical supplies and equipment. In 
recent years, this benefit has grown in  terms of Medicare beneficiaries 
receiving home health services, expenditures, and number of HHAs. 
All HHAs participating in the Medicare program must be compliant 
with 15 Medicare Conditions of Participation (CoP) and 69 standards.  
CMS contracts with State agencies to conduct initial HHA certification 
and recertification surveys to determine CoP compliance.  Since fiscal 
year 2006, pursuant to section 1891(c)(2)(A) of the Social Security Act,  
all HHAs have been subject to a recertification survey at least once 
every 36 months. In addition, State agencies annually survey a  
5-percent targeted sample of at-risk  HHAs.  CMS uses an algorithm to 
identify at-risk HHAs.  An HHA that receives one or  more standard-
level or condition-level deficiencies  must respond to the State agency 
with a plan of correction.  An HHA with one or more condition-level  
deficiencies  must come back into compliance within 90 calendar days 
from the completed survey date.  Noncompliance with one or more CoP  
is cause for termination of participation.  Termination is the only 
sanction available to CMS in response to HHA noncompliance.  CMS 
has not implemented intermediate sanctions against HHAs as directed 
by the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987). 
The report findings are based primarily on analysis of data from CMSs 
Online Survey Certification and Reporting System (OSCAR). We  
analyzed survey data for 5,661 active Medicare-certified HHAs as of 
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E X E C U T I V E   S U M M A R Y   
January 11, 2007. We also interviewed staff at CMS headquarters and 
regional offices, State agencies, and  HHAs. 
FINDINGS 
Fifteen percent of HHAs repeated  the same deficiency citation  on 
three consecutive surveys.  These cyclically deficient HHAs most 
frequently repeated deficiency citation is related to patient plans of 
care.  On the three most recent surveys, these HHAs received, on 
average, twice as many deficiency citations per survey compared to 
HHAs that did not repeat citations.  Among cyclically deficient HHAs, 
most are located in six States and tend to be concentrated in highly 
populated areas. 
CMS oversight of HHAs could be improved.  Currently, CMS does not 
use all available deficiency history information in its oversight of HHAs.   
We found that deficiency history beyond the most recent survey can be  
an important indicator of performance on the next survey and can 
improve CMSs identification of at-risk HHAs.  For HHAs with one or  
more condition-level deficiencies, CMS has no sanction other than 
initiating a termination track.   
RECOMMENDATIONS  
Based on our findings, we recommend that CMS:  
Use existing survey data to identify  patterns of deficiency citations 
and at-risk HHAs.  CMS should require surveyors to review all 
available survey data prior to each upcoming survey. In addition, CMS 
should include multiple survey results in its algorithm that identifies 
HHAs that are at risk of providing poor quality of care. 
Implement intermediate sanctions as directed  by the OBRA 1987.  
Currently, termination from the Medicare program is the only sanction 
for poor-performing HHAs.  Intermediate sanctions may include civil 
money penalties, suspension of all or part of Medicare payments, and  
appointment of temporary management for cyclically deficient HHAs.  
 
 
 
 
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AGENCY COMMENTSAND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS generally concurred with our recommendations. CMS indicated 
that, during the last several years,  it has implemented improvements to  
the oversight of HHAs,  many of which address the issue of repeated  
deficiencies.  
CMS concurred, in part,  with the recommendation that the agency use 
existing survey data to identify patterns of deficiency citations and 
at-risk HHAs; specifically, that CMS require surveyors to review all 
available survey data prior to each upcoming survey. CMS noted that 
section 2200A of the State Operations Manual requires surveyors to 
review complaint data, previous survey data, and reports generated by 
the Outcome and Assessment Information Set system when preparing 
to conduct an onsite survey. The agency will issue the final version of 
this report to the regional offices and State survey agencies and  
reinforce the necessity of reviewing  previous survey data. 
CMS does not concur with the second part of this recommendation: that 
the agency include multiple survey results in the algorithm that 
identifies a targeted sample of HHAs  that are at risk of providing poor 
quality of care. CMS suggests that including an algorithm of three 
standard surveys would result in newer HHAs, among others, not being 
included in the targeting process because these HHAs lack historical 
survey data. We excluded HHAs that did not meet the study criteria in 
order to determine clearly the relationship between repeat deficiencies 
and subsequent survey performance.  However, CMS would not need to 
exclude any HHAs when using an algorithm that makes use of 
historical data. CMS could modify the algorithm to include any 
available historical survey data that have been weighted, as 
appropriate. HHAs with fewer than four surveys included in OSCAR 
would be assessed based on the survey data that are available. Our 
analysis demonstrates that historical data can improve CMSs ability to 
identify at-risk HHAs.  CMS should use all available data to target 
those HHAs most at risk of providing poor quality of care. 
As an alternative to modifying the algorithm to include historical survey  
data, CMS could conduct analysis similar to that described in this 
report to identify HHAs with repeated deficiencies across multiple 
surveys. CMS could provide this information to State survey agencies  
annually to help surveyors identify HHAs that may be in need of closer 
review, whether or not they appear in the targeted sample. 
OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   iii   
   
E X E C U T I V E   S U M M A R Y   
CMS concurred with the recommendation to implement intermediate 
sanctions as directed by the OBRA 1987.  The agency indicated that 
changes in law and other regulations, together with the demands of 
additional improvement efforts, have impeded promulgation of the final 
rule. CMS outlined several initiatives it has undertaken during this 
time to address HHA performance and compliance.  
  OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   iv   
 
  T A B L E   O F   C O N T E N T S  
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
  
 
 
I N T RO DUC T IO N  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1 
  
 
 
F I N D IN G S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9  

  Fifteen percent of HHAs repeated the same deficiency citation 

         on three consecutive surveys  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
 
  CMS oversight of HHAs could be improved. . . . . . . . . . . . . . . . . .  11 
  
 
R E C O MMEN D A T ION S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  14 
  
  Agency Comments and Office of Inspector General Response . . .  15 

       
 
APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  17 
  
  A: 	Medicare HHA Conditions of Participation and Standards. . .  17 

  B: 	HHA Survey Cycles Prior to Fiscal Year 2006. . . . . . . . . . . . .  21 
  
  C:	  CMSs Algorithm to Identify Targeted Sample of  

               At-Risk HHAs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  22 
  
  D: 	Standard-Level Deficiency Citations That Account for  

               Half of All Deficiencies Across the Three Most Recent  

               Surveys for Cyclically Deficient HHAs. . . . . . . . . . . . . . . . . . .  23 
  
  E:	  Metropolitan Statistical Areas With High Numbers 

               of Cyclically Deficient HHAs. . . . . . . . . . . . . . . . . . . . . . . . . . .  24 
  
         F:  Agency Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  25 
  
 
 
A C K NO WL E D G M E N T S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  29 
    
