Home Health Agencies Used Multiple Strategies to Respond to the COVID-19 Pandemic, Although Some Challenges Persist, OEI-01-21-00110
- Issuer
- Office of Inspector General
- Document type
- Brief
Summary
An evaluation report by the U.S. Department of Health and Human Services Office of Inspector General, OEI-01-21-00110, dated October 2022, on how home health agencies (HHAs) responded to the COVID-19 pandemic. OIG surveyed a nationally representative sample of 400 HHAs, 396 of which participated in fall 2021, and interviewed 12 HHAs and CMS staff. The report finds that staffing challenges persist, that infection control challenges lessened by fall 2021, and that emergency preparedness plans fell short of fully addressing a global emergency. It recommends that CMS evaluate HHAs' telehealth use, evaluate how regulatory flexibilities affect quality of care, and work with ASPR TRACIE to update emergency preparedness trainings; CMS concurred with all three recommendations. Appendices cover flexibilities, survey responses and agency comments.
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U.S. Department of Health and Human Services
Office of Inspector General
Home Health Agencies Used
Multiple Strategies To
Respond to the COVID-19
Pandemic, Although Some
Challenges Persist
Ann Maxwell
Deputy Inspector General for Evaluation and Inspections
October 2022, OEI-01-21-00110
U.S. Department of Health and Human Services
Office of Inspector General
Report in Brief
October 2022, OEI-01-21-00110
Why OIG Did This Review Home Health Agencies Used Multiple
The COVID-19 pandemic required
home health agencies (HHAs) to Strategies To Respond to the COVID-19
adapt their care to respond to Pandemic, Although Some Challenges
COVID-19’s infectious nature, as
well as other circumstances from Persist
the pandemic. HHAs play an
important role in caring for What OIG Found
Medicare beneficiaries: in 2020, the Key Takeaway Like all health care providers, HHAs
first year of the COVID-19 Home health agencies (HHAs) have experienced multiple
pandemic, HHAs cared for over developed strategies to challenges to providing care during
3 million beneficiaries. The Centers respond to challenges during the COVID-19 pandemic. HHAs
for Medicare & Medicaid Services the COVID 19 pandemic, have continued to experience
(CMS) requires HHAs to prepare for including providing new longstanding staffing challenges as
and respond to emergencies and, incentives to maintain staff and well as new ones resulting from the
during those emergencies, CMS can seeking alternative sources of pandemic, such as maintaining
offer regulatory flexibilities and personal protective equipment. staffing despite quarantine and
supports (which we refer to HHAs have also benefited from isolation protocols. These staffing
collectively as regulatory CMS support, such as challenges persist for many HHAs
flexibilities) for various regulatory flexibilities and despite efforts to address them. In
requirements. This report provides expanded telehealth addition, HHAs faced numerous and
insights into HHAs’ experiences that allowances, but staffing widespread infection control
will help stakeholders continue challenges persist. In light of challenges, including accessing
managing the response to COVID- the expanded use of telehealth, personal protective equipment
19 and prepare for future more information is needed to (PPE) to limit exposure and spread,
emergencies. determine its future use across but these have mostly eased since
different home health services. early in the pandemic.
How OIG Did This Review
HHAs’ own strategies to respond to
We surveyed a nationally
the pandemic included offering paid leave to retain staff and finding PPE
representative sample of 400 HHAs,
from nontraditional sources. HHAs have also benefited from government
396 of which participated in
support—including regulatory flexibilities instituted in response to the
Medicare, in fall 2021 to ask about
declaration of a public health emergency—and this support has
their experiences early in the
mitigated some staffing challenges. For example, by the Federal
pandemic and at the time we
government’s allowing new types of providers to certify and order home
administered the survey. We
health services and complete certain patient assessments, HHAs could
projected our results to the 72
more efficiently provide care. Telehealth flexibilities under the public
percent of Medicare-participating
health emergency have also helped HHAs provide care while reducing
HHAs represented by our sample.
COVID-19 exposure and dealing with staffing shortages. However, HHAs’
In addition, we interviewed 12
challenges with telehealth raise questions about its future role in home
HHAs about notable challenges,
health care, and—because of limited reporting requirements—CMS has
strategies, or other experiences
limited insight into HHAs’ telehealth use. Finally, the emergency
they identified in their surveys. We
preparedness plans required by CMS guided HHAs’ responses to the
also interviewed staff at CMS about
pandemic but fell short of fully addressing a global emergency such as
its support of—and perspectives
on—HHAs’ provision of care during COVID-19.
the pandemic.
What OIG Recommends and How the Agency Responded
CMS has an opportunity to assess how to best help HHAs prepare for
and respond to future emergencies, as well as to evaluate how changes
to the home health landscape can better serve patients. To that end, we
recommend that CMS evaluate how HHAs are using telehealth—
specifically, the types of services provided via telehealth and the
characteristics of patients who benefit from these services. We also
recommend that CMS—to inform decision-making—evaluate how the
regulatory flexibilities it has offered in response to the COVID-19 public
health emergency affect the quality of home health care. Finally, we
recommend that CMS—in collaboration with the Administration for
Strategic Preparedness and Response’s (ASPR’s) Technical Resources,
Assistance Center, and Information Exchange (TRACIE)—apply lessons
learned from the COVID-19 pandemic to update and/or develop
emergency preparedness trainings and materials for HHAs on
responding to infectious disease outbreaks. CMS concurred with all
three recommendations.
TABLE OF CONTENTS
BACKGROUND................................................................................................................................................ 1
FINDINGS.........................................................................................................................................................9
Staffing challenges persist despite HHAs’ efforts to address them....................................................................... 9
HHAs’ infection control challenges were numerous and widespread early in the pandemic, but these
challenges lessened by fall 2021.......................................................................................................................................14
Although most HHAs used telehealth during the pandemic, challenges that HHAs experienced raise
questions about telehealth’s future role in home health ........................................................................................17
Emergency preparedness (EP) plans guided HHAs’ response to the pandemic, but the plans fell short
of fully addressing a global emergency such as COVID-19....................................................................................21
CONCLUSION AND RECOMMENDATIONS.......................................................................................... 25
Evaluate how HHAs are using telehealth—specifically, the types of services provided via telehealth
and the characteristics of patients who benefit from these services ..................................................................25
To inform decision-making, evaluate how the regulatory flexibilities it has offered in response to the
COVID-19 public health emergency affect the quality of home health care ...................................................26
In collaboration with ASPR TRACIE, apply lessons learned from the COVID-19 pandemic to update
and/or develop emergency preparedness trainings and materials for HHAs on responding to
infectious disease outbreaks ..............................................................................................................................................27
AGENCY COMMENTS AND OIG RESPONSE ........................................................................................ 28
DETAILED METHODOLOGY...................................................................................................................... 29
APPENDICES.................................................................................................................................................. 31
Appendix A: CMS Conditions of Participation (CoPs): Infection Prevention and Control ...........................31
Appendix B: Regulatory Flexibilities and Supports for Home Health Agencies During the COVID-19
Public Health Emergency (PHE) .........................................................................................................................................32
Appendix C: Analysis of Nonresponse Bias...................................................................................................................36
Appendix D: Home Health Agencies’ Responses to OIG’s Survey .......................................................................37
Appendix E: Agency Comments ........................................................................................................................................44
ACKNOWLEDGMENTS AND CONTACT ................................................................................................ 49
Acknowledgments ..................................................................................................................................................................49
Contact........................................................................................................................................................................................49
ABOUT THE OFFICE OF INSPECTOR GENERAL.................................................................................... 50
ENDNOTES .................................................................................................................................................... 51
BACKGROUND
OBJECTIVES
1. To identify HHAs’ key challenges to providing patient care during the
COVID-19 pandemic.
2. To identify key strategies HHAs used to address the challenges presented by
COVID-19.
The emergence of the COVID-19 pandemic in early 2020 affected health care
organizations across the United States. Hospitals reported decreases in elective
surgeries, and nursing homes experienced devastating outbreaks among residents.
Home health agencies (HHAs) were likewise affected and have reported challenges
ranging from procuring personal protective equipment (PPE) to staffing shortages. 1, 2,
3
To continue to serve the millions of Americans who rely on home-based care during
the pandemic, both HHAs and the Federal government, including Congress and CMS,
took action to address COVID-19-related challenges. 4, 5, 6
CMS plays a pivotal role in supporting HHA preparations and responses to
emergencies, including emerging infectious disease outbreaks such as COVID-19. For
example, CMS has supported HHAs during the COVID-19 public health emergency by
offering regulatory relief for various requirements that HHAs must meet. CMS also
requires HHAs to incorporate internal processes and procedures to prepare for future
emergencies.
This study provides insights into HHAs’ perspectives on the challenges they
experienced during the first months of the COVID-19 pandemic up until the end of
2021, as well as the strategies they used to address these challenges. These strategies
include HHAs developing their own approaches to address specific challenges, using
emergency preparedness plans required by CMS, and using the flexibilities that the
government has offered during the COVID-19 public health emergency. These
insights will help CMS, HHAs, and other stakeholders continue managing the
response to COVID-19 and prepare for future emergencies to ensure that
beneficiaries receive needed care.
