The Centers for Medicare and Medicaid Services has issued final rules governing home health agencies under Medicare and Medicaid that include a mix of manual and electronic informational and record-keeping provisions, along with several streamlining requirements that aid home health providers.

For instance, agencies are expected to give patients and caregivers written information about upcoming visits, medication instructions, treatments administered, instructions for specific care that a patient or caregiver performs, and the name and contact information of a home health agency clinical manager.

All patients have the right to receive their clinical information—in hard copy or electronic form—including the care plan and free of charge, with records available within four business days.

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The new rules also require “an integrated communication system” to ensure patient needs are met, care coordination among providers is in place, and there is active communication between an agency and a patient’s physicians.

Further, CMS is requiring home health agencies to have “a data-driven, agency-wide quality assessment and performance improvement program that continually evaluates and improves agency care for all patients at all times.” Standard infection controls also are mandated.

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Mindful of the varied level of health information technology capabilities among home health agencies, CMS is allowing electronic signatures for record authentication, but did not accept requests that providers maintaining clinical records electronically can scan signature documents and then destroy paper copies.

“While we understand that home health agencies may desire to destroy paper copies of signature documents in order to reduce physical storage space, we believe that maintaining the original, signed paper documents is essential for purposes of authentication of the documents,” CMS noted in the final rules.

While CMS agreed that electronic audit trails may be useful for some agencies, they should not be a minimum requirement for all agencies “because there is more than one way for a home health agency to achieve the goals accomplished by electronic audit trails.”

CMS also imposed a five-year period for retaining records but acknowledged that some agencies require a longer retention period. The final rule, to be published on January 13, is available here.

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