   
I N T R O D U C T I O N  
  I N T R O D U C T I O N  
OBJECTIVE 
To determine: 
1. 	  the extent to which Medicare home  health agencies (HHA) 
repeated the same deficiency citations across three consecutive 
surveys, and 
2. 	  whether the Centers for Medicare &  Medicaid Services (CMS) 
uses deficiency history in its oversight of HHAs. 
BACKGROUND 
Medicare Home Health Benefit and Medicare Expenditures 
Medicares home health benefit provides treatment for beneficiaries who 
have short- or long-term illnesses or  injuries and who are confined to 
their homes.1  Home health care is intended to reduce the need for 
hospitalization and institutionalization and to help beneficiaries 
maintain their independence and quality of life.  To qualify for home 
health services, a Medicare beneficiary must be homebound, be under 
an established plan of care by a physician, and need at least one home 
health therapeutic service or intermittent skilled nursing service  
(e.g., intravenous or intramuscular injections, intravenous feedings).2    
Services provided by a Medicare HHA include skilled nursing services, 
therapeutic services (physical and occupational therapy and   
speech-language pathology), home health aide services, medical social 
services, and certain medical supplies and equipment.3  These services  
are provided by the HHA or are provided under arrangements made by 
the HHA, and they must be ordered and periodically reviewed by a 
physician. In addition, HHAs must maintain patient clinical records 
and be licensed pursuant to State and local law.  By the end of 2006, 
there were approximately 8,800 Medicare-certified HHAs nationally.4  
In recent years, the number of Medicare beneficiaries receiving home  
health services has grown along with expenditures for those services.  
From 2001 to 2005, the number of Medicare beneficiaries served by 
HHAs increased 23 percent.  In 2005, HHAs provided services to almost 
 
1 Social Security Act ' 1835(a), 42 U.S.C. ' 1395n(a) (defining the term confined to his  
home). 
2 42 CFR  409.42. 
3 Social Security Act ' 1861(m), 42 U.S.C.  1395x(m). 
4 CMS Online Survey Certification and Reporting (OSCAR) System as of January 12, 2007. 
  OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   1   
   
I N T R O D U C T I O N   
3 million Medicare beneficiaries who averaged 31 visits per person.5   
Expenditures for home health services increased almost 50 percent from 
$8.6 billion in 2001 to $12.8 billion in 2005. 
HHA Conditions of Participation 
All HHAs participating in the Medicare program must be compliant 
with 15 Medicare Conditions of Participation (CoP) and 69 standards. 6   
The CoP are intended to  ensure the quality of services provided by 
HHAs.  The 15 HHA Medicare CoP fall into two areas:  administration 
and furnishing of services.  Twelve of the fifteen CoP  are subdivided into 
standards, which address specific aspects of the condition.   For example, 
the condition for clinical records includes standards that address the 
retention of records, the protection of records, record reviews, and 
evaluations of the HHA  program.  Among the 12 CoP that are 
subdivided, each condition can have from 1 to 23 standards.  Three CoP 
are not subdivided by standards.7  (See Appendix A for a list of all of the 
HHA CoP and standards.) 
Quality-of-care measures. One HHA condition requires Medicare-certified 
HHAs to report and transmit patient assessment data, within 30 days of 
completing the assessment, using the reporting Outcome and 
Assessment Information Set (OASIS).8  The OASIS is a group  of data 
elements collected from each HHA patient used  to manage and measure 
each patients care and outcomes.  For each HHA, CMS uses a subset of  
the OASIS data to calculate a score for 41 quality measures.9   CMS 
provides scores for 12 of the 41 quality measures for each HHA on its 
Home Health Compare Web site.10  These scores  are updated quarterly. 
 
5 CMS Health Care Information System data, 2007. 
6 Social Security Act  1891(a), 42 U.S.C.  1395bbb (a); 42 CFR pt. 484 (subparts  
B and C). 
7 The three CoP that are not defined further by standards are:  qualifying to furnish 
outpatient physical therapy or speech pathology services  
(42 CFR  484.38), medical social services (42 CFR  484.34), and release of patient 
identifiable OASIS information (42 CFR  484.11). 
8 42 CFR  484.20. 
9A list of the 41 quality measures can be found at 
http://www.cms.hhs.gov/HomeHealthQualityInits/10_HHQIQualityMeasures.asp#TopOfPage. 
Accessed on April 8, 2008. 
10 CMS, Information About Home Health Quality Measures.  Available online at 
http://www.medicare.gov/HHCompare/Home.asp?dest=NAV|Home|DataDetails#TabTop. 
Accessed on February 26, 2008. 
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I N T R O D U C T I O N   
HHA Survey  Process 
HHA  certification and recertification surveys. Pursuant to section 1891(b) of 
the Social Security Act,  CMS is responsible for ensuring that the HHA 
CoP and their enforcement are adequate to protect the health and  
safety of individuals receiving home health services.  To fulfill this duty, 
CMS contracts with State agencies to conduct initial HHA certification 
and recertification surveys (hereinafter referred to as surveys) to 
determine CoP compliance.11  The State agency also may conduct a 
survey at any time in response to complaints from HHA patients or 
other sources. 
During surveys, State agency surveyors (hereinafter referred to as 
surveyors) assess compliance with 7 of the 15 HHA CoP and the 
individual standards that fall within each, plus one additional HHA 
standard.12  13  CMS selected these seven CoP and one additional 
standard because they are associated most closely with patient care.  
The seven HHA CoP and one standard are: 
1. 	  42 CFR  484.10 Condition of Participation:  Patient Rights 
2. 	  42 CFR  484.11 Condition of Participation:  Release of Patient 
Identifiable OASIS Information 
3. 	  42 CFR  484.12 Condition of Participation:  Compliance with 
Federal, State, and Local Laws, Disclosure and Ownership 
Information, and Accepted Professional Standards and Principles 
4. 	  42 CFR  484.18 Condition of Participation:  Acceptance of  
Patients, Plan of Care, and Medical Supervision  
5. 	  42 CFR  484.36 Condition of Participation:  Home Health  
Aide Services  
6. 	  42 CFR  484.48 Condition of Participation:  Clinical Records  
 
11 Social Security Act ' 1864(a), 42 U.S.C.  1395aa (a). 
12 CMS State Operations Manual, Pub. No. 100-07, ch. 2,  2196.1A (rev. 1,  
May 21, 2004). 
13 An HHA may choose initial certification through one of three approved accrediting  
organizations with deeming authoritythe Joint Commission on Accreditation of Healthcare 
Organizations, the Community  Health Accreditation Program,  and the Accreditation 
Commission for Healthcare.  HHAs also may elect to be accredited and surveyed by one of the 
accrediting organizations.  CMS State Operations Manual, Pub. No. 100-07, ch. 2,  2210B 
(rev.1, May 21, 2004) and ch. 1,  1018D (rev. 1, May 21, 2004).  Recently, CMS approved 
deeming authority for the Accreditation Commission for Healthcare.  71 Fed. Reg. 9564  
(Feb. 24, 2006).  
 