Home Health Agencies
HHAs provide skilled nursing and therapeutic services to patients in a home-based
setting. HHAs are a critical component of our health care system. They can provide
an alternative to inpatient health care settings, when appropriate and feasible.
Services that HHAs can provide include post-operative care, occupational therapy,
and chronic disease management. 7 Many home health services require hands-on
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OEI-01-21-00110 Background | 1
contact between staff and patients. For example, a physical therapist may test a
patient’s strength, balance, and coordination to assess rehabilitation needs. In
addition, a nurse may change a patient’s wound dressing and monitor for signs of
infection following an operation. 8 Home health may also include services that do not
necessarily require hands-on contact and may be completed remotely, such as
behavioral therapy or social services. 9
Beneficiaries must meet certain conditions to qualify for home health care coverage
under Medicare—for example, they must be homebound, which means that they have
trouble leaving home without assistance because of injury or illness or have a
condition such that leaving their home is medically contraindicated. 10 Prior to
receiving home health care, beneficiaries must also meet face to face with a doctor (or
other allowed health care provider) related to the primary reason for the home health
care. 11 Although beneficiaries must be homebound to be eligible for home health
services covered by Medicare, they do not need to be hospitalized prior to receiving
care. 12 In 2020, three-fourths of Medicare home health episodes were not preceded
by a stay at a hospital or post-acute care institution, and more than 11,400 HHAs
provided care to 3.1 million Medicare fee-for-service beneficiaries. 13
To qualify as an HHA and participate in Medicare, an HHA must demonstrate that it
meets regulatory health and safety requirements, or the Conditions of Participation
(CoPs). Each CoP covers a broad topic (e.g., emergency preparedness) and then is
further defined by a set of specific standards that HHAs must meet. 14, 15 To assess
compliance with CoPs, State survey and certification agencies and Accrediting
Organizations (as applicable) typically conduct onsite inspections, including observing
home visits, on behalf of CMS. 16, 17
Rural HHAs may experience different challenges to providing home health care
compared to HHAs in more populated settings. For example, rural HHAs’ patients
may be spaced farther apart, requiring more travel time between visits. Some
evidence also suggests that, early in the pandemic, rural HHAs experienced different
challenges responding to COVID-19 compared to HHAs located in urban settings.
This includes potential differences in access to PPE and proportion of patients with
COVID-19. 18
The COVID-19 Pandemic
The virus that causes the disease known as COVID-19 is highly contagious and can
cause symptoms including fever, cough, and shortness of breath. 19 COVID-19 can
sometimes result in severe illness leading to hospitalization or death. 20 The Centers
for Disease Control and Prevention (CDC) identified the first U.S. laboratory-confirmed
case of COVID-19 in the United States in Washington State on January 20, 2020, and
the disease has since spread nationwide. 21 On January 31, 2020, the Secretary of
Health and Human Services declared a public health emergency. 22 On March 11,
2020, the World Health Organization characterized COVID-19 as a pandemic,
indicating that COVID-19 had spread to several countries or continents, potentially
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist
OEI-01-21-00110 Background | 2
affecting a large number of people. 23, 24 On March 13, 2020, the President declared a
national emergency. 25
As of September 23, 2022, CDC had reported over 95 million cases in the United
States and over one million deaths. 26 Since COVID-19’s emergence within the United
States, rates of infection and death have varied over time and within different
geographic locations. Factors that can affect COVID-19 infection rates include
vaccination rates, population density, and the presence of more contagious variants
of the COVID-19 virus. 27, 28
HHA Care During the COVID-19 Pandemic
As the COVID-19 pandemic evolved, HHAs had to adapt their care to respond to
COVID-19’s infectious nature as well as other circumstances caused by the pandemic,
such as decreased staff availability. During the public health emergency, CMS has
offered HHAs regulatory relief for various CMS requirements to support HHAs’
response to the pandemic. Furthermore, CMS provided guidance to support HHAs in
meeting infection control and emergency preparedness requirements.
CMS Guidance on Infection Control. To protect patients and staff, CMS requires
HHAs to meet the CoP for infection prevention and control (hereinafter referred to as
infection control). This includes following widely accepted guidelines (e.g., hand
hygiene) to prevent transmitting infectious diseases as well as educating staff,
patients, and caregivers on preventing infections (see Appendix A). 29 During the
pandemic, CMS provided HHAs with additional suggestions to address COVID-19. In
March 2020, it issued guidance that outlined further infection control
recommendations, such as how to screen patients for COVID-19 and use PPE
appropriately. CMS also directed HHAs to CDC—with which CMS engaged
regularly—for further guidance on infection control for COVID-19. For example, to
help address emerging supply shortages due to global disruptions, CMS suggested
that HHAs contact local authorities and follow CDC guidelines for optimizing
supplies. 30
HHA Flexibilities During the Public Health Emergency. After declaring a national
emergency on March 13, 2020, the President directed the Secretary of Health and
Human Services to temporarily waive or modify certain Medicare requirements during
the public health emergency. 31, 32 (The Secretary had declared a public health
emergency on January 31, 2020.) Beginning in March 2020, CMS issued a series of
regulatory waivers and new rules to support HHAs during the public health
emergency. 33, 34 (In this report, we refer to regulatory flexibilities, waivers, and new
rules as flexibilities.) For example, CMS allowed HHAs additional time to submit
patient assessment information. CMS has continued to modify and add to these
flexibilities. These flexibilities are available to HHAs nationwide for the duration of the
public health emergency and target different aspects of home health care. 35, 36 See
Appendix B for a full list of the flexibilities.
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The Coronavirus Aid, Relief, and Economic Security (CARES) Act (enacted on March 27,
2020) also included statutory changes to help HHAs provide care during the public
health emergency. Specifically, the CARES Act allowed additional types of providers
(nurse practitioners, clinical nurse specialists, and physician assistants) to certify
eligibility for home health care and order home health services. 37
Telehealth Flexibilities During the Public Health Emergency. Medicare telehealth
services refer to services that are provided remotely using technology between a
provider and a beneficiary. 38, 39 (Telehealth may also be referred to as telemedicine or
telecommunications technology.) Telehealth may include videoconferencing
(hereinafter, video) to conduct speech therapy visits; using a blood pressure cuff that
automatically sends information to a provider; or a phone call between a nurse and a
patient to discuss whether a patient’s worsening symptoms warrant an extra home
visit. 40, 41 For these technologies to qualify as telehealth, providers must use them to
improve a patient’s health care. 42 On the basis of this definition, CMS would not
consider administrative tasks, such as calling a patient to schedule an in-person
appointment, as telehealth. CMS specifies which services it considers telehealth as
covered under the Medicare home health benefit (i.e., Medicare does not cover all
uses of telehealth). 43, 44
The CARES Act directed the Department of Health and Human Services (HHS) to
encourage HHAs to use telehealth technology for services provided during the public
health emergency. 45 In response, CMS issued flexibilities that expanded HHAs’ ability
to use telehealth and thereby reduced infection risk. For example, CMS allowed HHAs
to perform certain Medicare-covered assessments and determine patients’
homebound status via telehealth or record review. 46 CMS also allowed the required
face-to-face encounter between a patient and authorized health care provider, who
certifies the patient as eligible for home care, to take place remotely. 47
In addition, effective on March 31, 2020, CMS permitted HHAs to use telehealth
technology services within the patient’s plan of care if these services are related to the
patients’ needs and do not replace needed in-person visits. 48, 49 CMS made this
regulatory change permanent effective January 1, 2021. (See Exhibit 1 for examples of
how HHAs can use telehealth—initially, limited to the duration of the public health
emergency, but now permanently.) 50 Although HHAs may choose to provide
telehealth services, HHAs cannot bill Medicare for telehealth services as equivalent to
an in-person visit—without a statutory change, CMS cannot directly reimburse HHAs
for telehealth services. 51 However, HHAs can report the costs of providing telehealth
services, such as the cost incurred to set up technology, as allowable administrative
and general costs within cost reports. 52, 53 HHAs submit cost reports to CMS each
year. CMS factors information reported within cost reports, including costs to provide
telehealth, into future Medicare payments to HHAs. 54
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Exhibit 1. Examples of how HHAs have been allowed to use telehealth under
the Medicare home health benefit, beginning with the COVID-19 public
health emergency*
Live video or audio visits between a Electronically transmitting health
patient and HHA provider information for a provider to access
later
Examples include:
Examples include:
• Assessing over video whether a
• A heart rate monitor that
patient can move properly after a hip
automatically sends data to the HHA
surgery
every 30 minutes
• Calling to make sure that a patient
• An HHA nurse who sends a visit
continues to take medication as
report to the patient's doctor via
prescribed
health application software for the
• Calling to determine whether a
doctor to evaluate at a later time
patient needs to visit their primary
care physician
* HHAs are also now able to provide these services under the Medicare home health benefit beyond the COVID-19
public health emergency.
Sources: HHS, What is telehealth?, June 29, 2022 (updated September 14, 2022); 55 CMS, COVID-19 Frequently Asked
Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing, updated January 7, 2021; 56 42 CFR § 409.46.
