Service Policy

Home Health Agency (HHA) Patient Acceptance-to-Service Policy and Procedure

Effective Date: 1/01/2025

Review Date: As services are changed, but no less than annually.

 

1. Purpose

The purpose of this policy is to establish a consistent, standardized process for the acceptance of prospective patients into Home Health Agency (HHA) services. The policy ensures that the HHA evaluates its capacity to meet the needs of the referred patient and complies with regulatory requirements outlined by the Centers for Medicare & Medicaid Services (CMS) at 42 CFR § 484.105(i). This policy aims to promote timely and appropriate care for patients while maintaining the quality and safety of services provided.

 

2. Scope

This policy applies to all patient referrals made to the HHA for home health services,
including skilled nursing, therapy services (physical, occupational, speechlanguage pathology), medical social services, and home health aide services.

 

3. Definitions

  • Referral: A formal request for home health services typically initiated by a provider, hospital discharge planner, or other authorized healthcare provider.
  • Capacity: The HHA's ability to meet the anticipated care needs of a referred patient, considering factors such as case load, staffing, and available
    resources
  • Case Load: The total number of patients currently under care by the HHA at any given time.
  • Case Mix: The types and complexity of patients currently under care, which may impact the ability of the agency to accept new patients.

4. Policy Overview

The HHA will only accept patients for home health services when there is a reasonable expectation that the agency has the capacity to meet the patient's care needs. The decision to accept or deny a referral will be made based on an evaluation of the following criteria:

 

➢ Anticipated Needs of the Referring Patient:

  • Evaluation of the patient's clinical condition, care requirements, and expected treatment duration.
  • Review of any specific medical orders, diagnoses, or recent hospitalizations provided by the referring provider.

➢ Case Load and Case Mix:

  • Consideration of the current number of patients being served by the HHA, ensuring that the agency is not overloaded and can provide
    adequate attention and resources to new referrals.
  • Assessment of the types of patients currently under care to determine if the agency can appropriately accommodate the complexity and
    type of services needed by the new patient.

➢ Staffing Levels:

  • The HHA will assess whether it has sufficient qualified staff (e.g., Registered Nurses, Therapists, Home Health Aides) to provide timely
    and appropriate care to the new patient without compromising the care of existing patients.
  • Staffing levels must meet the regulatory requirements and the needs of the agency's patient population.

➢ Skills and Competencies of the HHA Staff:

  • Assessment of whether the HHA staff has the necessary skills and competencies to meet the specific care needs of the referred patient.
  • If specialized services (e.g., wound care, specialized therapy) are required, the agency must ensure it has appropriately skilled staff to
    provide these services.

5. Procedures for Acceptance of Referrals

 

➢ Referral Intake:

  • Referrals are to be received through phone, fax, secure email.
  • Upon receiving a referral, the agency RN will initiate a preliminary review, ensuring that all necessary information (e.g., provider, orders, medical history, recent hospitalizations) is provided.

➢ Evaluation of Referral:

  • A qualified provider who will agree to oversee the plan of care and give/sign applicable orders on an ongoing basis.
  • If required by payer, documentation of a face-to-face encounter within the past 60 days or scheduled within the next 30 days with the qualified provider who has agreed to oversee the plan of care or if the  patient is coming from an inpatient facility with the referring provider from that facility.
  • Documentation in referral and/or face to face encounter qualifying patient for home health services (e.g., homebound status, skilled need, etc.)
  • A reimbursement source including preauthorization of visits if required.
  • The RN reviewing the referral, in collaboration with the clinical team, will assess the patient's anticipated care needs, case load, case mix, staffing availability, and staff competencies.
  • If the patient’s needs match the agency’s capacity, the referral will be moved forward for scheduling and care plan development.
  • If the agency determines it cannot meet the patient’s needs, the referral will be declined. In such cases, the referring provider will be notified, and alternative home health services may be recommended.

➢ Notification of Acceptance or Denial:

  • The referring provider and the patient (or their representative) will be notified of the agency’s decision to accept or deny the referral.
  • The patient will be provided with information regarding the specific services available and the duration and frequency of the services, as
    well as any limitations related to those services.
  • All decisions regarding the acceptance or denial of a referral will be documented in the patient’s electronic health record (EHR), or log, including the rationale for the decision.

6. Periodic Review and Updates:

  • The HHA’s leadership team will annually review the Patient Acceptance-to-Service Policy to ensure its continued relevance and compliance with regulatory requirements.
  • Any changes to the agency’s capacity, staffing, services, or referral process will be communicated to staff and made publicly available

7. Public Disclosure of Services and Limitations

 

The HHA will make available to the public clear and accurate information regarding the types of services offered, including any limitations related to specialty services, service duration, or service frequency. This information will be reviewed annually or more frequently as needed if services change.

  • Service Availability: Licensed RN & LVN private duty nursing, therapy services through contract.
  • Service Limitations: Always Home Nursing Services provide licensed RN & LVN private duty nursing for pediatric patients. Geographic service areas include Sacramento, Yolo, Solano, San Joaquin, Stanislaus, Merced, Madera, Mariposa, Tuolumne, Calaveras, Amador, El Dorado, Placer, Nevada, Santa Clara, Sierra, Sutter, Yuba, Napa, Lake, Colusa, Glenn, Butte, Plumas, and Tehama.
  • Public Access: Information will be accessible via the HHA’s website or by contacting the agency.

8. Compliance and Monitoring

  • The HHA will ensure compliance with CMS regulations, including 42 CFR § 484.105(i), by regularly auditing referral acceptance decisions and patient outcomes.
  • The Quality Assurance and Performance Improvement (QAPI) program will Monitor the effectiveness of the patient acceptance process and identify any areas for improvement.

9. References

  • 42 CFR § 484.105(i)

10. Policy Review and Revisions

  • This policy will be reviewed at least annually, or as changes occur in the agency’s operations or regulatory requirements. Updates will be
    communicated to all relevant staff. This policy shall be shared with all staff involved in the referral and admission process to ensure consistency and adherence to the HHA’s capacity and regulatory requirements.