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7. 	  42 CFR  484.55 Condition of Participation: Comprehensive 
Assessment of Patients 
8. 	  42 CFR  484.14(g) Coordination of  Patient Services (Standard) 
To assess those standards relating to patient care, surveyors review a  
case-mix stratified sample of clinical records and then conduct home 
visits for patients receiving HHA services.14 According to CMS policy, 
the number of record reviews and home visits varies based on the total 
number of unduplicated admissions requiring skilled services within a 
recent 12-month period.15 For example, an HHA that served between  
150 and 750 patients within a 12-month period will have a minimum of  
five to seven record reviews with home visits. In addition, the same 
HHA will receive 10 record reviews without a home visit.16 Surveyors 
also conduct several record reviews with and without home visits for 
patients who each experienced an adverse event outcome (e.g., emergent 
care for an injury caused by a fall or accident at home).17  
If an HHA has one or more standard-level or condition-level 
deficiencies, it is out of compliance and the surveyor provides the HHA  
with a Statement of Deficiencies and Plan of Correction form (Form 
CMS-2567) that includes evidence to support the deficiency citation.18   
The HHA must respond  with a plan of correction within 10 calendar 
days of receiving the form.19 An HHA with standard-level deficiencies is 
certified as in compliance by the State agency if the facility submits an 
acceptable plan of correction for achieving compliance within a 
reasonable period of time, which is generally no longer than 60 days 
after notification of the deficiencies.20 An HHA with one or more  
condition-level deficiencies is considered to be providing substandard  
care and cannot be certified as in compliance by the State agency based  
solely on a plan of correction.21 In these cases, the HHA is placed on a 
90-day termination track and is required to submit a credible 
 
14 CMS State Operations Manual, Pub. No. 100-07, ch. 2,  2200C4 (rev. 1, May 21, 2004). 
15 CMS State Operations Manual, Pub. No. 100-07, ch. 2,  2200C5 (rev. 1, May 21, 2004). 
16 CMS State Operations Manual, Pub. No. 100-07, ch. 2,  2200C6 (rev. 1, May 21, 2004). 
17 CMS State Operations Manual, Pub. No. 100-07, ch. 2,  2200C5 and 2200C6 (rev. 1, 
May 21, 2004). 
18 CMS State Operations Manual, Pub. No. 100-07, ch. 2,  2728 - 2728A (rev. 1,   
May 21, 2004). 
19 CMS State Operations Manual, Pub. No. 100-07, ch. 2, ' 2728 and 2728B (rev. 1, 
May 21, 2004). 
20 CMS State Operations Manual, Pub. No. 100-07, ch. 2,  2728B (rev. 1, May 21, 2004). 
21 CMS State Operations Manual, Pub. No. 100-07, ch. 3,  3012 (rev. 1, May 21, 2004). 
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I N T R O D U C T I O N   
allegation of compliance before the State agency conducts at least one  
revisit to determine whether compliance or acceptable progress has 
been achieved.22 23  
Provisions in the Omnibus Budget Reconciliation Act of 1987 (OBRA 
1987) directed CMS to implement intermediate sanctions against HHAs 
that are no longer in compliance with Federal requirements.24  The 
Secretary of the Department of Health and Human Services was 
directed to develop and implement intermediate sanctions no later than 
April 1, 1989, which were to include civil money  penalties, suspension of 
Medicare payments, and the appointment of temporary managers to 
problem HHAs.25  CMS proposed intermediate sanctions in 1991 but 
never finalized the regulation.26  As a result, the only remedy currently 
available to CMS in response to HHA noncompliance is termination.  
Survey frequency.  As mandated in statute, an HHA is subject to a 
recertification survey no later than 36 months from the previous 
recertification survey.27   Prior to fiscal year 2006, an HHAs survey 
frequency could vary from every 12 months to  every 36 months depending 
on the HHAs survey results.28  For example, a new HHA was subject to a 
survey every 12 months for the first 3 years.  If the HHA was  
deficiency-free for those  3 years, then it was placed on a 36-month survey  
schedule unless it received any deficiency citations on a subsequent 
survey.  In addition to conducting routine scheduled surveys, State 
agencies annually selected and surveyed a 5-percent random sample of 
HHAs on the 36-month survey cycle.29 (See Appendix B for further 
information on variable survey cycles prior to fiscal year 2006.) 
 
22 Ibid.  When an  immediate jeopardy to patient health and safety is documented, the State 
agency will initiate a 23-day termination track.  CMS State Operations Manual,  
Pub. No. 100-07, ch. 3,  3010B (rev. 1, May 21, 2004).  
23 Credible allegation of compliance is defined as a statement or documentation:  that is 
realistic in terms of the possibility of corrective action being accomplished between the exit 
conference and the date of allegation; and that indicates resolution of the problems.  CMS 
State Operations Manual, Pub. No. 100-07, ch. 3,  3016A (rev. 1, May 21, 2004). 
24 OBRRA of 1987, P.L. No. 100-203 ' 4023, Social Security Act ' 1891(e)(f), 
 42 U.S.C. 1395bbb (e)(f). 
25 Social Security Act  1891(f)(1).  
26 56 Fed. Reg. 37054 (Aug. 2, 1991). 
27 Social Security Act  1891(c)(2)(A).  A recertification survey is a standard survey as it is 
referred to in the statute. 
28 CMS State Operations Manual, Pub. No. 100-07, ch. 2,  2195 (rev. 1, May 21, 2004). 
29 CMS State Operations Manual, Pub. No. 100-07, ch. 2,  2195.E (rev. 1, May 21, 2004). 
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Since fiscal year 2006, CMS simplified its variable survey cycle with a 
new system.30 Instead of being subjected to variable survey cycles, all 
HHAs now are subject to recertification surveys at least once every   
36 months.   In addition to these surveys, CMS uses a 5-percent targeted  
sample that replaced the annual 5-percent random sample. The 
targeted sample is generated by an  algorithm that identifies HHAs at 
greatest risk of failing to provide quality care. (See Appendix C for 
further information on the algorithm.) CMS  indicates that it is using 
targeted sampling to utilize limited Medicare resources more 
effectively.31   Also, CMS no longer requires State agencies to survey 
HHAs 12 months after the initial certification survey. 
METHODOLOGY 
Scope 
As of January 11, 2007, CMSs OSCAR contained records for 18,731 
Medicare-certified HHAs. OSCAR maintains survey deficiency 
information for the four most recent surveys.  To limit our analysis to 
active HHAs, we excluded 9,908 HHAs with termination dates. Also, 
we excluded 157 HHAs with deemed status because the State agency 
does not conduct routine recertification surveys on these HHAs. 
Deemed status is received when an  HHA chooses certification through 
an approved accreditation organization. After we excluded deemed  
HHAs and those with termination dates, 8,666 active Medicare-certified 
HHAs remained in our study population. 
Analysis 
In this report, we refer to HHAs that have at least one deficiency 
citation repeated on three consecutive surveys as cyclically deficient.   
For the purpose of describing our methodology,  we refer to the four  
surveys in OSCAR numerically as 1, 2, 3, and 4  Survey 1 being the  
most recent survey conducted of that HHA and Survey 4 being the 
oldest survey in OSCAR. 
 
30 CMS, Division of Survey and Certification, Quality Assurance for the Medicare   
& Medicaid Programs, FY 2006 Mission & Priority Document, August 5, 2005. Through 
2008, CMS continues to apply this new system. CMS, Division of Survey and Certification, 
Quality Assurance for the Medicare & Medicaid Programs, FY 2008 Mission & Priority 
Document, August 8, 2007. 
31 Ibid. 
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I N T R O D U C T I O N   
For each of the two findings in this report, we analyzed data for a 
different subset of HHAs as shown in Table 1 below.  We identified 
cyclically deficient HHAs for each subset.  
 