Since the start of the pandemic, CMS and other sources have reported a dramatic
increase in the use of telehealth by Medicare beneficiaries, including HHAs, from that
of prior years. 57, 58, 59 A previous OIG study found that Medicare beneficiaries used 88
times as many telehealth services during the first year of the pandemic (March 2020
through February 2021) as they used in the prior year. 60 However, in a recent report
to Congress, the Medicare Payment Advisory Commission noted that Medicare
beneficiaries and providers had some concerns about whether telehealth offered the
same quality of care as did in-person services. 61
CMS-Required Emergency Preparedness Plans. As of November 2017, CMS requires
HHAs, along with other types of providers, to meet the CoP for emergency
preparedness. 62 CMS includes four core elements in its emergency preparedness
requirements (see Exhibit 2). HHAs must review these elements and update them
every 2 years. 63, 64
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Exhibit 2. CMS requires emergency preparedness plans to include four core
elements.
m Risk assessment
and planning
HHAs must perform risk assessments using an all-hazards
approach, which considers those emergencies or disasters
that are most likely to occur. Individual HHA emergency
preparedness plans may therefore vary due to differences in
location (e.g., if an HHA is in a tornado-prone area).
II Policies and
procedures
HHAs must develop policies and procedures based on
components of the emergency p reparedness plan and risk
assessment, such as how to track patients and staff during
an emergency.
B Communication
plan
HHAs must develop emergency communication plans that
comply with Federa l and State laws. These plans must
include important contact information as wel l as methods
for sharing patient information during emergencies.
($] Training and
testing program
HHAs must train staff and test their emergency plans via
drills.
Sources: CMS, “Emergency Preparedness Rule: What’s New based on the Medicare and Medicaid Programs; Regulatory
Provisions to Promote Program Efficiency, Transparency, and Burden Reduction Final Rule”; CMS, “Frequently Asked
Questions (FAQs): Emergency Preparedness Regulation,” January 2017. 65
As of 2019, CMS guidance on emergency planning instructs providers to include
emerging infectious diseases as part of their risk assessment’s all-hazards planning. 66
In March 2021, CMS updated that guidance to include additional information on
incorporating emerging infectious diseases into providers’ all-hazards planning. For
example, CMS added guidance on assessing PPE needs and screening patients,
among other considerations, during an infectious disease emergency. CMS also
suggested that providers develop policies to update their emergency preparedness
plans during emergencies that last longer than expected. 67
CMS directs HHAs to various resources to support emergency preparedness. For
example, CMS provides online training to health care providers on emergency
preparedness. 68, 69 CMS may also refer HHAs to the Administration for Strategic
Preparedness and Response’s (ASPR’s) Technical Resources, Assistance Center, and
Information Exchange (TRACIE), which periodically updates EP resources on its
website. 70
Related OIG Work
This study contributes to the Office of Inspector General’s (OIG’s) work on home
health care and on providers’ experiences during the COVID-19 pandemic. A 2021
OIG audit assessed infection control practices at eight HHAs and found that six HHAs’
infection control policies and procedures complied with CMS requirements and
COVID-19 guidance. 71 Another audit is underway to examine HHAs’ compliance with
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CMS’s regulations for telehealth services—i.e., the regulations that were initially
limited to the duration of the public health emergency, but subsequently made
permanent. 72
Prior OIG home health work focused on unverified patient lists used in home health
surveys and common characteristics of HHAs and physicians found in OIG-
investigated cases of home health fraud. 73, 74 OIG has also conducted a series of
compliance audits of home health care providers. A complete listing of OIG’s
ongoing evaluations and audits is available in our online Work Plan at
https://www.oig.hhs.gov/.
Methodology
This study used the following data sources: (1) a survey of a random sample of HHAs;
(2) interviews with a purposive sample of 12 HHAs; and (3) an interview with CMS
staff.
Scope
This study focuses on Medicare-participating HHA experiences from early in the
pandemic to the point that OIG surveyed or interviewed HHAs in September through
December 2021. As part of the survey and interviews, we asked HHAs about
challenges experienced early in the pandemic and in fall 2021. We defined “early in
the pandemic” to mean when the respondent HHA’s geographic area experienced its
first wave of COVID-19 infection.
Data Sources and Analysis
Survey of HHAs. We administered a survey between September and November 2021
to a random sample of 400 HHAs asking about their experiences during the COVID-
19 pandemic. Of the 377 eligible Medicare-participating HHAs we surveyed, we
received responses from 271, a 72-percent response rate. 75 We analyzed the survey
data to determine challenges HHAs experienced during the pandemic; strategies they
used to address those challenges; and HHAs’ experiences with telehealth, emergency
preparedness plans, and regulatory flexibilities. We produce estimates from these
data to speak to the experiences of Medicare-participating HHAs represented by our
respondents. See Appendix C for a description of our nonresponse bias analysis.
To identify HHAs as rural, we used 2019 Medicare claims data to determine whether
HHAs provided services to Medicare beneficiaries in mostly rural counties. We
identified 41 HHA survey respondents as rural. We analyzed rural HHAs’ survey
responses to describe the experiences of rural HHAs in our sample and do not
generalize these responses to all rural HHAs.
Interviews with HHAs. We interviewed staff from a purposive sample of 12 HHAs in
November and December 2021. We asked HHAs about their experiences during the
COVID-19 pandemic on the basis of their responses to our survey. We selected HHAs
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that indicated notable challenges, strategies, or other experiences during the
pandemic in their survey responses.
Interview with CMS. We conducted one interview with staff in CMS’s Center for
Clinical Standards and Quality and Center for Medicare regarding their perspectives
on HHAs’ experiences during the pandemic and the support provided to HHAs by
CMS. We conducted this interview on January 21, 2022.
See the Detailed Methodology on page 29 for additional information about our data
collection and analysis.
Limitations
We based our findings regarding HHAs on the information reported by HHAs in our
survey and during interviews. We did not independently verify the information HHAs
provided. We did not evaluate the effectiveness of the strategies HHAs reported
using to address challenges during the COVID-19 pandemic. Our results pertaining to
HHAs apply only to the population represented by the respondents and cannot be
generalized to all HHAs.
Standards
We conducted this study in accordance with the Quality Standards for Inspection and
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.
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FINDINGS
Staffing challenges persist despite HHAs’ efforts to address
them
HHA staffing levels are important to ensuring that patients receive needed and high-
quality care. Understaffed HHAs may be not able to send health care providers to
patients’ homes to the extent required in each patient’s plan of care. HHAs without
enough staff may also struggle to accept new patient referrals, which could affect
beneficiaries’ access to home health care.
The pandemic exacerbated longstanding staffing challenges for
HHAs and added new ones
The COVID-19 pandemic further strained HHAs’ ability to hire and keep staff (see
Exhibit 3). HHAs described longstanding (i.e., pre-pandemic) challenges retaining and
recruiting staff, including positions that
remain vacant because candidates either do
“We have [an] already tight market and a not apply or do not qualify for the position.
These challenges extended into the
limited number of nursing professionals living
pandemic. According to many HHAs,
in this area, staffing is always an issue. In the
challenges early in the pandemic included
light of the pandemic, [it has] made the nurse difficulty recruiting new clinical staff due to
shortage even more noticeable and increased competition from other health care
challenging.” – Senior HHA staff facilities or contract agencies (71 percent)
and staff leaving to work for these facilities
and contract agencies (51 percent). Two
HHAs noted difficulty in recruiting and
retaining staff because other companies offered higher wages.
In addition to longstanding staffing challenges that were exacerbated by the
pandemic, many HHAs faced challenges that emerged as a result of the COVID-19
pandemic (see Exhibit 3). Most HHAs (85 percent) had early challenges with limited
staff due to personal circumstances related to the pandemic, such as school closures,
or because of self-quarantine/isolation requirements. About half of HHAs struggled
early in the pandemic to pay contracted clinical staff due to higher contracting costs.
Finally, three HHAs that we interviewed also noted challenges with staff uneasiness
with caring for COVID-19 patients, which may have resulted in these patients not
receiving care or overburdening the staff willing to care for COVID-19 patients. Rural
HHAs that responded to our survey also experienced several of these same
longstanding and COVID-19-specific challenges. For example, 39 of 41 rural HHAs
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OEI-01-21-00110 Findings | 9
reported challenges with limited staff availability to work because of a COVID-19
exposure.
HHAs told us that staffing challenges made it difficult to complete patient visits and
accept new patients:
“We could not accept some referrals due to staffing challenges.” – Senior HHA staff
“When schools closed [we] had to discharge clients.” – Senior HHA staff
“We had the potential to see a lot of patients, but we didn’t always have the staff.” – Senior
HHA staff
According to many HHAs, both longstanding and new staffing challenges persist,
despite some improvement over the period of our review (see Exhibit 3). For example,
in fall 2021, 62 percent of HHAs still experienced challenges with recruiting new staff
due to competition from other facilities or health care contract agencies, and 40
percent still struggled with staff leaving to work for other health care facilities.
