Comprehensive COVID-19 / Coronavirus Guidance Provided by Senior Options:
Implementing the
Occupational Therapy 1135 Waiver
As  we continue to venture into this new world of the COVID-19 pandemic, Home Health Agencies face changes in the way we provide care. Some of these changes are related to Medicare guidelines and Conditions of Participation. Senior Options would like to focus on the waiver released for Home Health that enhances the capacity of Occupational Therapist guiding you through this updated waiver, along with giving you some best practice tips to improve the functionality of your therapy program. Below describes the relaxed waiver and highlights the best practice guidance.  
This Occupational Therapy waiver from CMS states: “CMS is waiving the requirement that OTs may only perform the initial and comprehensive assessment if occupational therapy is the service that establishes eligibility for the patient to be receiving home health care. This temporary blanket modification allows OTs to perform the initial and comprehensive assessment for all patients receiving therapy services as part of the plan of care, to the extent permitted under state law, regardless of whether occupational therapy is the service that establishes eligibility…….Expanding the category of therapists who may perform initial and comprehensive assessments to include OTs provides HHAs with additional flexibility that may decrease patient wait times for the initiation of home health services.
The American Occupational Therapy Association presented information clarifying how Home Health agencies can implement this waiver rule .  This waiver does give agencies the flexibility to allow an Occupational Therapist to perform initial and comprehensive assessments . For the duration of this waiver, this applies to any payer.
There are a few different scenarios your agency can consider:

1.        Occupational Therapy can potentially be the only service ordered for Home Health. Under normal circumstances, Home Health Conditions of Participation prohibits Occupational Therapy from being a qualifying service and cannot be ordered without traditional qualifying services-Skilled Nursing, Physical Therapy and/or Speech Therapy. In this circumstance, the OT can now perform both the comprehensive and initial assessment.

2.        Occupational Therapy can now perform initial assessments on certain homebound patients, allowing services to start sooner. In these cases, if multiple disciplines are ordered including Occupational Therapy, OT may be implemented earlier than other disciplines. Prior to this waiver, a qualifying discipline (SN, PT or ST) would have to be implemented before or on the same day as OT and that date would serve as the Start of Care. For the duration of this waiver, OT may do this initial assessment and allow for the comprehensive assessment to be completed within 30 days by another discipline. The date of this initial assessment would serve as the Start of Care. It is worth noting, that this waiver only refers to Occupational Therapy. According to the National Association for Home Care and Hospice, if agencies choose, Occupational Therapy may conduct both the initial and comprehensive assessment in therapy only or therapy & RN cases. Physical Therapy and Speech Therapy were not provided this flexibility, but CMS is considering extending the waiver to PT and SLPs. Under any circumstance, CMS states that the agency should match the needs of the patient to the clinician who performs the assessment, to the greatest extent possible.

Let’s now review the types of assessments that the Occupational Therapist may perform. The Initial Assessment and the Comprehensive Assessment that occur at the Start of Care will require further training and support for your Occupational Therapist as this is a new process change for this discipline. If you choose to have your therapist do either one of these assessments, it is suggested that your Occupational Therapist will likely need to be educated on the Start of Care processes within your agency.

So what is the difference between initial and comprehensive assessments and how it can apply to your agency?

What is the Initial Assessment ? It is defined in the Conditions of Participation (42 Code of Federal Regulations 484.55(a)). It includes the following:
  • The initial assessment must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician-ordered start of care date.
  • An initial assessment visit must be made to determine the immediate care & support needs of the patient & for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status.
  • In very many cases, this is accomplished in conjunction with the Comprehensive Assessment.
  • It does NOT have to be performed at the same time or by the same person performing the Comprehensive Assessment and the regulations do not require the same discipline do both assessments.
  • Two different clinicians or disciplines could be responsible for completing the initial and comprehensive assessments.

The components of the initial assessment require the clinician to establish the elements of eligibility for services, and eligibility can vary by payer. For a Medicare patient, eligibility requirements include: having orders for skilled care, that the patient is under the care of a physician, that services to be provided are reasonable and necessary, identifying that the patient has an intermittent need for services and that the patient meets homebound criteria.  The initial assessment must include an actual assessment to determine the immediate and support needs of the patient; i.e. identifying if there are emergent needs requiring EMS, identifying if there is a priority for one of the disciplines ordered, assessing for gaps in patient or caregiver knowledge that poses an immediate risk, and identifying immediate supply needs. 

All required consents and admission packet elements must be reviewed with the patient and signatures obtained as necessary. These include the Patient Rights & Responsibility, financial responsibility, identifying if the patient has a guardian or HCPOA, and reviewing Emergency Preparedness. 

The initial assessment also requires a skilled visit being completed and the medication reconciliation/drug regimen review completed. The medication list should still be reviewed by a Registered Nurse, as it is for Physical Therapy or Speech Therapy. The process of order review in Netsmart at the time the Order Run is completed, should continue to be done by a Registered Nurse in the agency. If after this nurse consultation is performed and there are any amendments made, they should also be signed by the responsible therapist.

What is the Comprehensive Assessment? It is defined in the Conditions of Participation (42 Code of Federal Regulations 484.55(b)). It includes:
  • Each patient must receive, a patient-specific, comprehensive assessment.
  • For Medicare beneficiaries, the Home Health Agency must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment.
  • Must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. Under the 1135 waiver this is extended to 30 days.
  • Time: no later than 5 calendar days after the start of care. (currently 30 days under the 1135 waiver).
  • The comprehensive assessment is the responsibility of one clinician, but collaboration is encouraged.
  • It allows for interaction among clinicians who have seen the patient (or reviewed the Drug Regimen Review) to optimize accuracy.
  • The agency has a 5-day window after the start of care for that collaboration to occur and data to be finalized.
  • The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information:
  • The patient's current health, psychosocial, functional, and cognitive status.
  • The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA.
  • The patient's continuing need for home care.
  • The patient's medical, nursing, rehabilitative, social, and discharge planning needs.
  • 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, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.
  • The patient's primary caregiver(s), if any, and other available supports, including their willingness and ability to provide care and their availability and schedules.
  • The patient's representative (if any).
  • Incorporation of the current version of the Outcome and Assessment Information Set (OASIS) items.

What is the emphasis in the comprehensive assessment? First it is an assessment. The Occupational Therapist needs to identify what the agency needs to know about the patient and their circumstances to provide appropriate patient-centered care and for the agency to receive appropriate payment. Occupational Therapists are generally familiar with the OASIS data set, but have not historically completed a Start of Care OASIS assessment. A review of the OASI S requirements at the Start of Care would potentially need to be reviewed with your designated Occupational Therapist(s).

Medication Reconciliation/Drug Regimen review needs to be completed for either initial or comprehensive assessments. Condition of Participation (42 Code of Federal Regulations 484.55 (c)) requires a review of all medications the patient is currently using (including OTC medications). This is needed to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. All of these elements of the medications must be completed in the medication profile by the OT, and will potentially require additional education for OT to implement. 

If you choose to have your Occupational Therapist perform either of these assessments, please proceed with caution and safety to ensure your therapist and patient have everything they need for a successful admission and care journey.   
Senior Options  is a not-for-profit organization serving LeadingAge members, by providing home health, hospice and home care advisory services and operational support. With 15 partners in 7 states, our experienced team of healthcare experts and advisors will guide you every step of the way, from initial feasibility studies to full operational support.
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