Table 1. Subsets of HHAs in the Report  
At Least One   At Least One  
Number of  Active   Deficiency  Repeated  Deficiency  Repeated on 
Type of HHA Subset  Medicare-Certified HHAs   on Survey  1, 2, and 3  Survey  2, 3, and 4 
HHAs with three or four surveys 
5,661  873   
(Subset used for the first finding.)  
HHAs with four surveys 
5,011  655 
(Subset used for the second finding.) 
Source:  Office of  Inspector General analysis of CMS survey data, 2008  
 
To determine the current extent of cyclical deficiency among  
Medicare-certified HHAs for the first finding, we analyzed OSCAR 
results from Surveys 1,  2, and 3 (i.e.,  the three most recent surveys).  Of 
the 8,666 active Medicare-certified HHAs in OSCAR, we excluded  
3,005 HHAs that did not have at least three consecutive surveys with at 
most 42 months between surveys or did not have surveys within  
42 months of January 11, 2007.32  We chose 42 months, which includes 
the 36-month survey cycle and up to 6 months for the State agency to 
complete the survey, as the maximum amount of time between 
surveys.33  From the remaining 5,661 HHAs, we identified 873 HHAs 
that each had at least one condition- or standard-level deficiency 
citation repeated on Survey 1, 2, and 3. 
As part of the second finding, to determine how cyclically deficient 
HHAs performed  on the subsequent survey, we identified each HHA  
that had at least one deficiency repeated on Survey 2, 3, and 4  
(i.e., cyclically deficient on the three consecutive surveys prior to the 
most recent survey).  We then compared the survey performance on 
Survey 1 (the most recent survey) of these cyclically deficient HHAs to 
all other HHAs. Of the 8,666 active Medicare-certified HHAs in 
OSCAR, we excluded 3,655 HHAs that did not have four consecutive 
surveys with at most 42 months between surveys or did not have 
 
32 We contacted CMSs Region V office to determine why some HHAs had current surveys 
longer than 3 years ago.  The regional office indicated that either the HHA had  deemed status  
or the State agencies had  not entered the most recent survey results into OSCAR. 
33 Currently, there is no CMS guidance regarding timely uploading of survey results into 
OSCAR. 
  OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   7   
   
I N T R O D U C T I O N   
surveys within 42 months of January 11, 2007.  From the remaining 
5,011 HHAs, we identified 655 HHAs that each had at least one 
condition- or standard-level deficiency citation repeated on Surveys 2, 3, 
and 4.  To determine the use of deficiency history in the oversight of  
HHAs, these HHAs also were used in an analysis with CMSs 5-percent 
targeted sample for fiscal year 2006. 
In addition, we conducted structured interviews with staff from CMSs 
Survey and  Certification Group and  surveyors from CMSs regional 
offices and State agencies.  We also visited several HHAs to gather 
information about the survey process and HHA operations.  
Limitations 
Our study is limited to the information in OSCAR.  This study did not 
assess the survey process or the accuracy of CMS data in OSCAR. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspections issued by the Presidents Council on Integrity and 
Efficiency and the Executive Council on Integrity and Efficiency. 
  OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   8   
   
F I N D I N G S  
  F I N D I N G S  
 
Fifteen percent of HHAs repeated the same   As of January 11, 2007, 873 HHAs 
deficiency  citation on three consecutive surveys  (15 percent) repeated at least  
one deficiency citation on each of 
their three most recent surveys.  Many cyclically deficient HHAs 
repeated more than one deficiency citation across multiple surveys.  Of 
the 873 cyclically deficient HHAs, 366 (42 percent) repeated at least two 
of the same citations on  each of their three most recent surveys, and  
47 (5 percent) repeated the same five or more citations.  Most cyclically 
deficient HHAs repeated standard-level citations; only six HHAs had a 
condition-level deficiency repeated on each of their three most recent 
surveys. 
The most frequently repeated deficiency citation is related to patient plans 
of care 
The 10 most frequently repeated deficiency citations, among cyclically 
deficient HHAs, are standard-level deficiencies  and account for  
79 percent of all repeated citations.  (See Table 2 on the next page for a 
list of the top 10 deficiencies.) 
Four of the ten deficiencies (G158, G159, G164, and G165) are 
associated with standards in the acceptance of patients, plan of care, 
and medical supervision condition.34  These four deficiency citations 
account for 48 percent of all repeated citations among cyclically deficient 
HHAs. Of 873 cyclically deficient HHAs, 404 (46 percent) received a 
repeated citation for not demonstrating that the written plan of care 
was reviewed by the patients physician (G158).  The other three 
deficiency citations show that the written plan of care did not cover 
pertinent diagnoses (G159), the agency staff did not alert the physician 
of changes in the patients condition (G164), and the agency staff did not 
administer drugs or treatments as  ordered by the physician (G165). 
 
 
 
 
 
 
 
 
34 Each standard  and condition is affiliated with a specific G tag (e.g., G158).  CMS uses  
G tags to identify deficiencies on the Statement of Deficiencies and Plan of Correction form.  
  OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   9   
   
F I N D I N G S  

Table 2. The 10 Most Frequently Repeated Standard- and Condition-Level Deficiency  Citations  
                Among Cyclically Deficient HHAs 
Percentage of  
All 1,662  Of the 873 Cyclically  
Repeated  Deficient HHAs, Number 
Deficiency   of HHAs That Repeated  
Standard-Level Deficiency Citation* (associated condition) (G tag)   Citations   the Citation** 
1. 	 Written plan of care established and periodically  reviewed by a doctor.  (Acceptance of 
24.3%  404
patients, plan of care, and medical supervision.)  (G158) 
2. 	 Plan of care covers all pertinent diagnoses.  (Acceptance of patients, plan of care, and 
15.3%  255
medical supervision.) (G159) 
3. 	 Clinical record maintained in accordance with accepted professional standards.  
12.6%  209
(Clinical records.) (G236) 
4. 	 The comprehensive assessment must include a review of all medications the patient is 
8.5%  141
currently taking.  (Comprehensive assessment of patients.)  (G337)  
5. 	 Agency professional staff promptly alerts the physician to any changes in the patients 
5.2%  86
condition. (Acceptance of patients, plan of care, and medical supervision.)  (G164) 
6. 	 Drugs and treatments are administered by  agency staff only as ordered by the 
3.0%  50
physician.  (Acceptance of patients, plan of care, and medical supervision.)  (G165) 
7. 	 All personnel furnishing services maintain liaison to ensure that their efforts are 
coordinated effectively and support the objectives outlined in the plan of care.   2.9%  49 
(Organization, services, and administration.)  (G143) 
8. 	 Registered nurse regularly  reevaluates the patients nursing needs.  (Skilled nursing 
2.5%  41
services.)  (G172) 
9. 	 Registered nurse (or another professional described in paragraph (d)(1) of this section) 
must make an onsite visit to the patients home no less frequently than every  2 weeks.   2.5%  41 
(Home health aide services.)  (G229)  
10.  A written summary  report for each patient is sent to the attending physician at least 
2.4%  40
every 60 days.  (Organization, services, and administration.)  (G145) 
       Total  79.2%   
 Source:  Office of Inspector General analysis of CMS survey data, 2007. 
*For complete descriptions, refer to CMSs State Operations Manual, Pub. No. 100-07, Appendix B (rev. 11, August 12, 2005). 
**The column Of the 873 Cyclically Deficient HHAs, Number of HHAs That Repeated the Citation does not sum to 873 because HHAs may be cited for more than  
one deficiency.  
 