Moreover, many HHAs continued to struggle with challenges that emerged due to the
pandemic. Despite some improvement, about half of HHAs still experienced
challenges with limited staff availability due to personal circumstances related to the
pandemic or because of self-quarantine/isolation requirements. In addition, HHAs
found that the challenge of paying contracted clinical staff—a challenge stemming
from higher contracting costs during the pandemic—decreased only slightly from
early in the pandemic; 44 percent of HHAs struggled with this in fall 2021.
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Exhibit 3. Many HHAs continued to experience staffing challenges well into the pandemic.*
Early in the pandemic Fall 2021
When an HHA 's area experienced September 21 to November 22,
its first wave of COV/O-19 2021
Recruiting new clinical staff due to
increased competition from other 71 % 62%
health care providers**
Clinical staff leaving this HHA to
work for other health care
providers**
51 %
..
Paying contracted clinical staff
due to higher contracting costs
during the pandemic
Limited staff availability to work
because of self-quarantine/
isolation due to COVID- 19
- 55%
exposure
Limited staff availability to work
due to personal circumstances 55%
related to the pandemic
■ Longstanding staffing challenges ■ COVID-19 specif ic staffing challenges
* All differences between the two time points are significant at the 0.05 level (n=271). See Appendix D for more details.
** These providers may include health care contract agencies or other health care facilities, such as hospitals.
Source: OIG analysis of survey data, 2022.
Although none of the challenges were fully resolved by fall 2021,
HHA-developed strategies and CMS flexibilities helped HHAs to
mitigate some staffing challenges
HHAs developed their own strategies to ensure that patients received care despite
staffing challenges (see Exhibit 4). Many HHAs found it useful to assist staff with
addressing COVID-19-related concerns, including by providing paid or unpaid leaves
of absence (65 percent) or benefits, such as flexible schedules (59 percent). Nearly as
many (58 percent) also benefited from training staff to perform tasks outside of their
usual duties, such as administrative work or duties in a different clinical area. In
addition, 40 percent of HHAs created and found it helpful to have specialized care
teams of clinical staff who only treat COVID-19 patients. For example, one HHA that
we interviewed created COVID-19 care teams composed of staff who volunteered to
see those patients. Furthermore, HHAs reported using COVID-19 relief funds, such as
the Provider Relief Fund, to recruit and maintain staff. 76 Two HHAs that we
interviewed used these funds to pay staff who were unable to work because of the
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pandemic, and two HHAs used the funds to offer hazard pay. However, another two
HHAs that we interviewed noted that using financial support to recruit new staff, such
as with signing bonuses, had limited effectiveness because of the lack of candidates
applying for open positions.
Exhibit 4. HHAs used and found helpful various strategies that they developed to respond to
staffing challenges during the pandemic.*
Provided paid and/or unpaid leaves of absence to
retain staff that are unable to work
- - -•
Provided staff benefits to address COVI D-19-
related concerns ---•
Trained staff to perform tasks outside of their usual
duties
---•
Created specialized care teams of clinical staff who
treat only COVID-19 patients
Developed new partnerships or used existing
partnerships with other HHAs or health care - - - - -•
facilities to share staff to fil l staffing gaps
--• ·.
* Surveyed HHAs also had the option to indicate if they used a strategy and did not find it helpful or if they did not use the strategy (see
Appendix D).
Source: OIG analysis of survey data, 2022.
In addition to developing their own strategies, HHAs relied on flexibilities that CMS
offered to help address staffing challenges (see Exhibit 5). CMS told us that it offered
flexibilities that increased time for staff to complete certain assessments and relaxed
training requirements to help with staffing constraints. About half of HHAs found
each of these helpful (54 percent and 41 percent, respectively). As required by
provisions in the CARES Act, CMS permanently amended regulations to authorize
nurse practitioners and physician assistants to certify and order home health services
in addition to physicians. HHAs told us that it made it easier and faster to admit new
patients. One HHA that we interviewed said that this flexibility was “huge” in getting
orders for home health services signed and implemented. CMS also expanded the
types of HHA staff who may perform initial and comprehensive patient assessments
to include occupational therapists (OTs), in addition to registered nurses, physical
therapists (PTs), and speech language pathologists (SLPs). 77 Three HHAs that we
interviewed told us that this flexibility helped them admit and assess patients more
quickly when staffing resources were stretched thin. (See Appendix B for a summary
of CMS flexibilities, including their status as of summer 2022.)
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Although CMS has taken actions to ease HHAs’ staffing challenges, it has limited
information on how these flexibilities have affected HHAs’ care. In March 2021, CMS
issued an update to the State Operation Manual’s Appendix Z—Emergency
Preparedness Interpretive Guidelines—to provide additional guidance for the
requirement that HHAs have policies and procedures that address emergency staffing
strategies. However, HHAs have discretion on which staffing strategies they use
during an emergency.
CMS receives feedback on the flexibilities via regular and ad hoc engagements with
HHA stakeholders. For example, stakeholders have told CMS that the flexibilities are
helpful and needed until the end of the COVID-19 public health emergency. CMS
told us that it used feedback from stakeholder engagements to inform decision-
making on which flexibilities to make permanent. However, CMS is not systematically
collecting data to capture how HHAs are using or benefiting from flexibilities that
aimed to help with staffing challenges or how flexibilities have affected the quality of
patient care.
Exhibit 5. HHAs used and found helpful the various flexibilities that CMS provided for them
to respond to staffing challenges during the COVID-19 public health emergency.*
- - -•
Authorizing additional practitioners to certify
beneficiaries for eligibility, order home health
services, and establish and review the care plan
Allowing OTs, PTs, and SLPs to perform certain
assessments for all patients receiving therapy
services - -•
Extending the 5-day completion requirement for the
comprehension assessment to 30 days
- -•
Waiving the requirement for onsite visits by a nurse
every 2 weeks
--•
Postponing the deadline for certain training
requirements for home health aides
- •
* Surveyed HHAs also had the option to indicate if they used a flexibility and did not find it helpful or if they did not use the flexibility (see
Appendix D).
Source: OIG analysis of survey data, 2022.
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HHAs’ infection control challenges were numerous and
widespread early in the pandemic, but these challenges
lessened by fall 2021
Because of COVID-19’s infectious nature, HHAs had to quickly pivot to continue to
provide needed care while also protecting patients and staff. Limiting the spread of
disease requires an understanding of how to prevent transmission and how to
appropriately care for infected patients. Enhanced infection control also requires
adequate levels of supplies, particularly PPE. However, limited knowledge of COVID-
19 as well as disrupted supply chains impeded HHAs’ ability to carry out these
important tasks early in the pandemic.
Early on, HHAs struggled to understand and navigate infection
control for COVID-19; they relied on government guidance,
trainings, and new protocols to help address this
According to HHAs, it was a challenge to mitigate transmission and care for COVID-19
patients at the beginning of the pandemic (see Exhibit 6). Because COVID-19 was a
novel disease, information regarding how to care for patients was limited and evolved
as understanding of the virus grew. Indeed, early in the pandemic, most HHAs (87
percent) experienced challenges with navigating evolving guidance about how to
treat COVID-19 patients. Four HHAs that we interviewed also described struggling to
interpret changing guidance to inform their infection
control protocols (e.g., changes in appropriate PPE
“Having to research and determine
use and post-exposure quarantine requirements). In
what information to base [p]olicies on addition, 88 percent of HHAs experienced challenges
has been very time consuming.” with unclear and conflicting Federal and/or State
– Senior HHA staff government guidance about COVID-19 infection
prevention and control. Likewise, most rural HHAs
that responded to our survey (34 of 41) reported
experiencing this challenge. HHAs described having
to devote sometimes substantial resources to researching government websites to
develop infection control protocols. These challenges with guidance affected patient
care: 56 percent of HHAs postponed caring for patients with positive COVID-19
diagnoses until they had adequate infection control procedures in place.
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Exhibit 6. Most HHAs experienced challenges with understanding and navigating infection
control information early on, although these challenges have decreased.*
Early in the pandemic Fall 2021
When an HHA 's area experienced September 27 to November 22,
its first wave of COV/0- 79 2027
Unclear State/Federal guidance about
how to treat COVI D-19 patients 89%
Unclear or conflicting State/Federal
guidelines about COVID-19 infection 88%
prevention and control
Navigating evolving guidance about
how to treat COVI D- 19 patients
87%
i!fi
* All differences between the two time points are significant at the 0.05 level (n=271). See Appendix D for more details.
Source: OIG analysis of survey data, 2022.
HHAs attempted to mitigate challenges with infection control while their
understanding of COVID-19 increased. In addition to continuing to comply with the
CoPs for infection prevention and control (see Appendix A), the COVID-19 pandemic
required HHAs to take further action to address COVID-19 infection challenges. From
the perspective of HHAs, nearly all (97 percent) found it helpful to use available
information to develop internal COVID-19 protocols, which can include information
on how to respond to an exposure. Moreover, nearly all HHAs found it helpful to
increase or improve trainings for staff on COVID-19 treatment (95 percent) and
provide staff with PPE training (96 percent). Although HHAs struggled with infection
control information early in the pandemic, HHAs still accessed and relied on
government sources, including CDC guidance, to inform protocols for minimizing
transmission.
