CMS Clarifies Expectations for Therapy Start-of-Care Assessment

Questions have been raised regarding what a therapist must include in their physical assessment at the start of care (SOC) for therapy only cases. Recently, a state surveyor took exception to an agency’s therapy SOC assessment that did not include an assessment of the patient’s bowel, lung and heart sounds. The surveyor claimed that without these elements being assessed the agency did not meet the requirements of a comprehensive assessment. The therapists maintained that assessing for bowel, lung and heart sounds are not within their training or scope of practice.

The National Association for Home Care & Hospice asked the Centers for Medicare and Medicaid Services (CMS) to clarify if it is expected for a therapy SOC assessment to include assessing for bowel, lung and heart sounds. CMS responded as follows, which includes the Condition of Participation citation for the Comprehensive Assessment from Guidelines to Surveyors – Home Health Agencies.

“The HHA is responsible for development of any assessment form used. Our only formal requirement is that the assessment be patient specific and includes OASIS, if applicable.”

It cited:

§484.55 Condition of Participation: Comprehensive Assessment of Patients

G330 (Rev. 11, Issued: 08-12-05; Effective/Implementation: 08-12-05)

Each patient must receive, and an HHA must provide, a patient specific, comprehensive assessment that accurately reflects the patient’s current health status and includes information that may be used to demonstrate the patient’s progress toward achievement of desired outcomes. The comprehensive assessment must identify the patient’s continuing need for home care and meet the patient’s medical, nursing, rehabilitative, social, and discharge planning needs. For Medicare beneficiaries, the HHA 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. The comprehensive assessment must also incorporate the use of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items, as specified by the Secretary.

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