Cyclically deficient HHAs received twice as many  deficiency citations 
On the three most recent surveys, cyclically deficient HHAs received, on 
average, 11.3 deficiency citations per survey compared to 5.7 citations 
for those HHAs that did not repeat citations.  The most frequently cited  
deficiency citations across the three surveys are similar for cyclically 
deficient HHAs and those HHAs that did not repeat citations. (See 
Appendix D for a list of standard-level deficiencies that account for half 
of all deficiencies across the three most recent surveys for cyclically 
deficient HHAs.)   
Cyclically deficient HHAs are concentrated in several States  
Of the cyclically deficient HHAs, 64 percent (556 of 873) are located in 
six States  California, Florida, Illinois, Iowa, Michigan, and Texas.  
  OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   10   
   
FFFFF IIIII NNNNN DDDDD IIIII NNNNN GGGGG SSSSS  
However, only 30 percent of all HHAs in our study population are from  
these six States. In California, Illinois, and Michigan, more than half of 
HHAs are cyclically deficient. Highly populated areas within five of the  
six States (except Iowa) contain a greater percentage of cyclically 
deficient HHAs compared to the rest of the State. For example, three 
metropolitan areas in California contain 76 percent (61 of 80) of 
cyclically deficient HHAs in the State.35 Approximately 68  percent of all 
HHAs in California are in these three metropolitan areas. One 
metropolitan area in Illinois contains 74 percent (117 of 159) of 
cyclically deficient HHAs in the State, whereas only 55 percent of HHAs 
in Illinois are in this metropolitan area. (See Appendix E for the 
distribution of cyclically deficient HHAs in the States mentioned above.) 
 
 
CMS conducts surveys as part of
CMS oversight of HHAs could be improved  
its oversight of HHAs. Currently, 
State agencies conduct recertification surveys at least once every 
36 months for each HHA. In addition, State agencies annually conduct  
surveys of a 5-percent targeted sample of at-risk  HHAs. Prior to each 
survey, surveyors are required to review previous survey data in 
addition to outcome reports and complaint data.36 However, surveyors 
are not required to  review all past survey data in OSCAR. We found 
that deficiency history, beyond the most recent survey, can be an 
important indicator of performance on the next survey. 
Cyclically deficient HHAs performed worse on the next survey than 
other HHAs 
We identified 655 cyclically deficient HHAs that repeated at least one 
deficiency on the three consecutive surveys prior to the most recent 
survey. Chart 1 on the next page shows that they went on to receive 
more deficiencies, on average, than other HHAs on the most recent 
survey. This difference was more pronounced among HHAs with at 
least six deficiencies on the prior survey. 
 
 
 
 
35 A metropolitan area refers to a metropolitan statistical area as defined by the  Office of  
Management and Budget and based on U.S. Census Bureau  data. A metropolitan area has at 
least one urbanized area with a population of 50,000 or more. 
36 CMS State Operations Manual, Pub. No. 100-07, ch. 2,  2200A (rev. 1, May 21, 2004). 
OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   11    
   
F I N D I N G S  

Chart 1.  Cyclically Deficient HHAs, on Average, Received More  
                Deficiencies on the Next Survey Than Other HHAs 
10 
n=364 
 e 9 
h
n t 8 
o
s 
ciey  7 
ne
ev
ciur 6 
of deficent s 5 
mber ost re 4  n=481  n=3,875 
um
n 3 
ge  n=291 
era 2 
v
A
1 
0 
0 to  5  6 or  more 
Number of deficiencies on the prior survey 
Cyclically Deficient  All other HHAs 
Source:  Office of  Inspector General analysis of CMS survey data, 2008.  
 
Cyclically deficient HHAs performed worse on the next survey than  
at-risk HHAs  without a history of cyclical deficiencies 
Although CMSs algorithm identifies at-risk HHAs, it can target HHAs 
better by including deficiency history information such as repeated 
deficiency citations.  As  shown in Chart 2 on the next page, cyclically 
deficient HHAs that were not identified as at-risk by CMSs algorithm 
for fiscal year 2006 received, on average, 6.9 deficiencies on their most 
recent survey. This is greater than the average of 3.7 deficiencies 
among at-risk HHAs without a history of cyclical deficiencies.37  
 
 
 
37 We excluded 33 HHAs for which the prior survey (Survey 2) occurred after  
October 1, 2005, because information about cyclical deficiencies would not have been available 
when CMS identified at-risk HHAs for fiscal year 2006.  We also excluded 
2,711 HHAs for which the most recent survey (Survey 1) occurred before October 1, 2005, 
because we wanted to limit this analysis to HHAs for which performance on the most recent  
survey was unknown at the time CMS identified at-risk HHAs for fiscal year 2006.   
  OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   12   
   
FF II NN DD II NN GG SS  
Chart 2. 	Cyclically Deficient HHAs Performed Worse Among Both 
              At-Risk HHAs and Not At-Risk HHAs 
9 
n=92 
8 
e
h
n t n=260 
o 7 
s 
e
nciey  6 
ev
ciur
defint s 5 
of ce n=189 
mber ost re 4  n=1,726 
um 3 
n
e 
g
a 2 
er
v
A
1 
0 
CMS fiscal year 2006 at-risk group  Not in at-risk group 
Cyclically Deficient  All Other HHAs 
Source: Office of  Inspector General analysis of CMS survey data, 2008.  
 
CMSs sanction options for HHAs with deficiency  citations are limited 
For HHAs with one or more condition-level deficiencies, CMS has no 
sanction other than initiating a termination track. An HHA that 
receives one or more condition-level deficiencies is required to submit a 
plan of correction and is subject to at least one revisit by the State 
agency to determine whether compliance has been achieved. An HHA  
that receives only standard-level deficiencies is required to submit an 
acceptable plan of correction before being certified as in compliance.  
Although provisions in the OBRA 1987 directed  CMS to implement 
intermediate sanctions for HHAs that failed to correct deficiencies, CMS 
did not finalize the regulation. Therefore, termination from  the 
Medicare program remains the only  Federal sanction for HHAs with 
deficiency citations, and it is used only rarely. In 2006, there were only 
21 involuntary HHA terminations.   
OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   13   
   