Nearly all HHAs faced challenges with accessing PPE and other
critical supplies to control the spread of COVID-19 early in the
pandemic, but these challenges eased over time
PPE and sanitizing products are essential for infection control. Their widespread
shortages early in the pandemic posed
challenges to safely caring for patients (see
Exhibit 7). According to HHAs, over 90 “[We] [n]ever thought that we
percent faced early challenges with accessing would not be able to obtain PPE.”
supplies such as masks, other types of PPE, – Senior HHA staff
and sanitizing products (e.g., sanitizing wipes,
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hand sanitizer). Nearly all rural HHAs that responded to our survey also experienced
these challenges early in the pandemic: 37 with accessing masks, 37 with accessing
other types of PPE, and 38 with accessing sanitizing products (of the 41 rural HHAs
that responded to our survey). These challenges with accessing supplies came at a
time when HHAs needed to use more supplies than ever to protect patients and staff
from COVID-19 infection. One HHA that we interviewed described its limited access
to supplies early in the pandemic as “absolutely horrific.”
Exhibit 7. Almost all HHAs struggled with accessing supplies early on, but these challenges
lessened over time.*
Early in the pandemic Fall 2021
When an HHA 's area experienced its September 21 to November 22,
first wave of COV/D- 19 2021
Access to masks 93%
Access to other types of PPE 91%
Access to sanitizing products 94%
High cost of PPE during the
89% 42%
pandemic
* All differences between the two time points are significant at the 0.05 level (n=271). See Appendix D for more details.
Source: OIG analysis of survey data, 2022.
Until supply chains stabilized, HHAs had to take unprecedented steps to address
limited supply access. Over half (57 percent) found it helpful to conserve PPE, such as
by re-using PPE normally meant for single use or by prioritizing PPE for the highest-
risk activities. In addition, almost half (42 percent) of HHAs found it helpful to
develop new, or use existing, partnerships with other HHAs or providers to obtain or
pool supplies. Finally, some
HHAs (31 percent) found it
helpful to access PPE through “Some of my staff and myself [sic] went to stores to try
nontraditional sources, such and find 90% alcohol to clean our equipment. We
as nail salons. One HHA that made [a]lcohol wipes out of industrial paper towels, we
we interviewed characterized went to hardware stores to get N95 masks.”
its activities to access scarce
– Senior HHA staff
supplies as follows: “we
[HHAs] were just doing what
we all could to survive.”
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Although most HHAs used telehealth during the pandemic,
challenges that HHAs experienced raise questions about
telehealth’s future role in home health
CMS implemented telehealth flexibilities for many types of providers during the
COVID-19 public health emergency, including flexibilities for HHAs. Indeed, as HHAs
struggled with shortages of staff and supplies due to COVID-19, telehealth provided
an opportunity to safely care for patients while reducing risk of infection. CMS
updated regulations in November 2020 to permanently allow HHAs to use telehealth
as part of their patients’ plans of care, even after the public health emergency ends. 78
This regulatory change makes it vital to understand how HHAs use telehealth and its
potential effects on patient care.
HHAs used telehealth to provide a variety of services to patients
during the pandemic, including phone calls for status checks and
video visits for therapy services
Most HHAs (73 percent) used telehealth during the pandemic and used
73%
it to conduct visits, share information, and facilitate interactions with
outside providers. Of the HHAs that used telehealth, just over three-
quarters (78 percent) provided live video or audio visits during the
pandemic (see Exhibit 8). 79 Three HHAs that we interviewed noted that
of HHAs used telehealth remote visits were particularly useful because of COVID-19’s infectious
during the pandemic nature. For example, HHAs were able to provide services to patients
who did not want providers in their homes, especially early in the
pandemic. HHAs also described using telehealth to supplement care,
such as through status checks for
patients with chronic illnesses or COVID-
19. One HHA told us that it made “daily “[Telehealth] helped us keep patients
phone calls to active COVID patients who
seen when they needed visits and keep
were under quarantine to assess the
need for an in-person visit.” Notably, them home and healthy.”
two HHAs that we interviewed told us – Senior HHA staff
that telehealth was useful for continuing
to provide patient care despite staffing
challenges.
Although Medicare does not cover this use of telehealth under the home health
benefit, nearly two-thirds of HHAs (63 percent) helped patients set up or participate in
telehealth services with a non-HHA provider such as a physician. HHAs described
using telehealth to facilitate remote communication with physicians and to meet
certain requirements for home health care. For example, one HHA that we surveyed
wrote that it “assisted patient[s] with telehealth visits with their physicians by setting
up appointments and having a clinician with them to report specific vital signs and
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OEI-01-21-00110 Findings | 17
other symptoms.” Furthermore, half of the HHAs we interviewed reported that they
would facilitate video calls between patients and physicians that, prior to the public
health emergency, were required to be conducted in person.
Just under half of HHAs (44 percent) electronically transmitted health information to
health care providers within and/or outside of the HHA. This may include
electronically sending information for a health care provider to later assess. HHAs
also reported using telehealth for remote patient monitoring, which involves leaving
equipment such as heart rate monitors with patients so that the HHA can continue to
monitor vital signs. One HHA that we surveyed told us that it used this for “vital sign
assessments for heart failure or other chronic conditions.”
Exhibit 8. HHAs used telehealth for different purposes during the
pandemic.*
Live, real-time services between a patient and a provider (in the HHA)
HHA providers helping patients set up or participate in telehealth services with
a provider outside of the HHA
Electronically transmitting patient health information to a provider for their
assessment at a different time
* Among HHAs that used telehealth during the pandemic.
Source: OIG analysis of survey data, 2022.
Challenges using telehealth in home health care may limit its
future use
From the perspective of many HHAs that used telehealth during the pandemic,
providing telehealth services often came with challenges (see Exhibit 9). Some
challenges were due to limitations with delivering telehealth services. For example,
home-based telehealth requires the patient’s home to have access to phone service,
internet, and equipment (such as a smartphone). About two-thirds of HHAs found
that insufficient internet access in patients’ homes was a challenge, and five HHAs that
we interviewed told us that patients struggled with accessing phone service and
equipment. In addition, almost two-thirds of HHAs found that most home care
services require physical contact with patients, such as providing wound care, which
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OEI-01-21-00110 Findings | 18
may affect the quality of care provided using telehealth. Three HHAs that we
interviewed noted that assessing patients, for example to evaluate mobility when a
patient is walking, is difficult to do over video. Other HHAs said that patients may be
less capable of taking their own vital signs, such as blood pressure or heart rates, than
are health care professionals. As a result, one HHA that we interviewed told us that
self-reported health information, whereby patients assess their own vital signs and
symptoms and communicate them to the HHA, “doesn’t reflect the real situation or
condition of the patient… [W]e can’t get an accurate picture of our patient because of
those limitations.”
According to HHAs, they also experienced financial challenges with using telehealth
(see Exhibit 9). Almost half of HHAs (44 percent) struggled with the high cost of
telehealth. HHAs cannot bill Medicare for telehealth services as equivalent to an in-
person visit, and two-thirds of HHAs found that this lack of direct reimbursement was
a challenge. HHAs that we interviewed told us that lack of direct reimbursement
meant they could not afford to use telehealth more frequently. For example, three
HHAs that we interviewed noted that setting up and using telehealth, including
purchasing the required equipment, is costly.
Exhibit 9. HHAs that used telehealth during the pandemic experienced challenges in
providing telehealth services.
Lack of direct reimbursement for •
telehealth services - - - - - - - - - - - - - - - - - - - ·: · ·
Insufficient internet access in patients'
homes
Requirement for physical contact with
----•
----•
- -•
patient for most care
High cost of providing telehealth
services
■ Challenges due to limitations ■ Challenges due to financial
delivering telehealth services concerns
Source: OIG analysis of survey data, 2022.
Rural HHAs may experience greater challenges providing telehealth services
compared to HHAs in other settings. Of the 31 rural HHAs that responded to our
survey and used telehealth during the pandemic, 25 identified insufficient internet
access as a challenge. HHAs serving patients in rural settings reported that their
patients often live in locations with limited or no cellular service or internet access and
have limited access to equipment necessary to facilitate telehealth services. One rural
HHA that we surveyed told us: “We can't provide [t]elemedicine to patients unless
there is adequate equipment in the home. In rural eastern Washington state, there is
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often not. There is also often not internet or cell phone service in the home, making
[t]elemedicine impossible.”
43%
HHAs that used telehealth during the pandemic
were divided on whether they plan to continue
using it after the pandemic, although government
support to overcome challenges may influence
this. Of the HHAs that used telehealth during the
pandemic, 43 percent anticipated that they will of HHAs that used telehealth
not use it afterwards. HHAs said that they during the pandemic will not
temporarily relied on telehealth to help address use it afterwards
pandemic-specific challenges, such as monitoring
high-risk COVID-19 patients or delivering services to patients who do not want
providers in their homes. Almost half of the HHAs we interviewed told us that there is
limited incentive to provide telehealth services, including after the pandemic, but that
they might reconsider if they received direct reimbursement for these services.
