Simione™ Healthcare Consultants


Series: Part 5 of 6

Considerations for Leadership and Personnel Qualifications, Skilled Professional and Home Health Aide Services


This is the fifth of six articles in a Simione series on the NEW Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) for Home Health, which are scheduled to take effect in July 2017.


The new Home Health CoPs contain several changes related to personnel, including requirements for the administrator role and qualifications. These changes include a requirement that the administrator be available during working hours, as well as responsible for day-to-day operations. Agencies should carefully assess the impact these changes have on their current operational practices. In the comments for the new CoPs, CMS makes clear their expectation for an Administrator: “Our expectation is that the administrator will be actively involved in the daily responsibilities of running the HHA, and that HHAs will be able to demonstrate such involvement upon survey. We do not specify the way this daily involvement must occur. We did not propose, nor are we finalizing, a requirement that each HHA have a full-time administrator. Therefore, it is permissible within these regulations for an administrator to work part-time for more than one HHA. However, we believe that the expectation of active involvement in daily operations and regular availability to patients, caregivers and representatives would be difficult, if not impossible, for an administrator to meet if he or she is responsible for operating numerous HHAs on any given day.”


In the revised CoP (484.105 Standard: Administrator), the administrator must:

  • Be appointed by and report to the governing body
    • Be responsible for all day-to-day operations of the HHA
    • Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours
    • Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies
  • When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section.
  • Be available (or the predesignated person) during all operating hours

The personnel qualifications for Administrators has also been revised to reflect additional education and experience for Administrators hired on or after July 13, 2017. Administrators in the position prior to the effective date are grandfathered in.


  • For individuals who began employment with the HHA prior to July 13, 2017, an administrator is:
    • A licensed physician
    • A registered nurse
    • Trained and experienced in health service administration with at least 1 year of supervisory, administrative experience in home health or a related health care program
  • For individuals who begin employment with an HHA on/after July 13, 2017, an administrator is:
    • A licensed physician
    • A registered nurse
    • Or the recipient of an undergraduate degree
    • AND has experience in health service administration, with at least 1 year of supervisory or administrative experience

The standard for having a supervising nurse has been replaced by a new standard to have a Clinical Manager. The Clinical Manager is defined as:

  • A person who is a licensed physician, physical therapist, speech-language pathologist, occupational therapist, audiologist, social worker, or registered nurse.

A home health agency is required to have one or more Clinical Managers that will provide oversight of all patient care services and personnel. The oversight must include:

    • Making patient and personnel assignments
    • Coordinating patient care
    • Coordinating referrals
    • Assuring that patient needs are continually assessed
    • Assuring the development, implementation and updates of the individualized plan of care

The new COP 484.75 for Skilled Professional Services combines and revises 484.30 Skilled Nursing Services, 484.32 Therapy Services and 484.34 Medical Social Services. The new rules include:

  • Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in § 409.44 of this chapter, and physician and medical social work services as specified in § 409.45 of this chapter. Skilled professionals who provide services to patients directly or under arrangement must participate in coordination of care.
    • Standard: (a) Provision of services by skilled professionals
      • Skilled professional services are authorized, delivered and supervised only by health care professionals who meet the appropriate qualifications specified under § 484.115 and who practice according to the HHA’s policies and procedures
    • Standard (b) Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to the following:
      • Ongoing interdisciplinary assessment of the patient
      • Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s)
      • Providing services that are ordered by the physician as indicated in the plan of care
      • Patient, caregiver, and family counseling
      • Patient and caregiver education
      • Preparing clinical notes
      • Communicating with the physician who is responsible for the plan of care and other health care practitioners (as appropriate) related to the current plan of care
      • Participation in the HHA’s QAPI program
      • Participation in HHA-sponsored in-service training
    • Standard (c) Supervision of skilled professional assistants
      • Nursing services are provided under the supervision of a registered nurse that meets the requirements of § 484.115(k)
      • Rehabilitative services are provided under the supervision of an occupational or physical therapist who meets the requirements of § 484.115(f) or (h), respectively
      • Medical social services are provided under the supervision of a social worker that meets the requirements of § 484.115(m)

The regulations for Home Health Aides contain significant changes to the overall home health regulations, particularly in the supervision of Home Health Aides 484.80, including:


    • Change in the language for Home Health Aide qualifications regarding facility training
      • A nurse aide training and competency evaluation program approved by the state as meeting the requirements of § 483.151 through § 483.154 of this chapter, who is currently listed in good standing on the state nurse aide registry
    • CMS is requiring that agencies address the communication skills of the aides as part of their training and part of the assessment of the aide with the addition of the following language to the home health aide training program:
      • (3) A home health aide training program must address the following subject areas: (i) Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff.
    • The new rules also have added areas in which training and competency must be completed.
      • Under the sections for appropriate and safe techniques in performing personal hygiene and grooming tasks that include:
        • (C) Hair shampooing in sink, tub, and bed;
        • (xiii) Recognizing and reporting changes in skin condition
    • The agency will be responsible to ensure that these added areas of training and competency are completed by 7/13/2017 for current and new HHAs

(4) The HHA must maintain documentation that demonstrates that the requirements of this standard have been met.


  • There is a clarification on aide training for the qualification for instructors, as well as additional exclusions from performing their own competency and aide training for agencies that have been excluded from participation in federal programs.
    • (e) Standard: Qualifications for instructors conducting classroom and supervised practical training. Classroom and supervised practical training must be performed by a registered nurse who possesses a minimum of 2 years of nursing experience, at least 1 year of which must be in home health care, or by other individuals under the general supervision of the registered nurse
    • (vi) The registered nurse instructor must not have been excluded from participating in federal health care programs or debarred from participating
  • There are also additions to the assignment, reporting and supervision of the HHA:
    • The revisions include that the assignment and care plan for a HHA can be completed by the appropriate skilled professional and not just the RN.
      • (g) Standard: Home health aide assignments and duties. (1) Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for the HHA prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist).
    • Another addition is language that supports the HHA as part of the care delivery team to the patient, who reports changes in the patient condition and completes documentation.
      • (4) HHAs must be members of the interdisciplinary team, reporting changes in the patient’s condition to a registered nurse or other appropriate designee, and completing appropriate records in compliance with agency policies and procedures.
  • Home Health Aide supervision has some significant changes that agencies should pay close attention to implement prior to the effective date of 7/13/17.
    • Revisions to the home health aide supervision outlines who can do every 14day supervision to include other skilled professionals, and to clarify that the supervision does not need to be completed by the same clinician that completed the aide assignment and plan of care.
      • (h) Standard: Supervision of home health aides. (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in § 484.80(g), must make an onsite visit to the patient’s home no less frequently than every 14 days. The home health aide does not have to be present during this visit.
    • Annual in-person/in-home supervisory visits have been added as a requirement for the home health aide. If this practice is new to your agency, this should be completed on all aides prior to the effective date of 7/31/17.
      • (iii) A registered nurse or other appropriate skilled professional must make an annual on-site visit to the location where a patient is receiving care to observe and assess each aide while he or she is performing care.
    • Specific criteria have been added to be addressed at the aide supervisory visits. Agencies should incorporate this language into their aide supervision documentation to ensure that aides furnish care in a safe and effective manner, including, but not limited to:
        • (i) Following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional
        • (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family
        • (iii) Demonstrating competency with assigned tasks
        • (iv) Complying with infection prevention and control policies and procedures
        • (v) Reporting changes in the patient’s condition
        • (vi) Honoring patient rights

Share This