F I N D I N G S  
  R E C O M M E N D A T I O N S  
 
An analysis of HHA deficiency history data shows that 15 percent of 
HHAs are cyclically deficient.  Furthermore, HHAs with repeated  
deficiencies  perform worse on subsequent surveys.  However, CMS does 
not use deficiency history in its oversight of HHAs.  Also, for HHAs with 
one or more  condition-level deficiencies, CMS has no sanction other 
than initiating a termination track.  Based on our findings, we 
recommend that CMS: 
Use Existing Survey Data To Identify  Patterns of Deficiency Citations and  
At-Risk HHAs 
CMS should require surveyors to review all available survey data prior 
to each upcoming survey.  Because CMS uses the number of  deficiencies  
as an element to identify at-risk HHAs, cyclically deficient HHAs could  
be considered at risk because they generally receive more citations.  
Identifying repeat deficiency areas could help surveyors and HHAs 
identify areas for improvement.  In addition, CMS could focus efforts on  
those States with large numbers of cyclically deficient HHAs. 
CMS should include multiple survey results in its algorithm that 
identifies the targeted sample of HHAs that are at risk of providing poor  
quality of care.  Because HHAs with a history of cyclical deficiencies  
perform worse on subsequent surveys, deficiency history can be an 
important indicator of future performance.  Currently, the algorithm 
does not include results from surveys conducted prior to the most recent 
survey. As a result, CMS and surveyors may miss HHAs in need of 
more frequent review.  CMS could incorporate prior survey  data from 
OSCAR into the algorithm. 
Implement Intermediate Sanctions as Directed by the OBRA 1987 
Currently, termination from the Medicare program is the only sanction 
for poorly performing HHAs.  We found that the most frequently cited 
deficiency for cyclically deficient HHAs identify problems related to 
patient plans of care.  In some cases, termination may be the 
appropriate action.  However, less  severe sanction options could be 
effective in addressing performance problems that do not immediately 
jeopardize patient health and safety. Options for additional sanctions 
may include civil money penalties, suspension of all or part of Medicare 
payments, and appointment of temporary management for cyclically 
deficient HHAs. 
  OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   14   
   
R E C O M M E N D A T I O N S  

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS generally concurred with our recommendations. CMS indicated 
that during the last several years, it has implemented improvements to 
the oversight of HHAs,  many of which address the issue of repeated  
deficiencies.  These changes include:  (1) oversight of branch locations,   
(2) the addition of new OASIS reports, (3) increased training of 
surveyors, (4) identification of a targeted sample of HHAs, and (5) the 
development of a State Performance Standards System.      
CMS concurred, in part,  with the recommendation that the agency use 
existing survey data to identify patterns of deficiency citations and  
at-risk HHAs; specifically, that CMS should require surveyors to review  
all available survey data prior to  each upcoming  survey.  CMS notes  
that section 2200A of the State Operations Manual requires surveyors 
to review  complaint data, previous survey data, and reports generated 
by the OASIS system when preparing to conduct an onsite survey.  The 
agency will issue the final version of this report to the regional offices 
and State survey agencies and reinforce the necessity of reviewing 
previous survey data.  We recommend that CMS specifically instruct 
surveyors to review data beyond the most recent survey and to highlight 
patterns of noncompliance such as repeat deficiencies across multiple 
surveys. 
CMS does not concur with the second part of this recommendation:  that 
the agency include multiple survey results in the algorithm that 
identifies a targeted sample of HHAs  that are at risk of providing poor 
quality of care. CMS suggests that including an algorithm of three 
standard surveys would result in newer HHAs, among others, not being 
included in the targeting process because these HHAs lack historical 
survey data. We excluded HHAs that did not meet the study criteria in 
order to determine clearly the relationship between repeat deficiencies 
and subsequent survey performance.  However, CMS would not need to 
exclude any HHAs when using an algorithm that makes use of 
historical data.  CMS could modify the algorithm to include any 
available historical survey data that have been weighted, as 
appropriate.  HHAs with fewer than four surveys included in OSCAR 
would be assessed based on the survey data that are available. Our 
analysis demonstrates that historical data can improve CMSs ability to 
identify at-risk HHAs.  CMS should use all available data to target 
those HHAs most at risk of providing poor quality of care. 
  OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   15   
   
R E C O M M E N D A T I O N S  
As an alternative to modifying the algorithm to include historical survey  
data, CMS could conduct analysis similar to that described in this 
report to identify HHAs with repeated deficiencies across multiple 
surveys.  CMS could provide this information to State survey agencies  
annually to help surveyors identify HHAs that may be in need of closer 
review, whether or not they appear in the targeted sample. 
CMS concurred with the recommendation to implement intermediate 
sanctions as directed by the OBRA 1987.  The agency indicated that 
changes in law and other regulations, together with the demands of 
additional improvement efforts, have impeded promulgation of the final 
rule. CMS outlined several initiatives it has undertaken during this 
time to address HHA performance and compliance.  
CMS also indicated that one finding not addressed in detail in the  
recommendations may prove useful in targeting HHAs.  CMS may rely  
on information that cyclical deficient HHAs are concentrated in six 
States to assist them in  targeting future surveys.    
We revised our description of HHAs  statutorily required survey 
frequency to address CMSs technical comments. 
The text of  CMSs comments is available in Appendix F. 
  OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   16   
   
  A P P E N D I X ~ A
Medicare HHA Conditions of Participation and Standards  
 
* Conditions reviewed in all home health agency certification and recertification 

surveys.  CMS State Operations Manual, Pub. No. 100-07, ch. 2,  2196.1A (rev. 1, 

May 21, 2004). 
 
** This is a general description of the standard because a title for the standard is not 

provided. 

 
Administration  
42 CFR  484.10 Condition of Participation:  Patient Rights * 
(a) Standard: Notice of Rights 
(b) Standard:  Exercise of Rights and Respect for Property and Person 
(c) Standard: 	Right to be Informed and to Participate in Planning  
     Care and Treatment 
(d) Standard:  Confidentiality of Medical Records 
(e) Standard: Patient Liability for Payment 
(f) Standard: Home Health Hotline 
42 CFR  484.11 Condition of Participation:  Release of Patient  
      Identifiable Outcome and Assessment Information Set (OASIS) 
     Information * 
42 CFR  484.12 Condition of Participation:  C	 ompliance with Federal,  
     State, and Local Laws, Disclosure and Ownership Information, and  
     Accepted Professional Standards and Principles * 
(a) Standard:  C	 ompliance with Federal, State, and Local Laws  
      and Regulations 
(b) Standard:  Disclosure of Ownership and Management Information 
(c) Standard:  	Compliance with Accepted Professional Standards  
     and Principles  
42 CFR  484.14 Condition of Participation:  O	 rganization, Services,   
     and Administration   
(a) Standard: Services Furnished 
(b) Standard:  Governing Body 
(c) Standard: Administrator 
(d) Standard:  Supervising Physician or Registered Nurse 
(e) Standard: Personnel Policies 
  OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   17   
   
A P P E N D I X   ~   A  
(f) Standard: Personnel Under Hourly or Per Visit Contracts 
(g) Standard: Coordination of Patient Services *  
(h) Standard:  Services Under Arrangement 
(i) Standard: 	Institutional Planning 
(i)(1) Standard: Annual Operating Budget 
(i)(2) Standard:  Capital Expenditure Plan 
(i)(3) Standard:  Preparation of Plan and Budget  
(i)(4) Standard: Annual Review of Plan and Budget 
(j) Standard: Laboratory Services 
42 CFR  484.16 Condition of Participation:  	Group of Professional  
     Personnel 
(a) Standard: Advisory and Evaluation Function  
42 CFR  484.18 Condition of Participation:  A	 cceptance of Patients,  
     Plan of Care, and Medical Supervision * 
(a) Standard:  Plan of Care 
(b) Standard:  Periodic Review of Plan of Care 
(c) Standard: Conformance with Physician Orders 
42 CFR  484.20 Condition of Participation:  Reporting OASIS Information  
(a) Standard:  Encoding OASIS Data  
(b) Standard: Accuracy of Encoded OASIS Data 
(c) Standard: Transmittal of OASIS Data 
(d) Standard:  Data Format 
 