On the other hand, over half (57 percent) of HHAs that used telehealth during the
pandemic anticipated that they will continue to use telehealth after the pandemic,
including in ways that incorporate lessons learned. For example, one HHA that we
interviewed created a more detailed telehealth-based virtual assessment for patients
it considered at higher risk for rehospitalization, including COVID-19 patients. HHAs
also acknowledged that although telehealth is not appropriate for all HHA-based
care, telehealth may be better suited to certain home health services. One HHA that
we surveyed told us that it thought CMS should reimburse HHAs for telehealth
services that supplement in-person care: “provide reimbursement for virtual skilled
nursing visits with patients as an adjunct to in-person visits (not as a replacement).
This could minimize rehospitalizations.”
CMS lacks full insight into HHAs’ use of telehealth due to limited
reporting requirements
HHAs report limited information about their telehealth use to CMS. CMS requires
HHAs to report the direct costs of providing telehealth on their cost reports, but these
do not include further detail on the types of services for which HHAs use telehealth. 80
HHAs cannot bill Medicare for telehealth visits as comparable to in-person visits and
are currently not required to report telehealth use on their claims. Therefore, CMS is
unable to capture specific details on the extent and nature of how HHAs use
telehealth. CMS told us that these limitations affect the extent to which CMS can
evaluate and review HHAs’ telehealth use. For example, CMS cannot track the
frequency with which HHAs use telehealth over time or the types of services they
provide with telehealth.
CMS plans to assess available information on HHAs’ telehealth use and to explore
options to gather additional information. For example, in a calendar year (CY) 2021
final rule, CMS allowed HHAs to include remote patient monitoring and other
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telehealth technology within cost reports as allowable administrative and general
costs. CMS plans to assess these data when it receives those cost reports. 81 In June
2022, CMS issued a CY 2023 proposed rule allowing HHAs to voluntarily report
telehealth use on claims starting January 2023. 82 The proposed rule, if enacted, will
require this information by July 2023. However, Medicare could not directly
reimburse these services without a change in statute. CMS is also soliciting
comments on how it intends to capture telehealth use on claims as well as on the
appropriateness of telehealth in the home health context. Currently, CMS also
engages with HHAs and other stakeholders on both a regular and as-needed basis
and may receive feedback on telehealth through these engagements. CMS
acknowledges the importance of gaining a more complete picture of HHAs’ telehealth
use to inform future decision-making.
Emergency preparedness (EP) plans guided HHAs’ response to
the pandemic, but the plans fell short of fully addressing a
global emergency such as COVID-19
CMS requires that HHAs conduct risk assessments to inform their EP plans. Risk
assessments must use an all-hazards approach to consider a broad range of
emergencies that may affect the HHA and its patient population. HHAs have wide
latitude to determine the contents and structure of their EP plans. Because each risk
assessment is specific to the HHA, EP plans vary on the basis of emergency scenarios
HHAs identify and how HHAs plan to address these emergencies. This includes
determining how to include emerging infectious diseases as part of their all-hazards
risk assessment, as required by CMS in 2019.
Almost all HHAs with EP plans found them helpful with
responding to the challenges of the COVID-19 pandemic
Nearly all HHAs (98 percent) that had an EP plan during the pandemic benefited from
these plans, including with challenges related to infection control guidelines and
accessing supplies (see Exhibit 10). Notably, 91 percent of HHAs with an EP plan
during the pandemic found the plan to be helpful with addressing infection control
challenges. One HHA that we interviewed told us that, prior to the pandemic, its EP
plan included infection control guidelines based on other infectious diseases such as
influenza and severe acute respiratory syndrome. Although these guidelines were not
specific to COVID-19, they were helpful for reducing its transmission. In addition, 81
percent of HHAs that had an EP plan found them to be helpful with addressing supply
challenges. For example, one HHA we spoke with explained that its local health and
emergency departments became important resources for help with supplies when it
was faced with pandemic-related shortages. That HHA developed relationships with
those entities prior to the pandemic through emergency drills required by CMS.
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Exhibit 10. HHAs that had EP plans during the pandemic found these EP plans helpful.
Helpful overall 98%
Helpful responding to challenges with infection
91%
control
Helpful responding to challenges with supplies 81%
Helpful responding to challenges maintaining
74%
appropriate staffing
Source: OIG analysis of survey data, 2022.
About three-quarters (74 percent) of HHAs also found their EP plans to be helpful
with addressing staffing challenges. A couple of HHAs that we interviewed described
how their plans supported their responses by outlining each staff member’s
responsibilities during an emergency. According to one HHA, “if we didn’t have an
emergency management infrastructure in place I don’t know if we would have had as
effective of a response. Everyone knew their roles.”
Because HHAs’ EP plans generally focused on local, temporary
emergencies, many fell short in a sustained, global emergency
Although EP plans provided a useful framework
51%
for responding to the pandemic, about half of
HHAs that had an EP plan found it challenging
that their EP plans were more suitable to a local
of HHAs with an EP plan found it
“It’s not like a fire, or earthquake, that hits a challenging that their plan was
certain area or population and you use your more suitable to a local emergency
EP to get through it, clean up the aftermath than to a national or global
emergency such as COVID-19
and move on. This pandemic is a disaster like
no other, that has infiltrated every aspect of emergency than to a national or global
emergency such as COVID-19. CMS
society…” – Senior HHA staff
instructed HHAs to include emerging
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infectious diseases in its 2019 EP plan guidance, and 93 percent of HHAs did so
before the pandemic. However, nearly half of the HHAs we interviewed told us that
their plans focused on emergencies that were more likely to affect their geographic
area, such as weather events. One HHA described how its plan included information
on responding to hurricanes, including contacting patients to determine plans for
evacuation, but noted that this did not prepare it for COVID-19. Another HHA said
that its EP plan did not originally cover situations in which staff could not enter
patients’ homes, as was the case during the COVID-19 pandemic. This HHA said that
prior to the pandemic, it had not considered emergency preparedness “on a global
platform.”
HHAs adjusted their emergency planning to respond to COVID-19
and identified how CMS could further help them with this
planning
To support their COVID-19 response, HHAs developed new, separate response plans
as well as adjusting their existing EP plans. In fact, 85 percent of HHAs developed a
separate response plan specific to COVID-19. These plans, which CMS does not
require, included information on testing staff and patients for COVID-19, treating
patients with COVID-19, and work-from-home policies, among other information.
One HHA that we interviewed described a flow chart included in its COVID-19 plan
that guides staff through determining whether an employee should isolate or
quarantine after an exposure. In addition, as of fall 2021, almost all HHAs (97 percent)
modified or planned to modify their existing EP plans to apply lessons learned during
the pandemic. For example, one HHA that we interviewed updated its EP plan to
include screening questions about whether patients had been exposed to any
infectious disease, such as influenza. Another updated the supply policy in its EP plan
to maintain a 90-day reserve of new supplies.
HHAs expressed that they would benefit from more support from CMS on developing
and using their EP plans to meet the challenges of an infectious disease emergency.
Of the HHAs that responded to our question,
two-thirds (67 percent) said that CMS could
better support HHAs by providing more
One senior HHA staff member
information on the content and
recommended that CMS provide
implementation of these EP plans during an
“designated training for HHAs to follow as infectious disease emergency. For example,
guides for infectious disease emergencies one HHA suggested that CMS provide
that are at a national or global level.” examples of guidelines that other HHAs used
and found helpful when responding to an
emerging infectious disease. Another HHA
we surveyed requested that CMS provide
more training on using EP plans to respond to an emerging infectious disease
emergency.
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Amidst the COVID-19 public health emergency, CMS has taken steps to help HHAs
with their EP plans. In March 2021, CMS issued updated guidance for EP plans and
prompted HHAs to include more information on emerging infectious diseases. CMS
also told us that it plans to solicit and use feedback from providers, including HHAs,
about their experiences during the public health emergency to make future changes
to this guidance. Finally, CMS told us that it coordinates with ASPR TRACIE to offer
HHAs additional guidance on emerging infectious diseases, including COVID-19.
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CONCLUSION AND RECOMMENDATIONS
The COVID-19 pandemic presented substantial challenges for HHAs and their
capacity to care for patients. The challenges included the novel nature of the
virus, as well as challenges with staffing, infection control, supply shortages,
and emergency planning, among others.
HHAs and CMS took steps to address these challenges as knowledge
regarding the pandemic evolved. The regulatory flexibilities that CMS offered
helped HHAs as they grappled with how to respond to the COVID-19
pandemic. HHAs used telehealth to fill gaps in their capacity to provide
services and adjusted their emergency plans, in addition to other
actions. Indeed, as knowledge about the virus increased, supply chains
stabilized, and HHAs took steps to continue caring for patients, some of the
earliest challenges abated.
However, HHAs’ experiences responding to the pandemic point to continued
challenges. With HHAs using telehealth in new ways, questions have emerged
about whether and how it can best serve beneficiaries in the home health
realm. In addition, staffing challenges—which were also present prior to the
pandemic—persist, despite HHAs’ use of regulatory flexibilities and their own
efforts to address staffing.
As the immediacy of the pandemic lessens, CMS has an opportunity to assess
how to best help HHAs prepare for and respond to current and future
infectious disease outbreaks. Furthermore, changes to the home health care
landscape, including expanded telehealth allowances, merit further study to
understand how these changes best serve patients.
To that end, we recommend that CMS:
Evaluate how HHAs are using telehealth—specifically, the
types of services provided via telehealth and the
characteristics of patients who benefit from these services
CMS could use such an evaluation to refine its approach to telehealth in the
home health environment. With CMS permanently allowing HHAs to use
telehealth as part of a patient’s plan of care, understanding the strengths and
limitations of telehealth in home health is important to ensuring that patients
receive beneficial and high-quality care. For example, home health patients
may benefit from certain telehealth services, such as remote patient
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OEI-01-21-00110 Conclusion and Recommendations | 25
monitoring or status checks, but may benefit less from other services through
telehealth, such as physical therapy visits or wound care. Examining HHAs’
telehealth use and its effects on access, equity, quality of care, and program
integrity will provide vital insights into whether and how telehealth can best
serve home health patients.
To better determine the types of services provided by telehealth and
characteristics of patients who benefit from these services, CMS should collect
and analyze data on HHAs’ telehealth use. CMS is planning to examine
telehealth information included on HHAs’ cost reports once HHAs submit
these data. CMS’s CY 2023 proposed rule for home health allows HHAs to
voluntarily report telehealth use on claims starting in January 2023. The
proposed rule, if enacted, will require this information by July 23, 2023. CMS is
also soliciting comments on how CMS intends to capture telehealth use on
claims as well as the appropriateness of home health care via telehealth given
the hands-on nature of many home health services. We encourage CMS to
analyze claims data, as well as other relevant data it collects or identifies, if
any, to evaluate HHAs’ use of telehealth.
To inform decision-making, evaluate how the regulatory
flexibilities it has offered in response to the COVID-19
public health emergency affect the quality of home health
care
CMS has limited information on how flexibilities affected patient care during
the public health emergency. CMS obtained feedback on the flexibilities
through structured and ad hoc engagements with stakeholders during the
public health emergency and used this feedback to inform decisions about
which flexibilities to make permanent. However, CMS has not systematically
evaluated these flexibilities, including the impact of these flexibilities on the
quality of patient care.
CMS should conduct a systematic review to gain insights into how the
flexibilities offered during the public health emergency—whether as a whole
or individually, and including those that are now permanent—affect the
quality of patient care. CMS could collect data from HHAs or analyze claims,
assessment data, and/or patient feedback to examine changes in quality of
care during the public health emergency that may relate to the flexibilities.
CMS could use this review to inform decision-making regarding which
flexibilities to use during future emergencies.
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In collaboration with ASPR TRACIE, apply lessons learned
from the COVID-19 pandemic to update and/or develop
emergency preparedness trainings and materials for HHAs
on responding to infectious disease outbreaks
CMS has an opportunity to provide additional support to HHAs responding to
infectious disease emergencies, including those that are sustained and
widespread. Indeed, HHAs told us that they desire and would benefit from
more guidance. CMS already provides online trainings on emergency
preparedness for health care providers and also collaborates with ASPR
TRACIE to support HHAs’ emergency preparedness, including by conducting
technical reviews of ASPR TRACIE materials for HHAs.
CMS has solicited feedback from providers, including hospitals and nursing
homes, on their experiences using their EP plans during COVID-19. CMS
should also directly engage with HHAs on their experiences using their EP
plans. CMS should share feedback with ASPR TRACIE, and, in collaboration
with ASPR TRACIE, use this feedback as well as the findings of this study to
inform emergency preparedness trainings and materials (whether as updates
to existing resources or to develop new resources). These trainings and
materials should reflect lessons learned from the COVID-19 pandemic. To
guide these efforts, CMS could review existing CMS and ASPR TRACIE
emergency preparedness resources, including those that are currently under
development, to identify opportunities to incorporate lessons learned. For
identified opportunities, CMS could collaborate with ASPR TRACIE to develop
new, or modify existing, resources.
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OEI-01-21-00110 Conclusion and Recommendations | 27
AGENCY COMMENTS AND OIG RESPONSE
CMS concurred with all three of our recommendations, as detailed below.
First, CMS concurred with our recommendation to evaluate how HHAs are using
telehealth—specifically, the types of services provided via telehealth and the
characteristics of patients who benefit from these services. In the CY 2023 Home
Health Prospective Payment System proposed rule, CMS stated its plans to require
that HHAs report the use of telehealth on home health claims beginning July 2023.
Collecting this information is vital to understanding the strengths and limitations of
telehealth in the home health environment, as well as the characteristics of patients
who benefit from telehealth services. We look forward to updates in CMS’s Final
Management Decision on both its evaluation of HHAs’ use of telehealth as well as
how patients have benefited from these services.
Second, CMS concurred with our recommendation to evaluate how regulatory
flexibilities offered during the COVID-19 public health emergency affect the quality of
home health care. CMS stated that it is holding listening sessions seeking feedback
from providers, including HHAs, on what flexibilities have been the most or least
helpful during the public health emergency. In its Final Management Decision, CMS
should detail its efforts to systematically review how the flexibilities offered during the
COVID-19 public health emergency, either individually or as a whole, affected the
quality of patient care.
Third, CMS concurred with our recommendation to collaborate with ASPR TRACIE to
apply lessons learned from the COVID-19 pandemic to update and/or develop
emergency preparedness trainings and materials for HHAs on responding to
infectious disease outbreaks. CMS stated that it recently published case studies of
how 30 nursing homes and hospitals responded to challenges during the onset of the
COVID-19 pandemic. In this report, we recommend that CMS engage directly with
HHAs on their experiences using EP plans during the pandemic. In its Final
Management Decision, CMS should describe its direct engagement with HHAs, as well
as its steps to collaborate with ASPR TRACIE, to update and/or develop emergency
preparedness trainings and materials for the home health environment.
For the full text of CMS’s comments, see the appendix at the end of this report.
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OEI-01-21-00110 Agency Comments and OIG Response | 28
DETAILED METHODOLOGY
This study used the following data sources: (1) a survey of a random sample of HHAs;
(2) interviews with a purposive sample of 12 HHAs; and (3) an interview with CMS
staff.
Scope
This study focuses on Medicare-participating HHA experiences from early in the
pandemic to the point that OIG surveyed or interviewed HHAs in September through
December 2021. As part of the survey and interviews, we asked HHAs about
challenges experienced early in the pandemic and in fall 2021. We defined “early in
the pandemic” to mean when the respondent HHA’s geographic area experienced its
first wave of COVID-19 infection.
Sample
We selected a nationally representative, simple random sample of 400
Medicare/Medicaid-participating HHAs to ask about their experiences during the
COVID-19 pandemic. We selected the random sample from among the 11,418 HHAs
listed in CMS’s Certification and Survey Provider Enhanced Reporting (CASPER)
system as of June 2021. 83 Of the 400 sampled HHAs, we removed 19 closed HHAs
and 4 HHAs that participated only in Medicaid, bringing the total to 377 HHAs
included in our sample. 84
Survey
We sent an electronic survey to the sampled HHAs between September 21, 2021, and
November 22, 2021; 271 HHAs responded, for a 72-percent response rate. We
contacted each HHA with at least two letters and a phone call before determining that
an HHA was a nonrespondent. 85 We project our sample to the 72 percent of the
11,265 Medicare-participating HHAs represented by our respondents. We conducted
a nonresponse analysis to assess whether nonresponding and responding HHAs in
our sample differed with regard to certain variables. See Appendix C for a description
of our nonresponse bias analysis.
The survey included questions about HHAs’ challenges during the COVID-19
pandemic; strategies to address these challenges; and the use of telehealth,
regulatory flexibilities, and emergency preparedness plans during the pandemic. It
also collected background information about the HHA. We produced estimates from
these survey data to describe the experiences of Medicare-participating HHAs
represented by our respondents during the pandemic. We performed t-tests to
determine statistically significant differences in the proportions of HHAs experiencing
challenges early in the pandemic compared to at the time of the survey. Significant
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OEI-01-21-00110 Detailed Methodology | 29
differences were determined at the 0.05 level. See Appendix D for estimates and p-
values, where appropriate.
We analyzed open-ended survey responses by categorizing these responses by
theme. We used open-ended survey responses to add context to our survey
estimates and provide insight into HHAs’ experiences during the COVID-19 pandemic,
including challenges and strategies used to address challenges. We counted the
number of responses that directly answered the survey question to produce estimates
from these data.
Rural HHA Analysis
To identify HHAs as rural, we obtained 2019 Medicare claims data for the HHAs in our
sample and determined the percentage of care episodes HHAs provided to Medicare
beneficiaries in rural Core Based Statistical Areas (CBSAs). We used 2019 Medicare
claims data because 2019 is the most recent year for which claims are complete. 86 We
defined rural HHAs as HHAs that provided 50 percent or more of their care episodes
in rural CBSAs. 87 We identified 41 rural HHAs that responded to our survey (18
percent of respondents with 2019 Medicare claims). 88
We analyzed rural HHAs’ survey responses to describe the experiences of rural HHAs
in our sample during the COVID-19 pandemic. We do not generalize these responses
to all rural HHAs.