Furnishing of Services  
42 CFR  484.30 Condition of Participation:  Skilled Nursing Services 
(a) Standard: Duties of the Registered Nurse 
(b) Standard:  Duties of the Licensed Practical Nurse 
42 CFR  484.32 Condition of Participation:  Therapy Services  
(a) Standard:  	Supervision of Physical Therapy Assistant and  
    Occupational Therapy Assistant  
(b) Standard:  Supervision of Speech Therapy Services 
  OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   18   
   
AA PP PP EE NN DD II XX   ~~   AA  
42 CFR  484.34 Condition of Participation: Medical Social Services 
42 CFR  484.36 Condition of Participation: Home Health Aide Services *  
(a) Standard: 	Home Health Aide Training 
(a)(1) Standard: Content and Duration of Training 
(a)(2) Standard: Conduct of Training 
(a)(3) Standard: Documentation of  Training 
(b) Standard: 	Competency Evaluation and In-Service Training 
(b)(1) Standard: Applicability 
(b)(2) Standard: Content and Frequency of Evaluations and  
          Amount of In-Service Training 
(b)(3) Standard: Conduct of Evaluation and Training 
(b)(4) Standard: Competency Determination 
(b)(5) Standard: Documentation of  Competency Evaluation 
(b)(6) Standard: Effective Date 
(c) Standard: 	Assignment and Duties of the Home Health Aide 
(c)(1) Standard: Assignment 
(c)(2) Standard: Duties 
(d) Standard: 	Supervision 
(d)(1) Standard: Supervisory Visit **   
(d)(2) Standard: On-site Visit for Patients Receiving Skilled  
         Nursing Care ** 
(d)(3) Standard: On-site Visit for Patients Not Receiving Skilled 
         Nursing or Rehabilitation Therapy Services ** 
(d)(4) Standard: Home Health Aide Services Not Provided by an 
         Employee of the Agency ** 
(d)(4)(i) Standard: Ensuring Overall Quality of Care Provided 
            by Aide ** 
(d)(4)(ii) Standard: Supervision of Aides Services ** 
(d)(4)(iii) Standard: Ensuring Home Health Aides Meet 
               Training Requirements **  
(e) Standard: Personal Care Attendant: Evaluation Requirements 
OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   19   
   
A P P E N D I X ~ A  
42 CFR  484.38 Condition of Participation:  Qualifying to Furnish  
     Outpatient Physical Therapy or Speech Pathology Services 
42 CFR  484.48 Condition of Participation:  Clinical Records *  
(a) Standard:  Retention of Records 
(b) Standard:  Protection of Records 
42 CFR  484.52 Condition of Participation:  E	 valuation of the Agency's    
     Program  
(a) Standard:  Policy and Administrative Review  
(b) Standard: Clinical Record Review 
42 CFR  484.55 Condition of Participation:  C	 omprehensive 
Assessment of Patients *  
(a) Standard:  I	 nitial Assessment Visit 
(a)(1) Standard:  Determine Immediate Care and Support and  
      Medicare Eligibility ** 
(a)(2) Standard: Visit by Rehabilitation Skilled Professional ** 
(b) Standard: Completion of the Comprehensive Assessment  
(c) Standard: Drug Regimen Review  
(d) Standard:  Update of  the Comprehensive Assessment 
(e) Standard: Incorporation of OASIS Data Items 
 
  OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   20   
   
  A P P E N D I X ~ B
HHA Survey  Cycles Prior to Fiscal Year 2006 
Prior to fiscal year 2006, the Centers for Medicare  & Medicaid Services 
(CMS) assigned home health agencies (HHA) a survey frequency based  
on their most recent survey performance.38  Surveyors generally 
conducted unannounced recertification surveys every 12 to 36 months 
based on their Medicare enrollment  and survey history.39  In addition to 
conducting routine surveys, State agencies annually selected a  
5-percent random sample of HHAs on the 36-month survey cycle. This  
random sample of HHAs  received a recertification survey within 16 to 
20 months following its last recertification survey.40    
If an HHA was not out  of compliance with any Conditions of 
Participation (CoP) during the first  3 years after the HHA opened  or 
changed ownership, then the HHA was placed on a 36-month 
recertification survey cycle.  An HHA remained on a 36-month 
recertification survey cycle if (1) no condition-level deficiencies were out 
of compliance in any of the previous three recertification surveys; (2) no  
standard-level deficiencies were  cited under the  acceptance of patients, 
plan of care, and medical supervision condition (42 CFR  484.18) or the 
comprehensive assessment of patients condition (42 CFR  484.55) in 
the previous survey; and (3) no complaints resulted in deficiency 
citations since the previous survey.41    
An HHA that failed to meet at least one of the CoP was considered to be  
providing substandard care and required more scrutiny.  If the HHA 
came back into compliance, it received a survey  within 4 to 6 months 
from the date compliance was established.42  If the HHA maintained 
compliance, then it was placed on a 12-month survey cycle until the 
HHA received no condition-level deficiency citations for at least  
2 consecutive years.  
 
 
38 CMS State Operations Manual, Pub. No. 100-07, ch. 2,  2195 (rev. 1, May 21, 2004). 
39 Beginning in 1999, the time between surveys for most HHAs increased from a range of   
9 to 15 months  up to 36 months. 
40 CMS State Operations Manual, Pub. No. 100-07, ch. 2,  2195.E (rev. 1, May 21, 2004).  
41 CMS State Operations Manual, Pub. No. 100-07, ch. 2,  2195.A (rev. 1, May 21, 2004). 
42 CMS State Operations Manual, Pub. No. 100-07, ch. 2,  2195.D (rev. 1, May 21, 2004). 
  OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   21   
   
  A P P E N D I X ~ C
CMSs Algorithm To Identify Targeted Sample of At-Risk HHAs  
To produce the 5-percent targeted sample, the Centers for Medicare & 
Medicaid Services (CMS) now applies an algorithm that identifies  
at-risk home health agencies (HHA) in each State.  For each active HHA  
that is not due for a 36-month survey, the algorithm assigns a survey  
priority score that is comprised of the following six data elements:   
1. 	  Total number of standard-level deficiencies for the HHA  on the 
most recent survey; 
2. 	  Total number of condition-level deficiencies for the HHA  on the 
most recent survey; 
3. 	  Total number of standard-level deficiencies on the most recent 
survey common to closed/terminated  HHAs; 
4. 	  Total number of risk-adjusted quality improvement outcomes  
(e.g., improvement in upper body dressing) less than a 
calculated threshold value as determined by CMS; 
5. 	  Total number of non-risk-adjusted quality improvement 
outcomes (e.g., improvement in cognitive function) less than a 
calculated threshold value as determined by CMS; and  
6. 	  Total number of adverse events deemed worse than a 

calculated threshold value as determined by CMS.43  

The algorithm generates a score that CMS uses to identify HHAs that 
are at risk of providing poor quality of care.  At  the beginning of each 
fiscal year, CMS shares a targeted list with each State agency that is 
comprised  of the 10 percent of HHAs that have the highest  
(i.e., worst) scores in the State.  Using CMSs targeted list, State 
agencies then apply their additional knowledge of the HHAs to select 
the final 5-percent targeted sample for survey.44  The 36-month survey  
clock will be reset for HHAs selected for the targeted sample.  
 
 
43 University of Colorado at Denver and Health Sciences Center, Improving Protocols for 
Home Health Agency Assessment in the Survey Process, Appendix E:  Survey Priority Score 
Algorithm, June 2006. 
44 Quality Assurance for the Medicare & Medicaid Programs:  FY 2006 Mission & Priority 
Document, CMS, Survey and Certification  Group, Center for Medicaid  and State Operations, 
p. 11, August 2005. 
  OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   22   
   
   A P P E N D I X ~ D
Standard-Level Deficiency Citations That Account for Half of All Deficiencies Across the Three Most  
Recent Surveys for Cyclically Deficient HHAs (n=873) 
Percentage of  
Deficiency Citations for 
Cyclically Deficient 
Deficiency Citation (G tag)*  HHAs  
1. 	 Care follows a written plan of care established and periodically reviewed by  a doctor of medicine, 
7.5%
osteopathy, or podiatric medicine.  (G158) 
2. 	 The plan of care  developed in consultation with the agency staff covers all pertinent diagnoses, including 
mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation 
potential, functional limitations, activities permitted, nutritional requirements, medications and treatment,  6.0% 
any safety measures to protect against injury, instructions for timely discharge or referral, and any  other 
appropriate items.  (G159) 
3. 	 A clinical record containing pertinent past and current findings in accordance with accepted professional 
standards is maintained for every patient receiving home health services.  In addition to the plan of care, 
the record contains appropriate identifying information; name of physician; drug, dietary, treatment, and  5.5% 
activity orders; signed and dated clinical and progress notes; copies of summary  reports sent to the 
attending physician; and a discharge summary.  (G236) 
4. 	 The comprehensive assessment must include a review of all medications the patient is currently using in 
order to identify  any potential adverse effects and drug reactions, including ineffective drug therapy, 
3.6%
significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug 

therapy.  (G337) 
 
5. 	 Agency professional staff promptly alerts the physician to any changes that suggest a need to alter the  
3.5%
plan of care. (G164) 
6. 	 The registered nurse (or another professional described in paragraph (d)(1) of this section) must make 
2.9%
an onsite visit to the patients home no less frequently than every 2 weeks.  (G229) 
7. 	 Drugs and treatments are administered by  agency staff only as ordered by the physician with the 
exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per 
2.7%
agency policy developed in consultation with a physician, and after an assessment of considerations.  

(G165) 

8. 	 All personnel furnishing services maintain liaison to ensure that their efforts are coordinated effectively 
2.7%
and support the objectives outlined in the plan of care.  (G143) 
9. 	 A written summary  report for each patient is sent to the attending physician at least every 60 days.  
2.5%
(G145)  
10. 	 Written patient care instructions for the home health aide must be prepared by the registered nurse or  
other appropriate professional who is responsible for the supervision of the home health aide under  2.2% 
paragraph (d) of this section.  (G224) 
11. 	 The clinical record or minutes of case conferences establish that effective interchange, reporting, and 
2.1%
coordination of patient care does occur.  (G144) 
12. 	 The HHA and its staff must comply with accepted professional standards and principles that apply to 
2.0%
professionals furnishing services in a home health agency.  (G121)  
13. 	 The registered nurse makes the initial evaluation visit and regularly  reevaluates the patients nursing 
2.0%
needs. (G172) 
14. 	 The HHA furnishes skilled nursing services by or  under the supervision of a registered nurse and in 
1.9%
accordance with the plan of care.  (G170) 
15. 	 The registered nurse prepares clinical and progress notes, coordinates services, and informs the 
1.9%
physician and other personnel of changes in the patients condition and needs.  (G176) 
16. 	 If a physician refers a patient under a plan of care  that cannot be completed until after an evaluation visit, 
1.5%
the physician is consulted to approve additions or modifications to the original plan.  (G160) 
      Total  50.5%  
Source:   Office of Inspector General analysis of  the Centers for Medicare &  Medicaid  Services survey data, 2007. 
* Each  standard and condition is affiliated with a specific G tag  (e.g., G158).  CMS uses G tags  to identify deficiencies on  the Statement of Deficiencies and Plan  
of Correction form.  
  OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   23   
   
  A P P E N D I X ~ E
Metropolitan Statistical Areas With High Numbers of Cyclically  Deficient HHAs 
Number of HHAs  
With at Least  Number of HHAs   Percentage of HHAs  
State  Metropolitan  Statistical Area  One Citation  in  With Repeat  With Repeat 
Each of Last   Citations  Citations 
Three Surveys  
Los Angeles-Long Beach-Santa Ana  46  31  67% 
Riverside-San Bernardino-Ontario   27  12  44% 
CALIFORNIA  San Diego-Carlsbad-San Marcos   19  18  95% 
Rest of CA  43  19  44% 
     State Total  135  80  59%  
Cape Coral-Fort Meyers   14  6  43% 
Miami-Fort Lauderdale-Miami Beach  140  15  11% 
FLORIDA 
Rest of Florida  238  17  7% 
     State Total  392  38  10%  
Chicago-Naperville-Joliet  139  117  84% 
ILLINOIS  Rest of Illinois  113  42  37% 
     State Total  252  159  63%  
Cedar Rapids  11  4  36% 
Des Moines-West Des Moines  4  3  75% 
IOWA  Waterloo-Cedar Falls  15  3  20% 
Rest of Iowa   145  49  34% 
     State Total  175  59  34%  
Detroit-Warren-Livonia  51  31  61% 
MICHIGAN  Rest of Michigan  54  32  59% 
     State Total   105  63  60%  
Dallas-Fort Worth-Arlington  132  38  29% 
Houston-Sugar Land-Baytown  124  21  17% 
McAllen-Edinburg-Mission  29  11  38% 
TEXAS 
San Antonio  68  30  44% 
Rest of Texas  384  57  15% 
     State Total  737  157  21%  
Source:   Office of Inspector General analysis of  the Centers for Medicare &  Medicaid  Services survey data, 2007. 
 
  OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   24   
   
   A P P E N D I X ~ F
Agency Comments 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
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A P P E N D I X   ~   F  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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A P P E N D I X   ~   F  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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A P P E N D I X   ~   F  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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A P  PA EC NKDNI OX W  ~L  EF D  G M E N T S
 
 
This report was prepared under the  direction of Timothy S. Brady, 
 
Regional Inspector General for Evaluation and Inspections in the  

San Francisco regional office, and Deborah W. Harvey, Deputy Regional 

Inspector General. 

China Tantameng and Camille Harper were coleaders for this study.  

Other Office of Evaluation and Inspections staff from the San Francisco 

regional office who contributed include Scott Hutchison; central office 

staff who contributed include Rob Gibbons and Sandy Khoury. 

 
 
 
  OEI-09-06-00040   DEFICIENCY  HISTORY AND RECERTIFICATION OF  MEDICARE HOME HEALTH AGENCIES   29