Stakeholder Interviews
We interviewed staff from a purposive sample of 12 HHAs in November and
December 2021. We selected these HHAs on the basis of survey responses that
indicated notable challenges, strategies, or other experiences that may be useful to
CMS, the HHA industry, and other stakeholders. We use data from these interviews to
add context to our survey data and provide insight into HHAs’ experiences during the
COVID-19 pandemic. We do not use these interviews to generalize to all HHAs. Of
the 12 HHAs we interviewed, we identified 4 as rural on the basis of their 2019
Medicare claims.
We also interviewed CMS staff in the Center for Clinical Standards and Quality and
Center for Medicare on January 21, 2022. We asked about CMS’s support of, and
perspectives on, HHAs providing care during the pandemic, including (1) guidance
that CMS provided to HHAs; (2) HHAs’ use of regulatory flexibilities provided by CMS;
(3) HHAs’ challenges with staffing and PPE; (4) HHAs’ use of telehealth; and (5) HHAs’
use of emergency preparedness plans and development of COVID-19-specific
response plans.
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OEI-01-21-00110 Detailed Methodology | 30
APPENDICES
Appendix A: CMS Conditions of Participation (CoPs): Infection
Prevention and Control
CMS requires HHAs to maintain and document an infection control program to
prevent and control infections and communicable diseases. 89 To achieve compliance
with the CoP for infection prevention and control, HHAs must meet four standards:
• Prevention: HHAs must follow accepted standards of practice, including the
use of standard precautions, to prevent the transmission of infections and
communicable diseases.
• Control: HHAs must maintain a coordinated agency-wide program for the
surveillance, identification, prevention, control, and investigation of infectious
and communicable diseases.
• Education: HHAs must provide infection control education to staff, patients,
and caregivers.
• COVID-19 vaccination of home health agency staff: As of December 6, 2021,
CMS requires COVID-19 vaccinations for HHA staff. HHAs must develop and
implement policies and procedures to ensure that all staff receive required
vaccinations for COVID-19. 90
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OEI-01-21-00110 Appendix A | 31
Appendix B: Regulatory Flexibilities and Supports for Home
Health Agencies During the COVID-19 Public Health Emergency
(PHE)
Regulatory flexibility or Relevant regulation Status as of summer 2022
support (if applicable)
Extend the 5-day completion 42 CFR § 484.55(b)(1) Waiver in effect for the
requirement for the duration of the PHE for
comprehensive assessment to 30 COVID-19. 91
days
Waive the 30-day Outcome and 42 CFR § 484.45(a) Waiver in effect for the
Assessment Information Set duration of the PHE for
(OASIS) submission requirement. COVID-19. 92
HHAs must submit OASIS data
prior to submitting their final
claim in order to receive
Medicare payment.
Allow HHAs to perform 42 CFR § 484.55(a) Waiver in effect for the
Medicare-covered initial duration of the PHE for
assessments and determine COVID-19. 93
patients’ homebound status
remotely or by record review
Allow the required face-to-face 42 CFR § Waiver in effect for the
encounter for home health 424.22(a)(1)(v)(B) duration of the PHE for
services to be conducted via COVID-19. 94
two-way audio-visual
telecommunications technology
from the patients’ home
Waive requirement for an onsite 42 CFR § 484.80(h) Waiver in effect for the
visit by a nurse every two weeks duration of the PHE for
COVID-19. 95
Waive requirement for a nurse 42 CFR § 484.80(h)(1) Waiver in effect for the
supervisory assessment of home duration of the PHE for
health aide services every two COVID-19. 96
weeks
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Authorize “allowed 42 CFR § 484.55(a)(2) Flexibility made permanent in
practitioners,” in addition to and § 484.55(b)(3) the Coronavirus Aid, Relief,
physicians, to certify and Economic Security Act. 97
beneficiaries for eligibility, order
home health services, and
establish and review the care
plan. (Allowed practitioners are
defined at 42 § CFR 484.2 as
physician assistants, nurse
practitioners, or clinical nurse
specialists.)
Postpone deadline to 42 CFR § 484.80(d) Waiver in effect for the
completing requirement that duration of the PHE for
each home health aide receive COVID-19. 98
12 hours of in-service training in
a 12-month period
Allow occupational therapists, 42 CFR § 484.55(a)(2) Occupational therapist
physical therapists, and speech and § 484.55(b)(3) flexibility made permanent in
language pathologists to the Consolidated
perform initial and Appropriations Act, 2021. 99
comprehensive assessment for
all patients receiving therapy Specifically, the rule made
services permanent the flexibility
allowing occupational
therapists to complete the
initial and comprehensive
assessments for patients when
occupational therapy is on the
home health plan of care, with
either physical therapy or
speech therapy, and when
skilled nursing services are not
initially in the plan of care.
Allow HHAs to use telehealth for 42 CFR § 409.43(a) Flexibility made permanent in
visits and services within the Calendar Year 2021 Home
patient’s plan of care, as long as Health Prospective Payment
the telehealth services do not System Final Rule. 100
replace needed in-person visits
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Waive requirements to provide 42 CFR § 484.58(a) Waiver in effect for the
detailed information regarding duration of the PHE for
discharge planning to patients COVID-19. 101
and their caregivers, or the
patient’s representative in
selecting a post-acute care
provider, by using and sharing
data that includes, but is not
limited to, (another) HHA, skilled
nursing facility, inpatient
rehabilitation facility, and long-
term care hospital quality
measures and resource use
measures
Extend deadline to provide a 42 CFR § 484.110(e) Waiver in effect for the
patient with a copy of their duration of the PHE for
clinical record from 4 days to 10 COVID-19. 102
days
Postpone requirement for nurse 42 CFR § Waiver in effect for the
to make an annual onsite 484.80(h)(1)(iv) duration of the PHE for
supervisory visit (direct COVID-19. 103
observation) of home health
aide services
Narrow scope of Quality 42 CFR § 484.65(a)– Waiver in effect for the
Assurance and Performance (d) duration of the PHE for
Improvement (QAPI) to COVID-19. 104
concentrate on infection control
issues
Exempt HHAs from the Home 42 CFR § 484.245 Waiver no longer in effect.
Health Quality Reporting HHAs were required to resume
Program (QRP) reporting quality reporting data
requirements. The time period submission on July 1, 2020. 105
covered by this exemption is
October 1, 2019, through June
30, 2020.
Implement a policy to align 42 CFR § 484.315(b) Waiver in effect for the
Home Health Value-Based duration of the PHE. 106
Purchasing (HHVBP) Model data
submission requirements with
any exceptions or extensions
granted for purposes of the
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OEI-01-21-00110 Appendix B | 34
Home Health QRP during the
PHE for the COVID-19 pandemic,
as well as a policy for granting
exceptions to the New Measures
data reporting requirements
under the HHVBP Model during
the PHE for the COVID-19
pandemic
Allow Medicare Administrative 42 CFR § Waiver in effect for the
Contractors to extend the auto- 484.205(h)(2)(iv) duration of the PHE for
cancellation date of Requests for COVID-19. 107
Anticipated Payments during
emergencies
Allow HHAs that participate in Waiver no longer in effect.
the Review Choice CMS resumed RCD operations
Demonstration (RCD) for Home on August 3, 2020. 108
Health Services to pause their
participation for the duration of
the PHE
Delay cost report filing deadlines 42 CFR § Waiver no longer in effect.
for cost reporting periods 413.24(f)(2)(i) CMS resumed regular cost
ending between October 1, report deadlines. 109
2019, and December 31, 2020
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Appendix C: Analysis of Nonresponse Bias
To examine the extent of potential nonresponse bias, we compared whether our 271
respondent HHAs differed from the nonrespondents and the population of 11,265
Medicare-participating HHAs (as of June 2021) on certain characteristics. Specifically,
we examined the number of branches operated by HHAs, the location of HHAs in
rural or urban Core Based Statistical Areas, and the number of staff employed by
HHAs. These characteristics did not significantly differ between our respondent
HHAs, nonrespondent HHAs, and all HHAs within our scope. Although these
comparisons do not preclude the possibility of nonresponse bias, they suggest that
our respondent HHAs are similar to the nonrespondents and the population of
Medicare-participating HHAs.
We also examined how our survey results would have changed if all nonrespondent
HHAs in our sample had responded differently from our respondent HHAs (e.g., the
worst-case scenario). For, example, our projection pertaining to telehealth usage (73
percent) would have changed from 73 percent to 52 percent, which is still a majority.
Given that the nonrespondents were similar to the respondents in the characteristics
we examined, a more reasonable scenario is that some of the nonrespondents would
have agreed with the respondents and the realized bias may be small.
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Appendix D: Home Health Agencies’ Responses to OIG’s Survey
HHA experiences with staffing during the COVID-19 pandemic
Sample Point 95% confidence
Description
size estimate interval
Challenges with HHAs’ staffing during the COVID 19 pandemic
Clinical staff leaving this HHA to work for other health care facilities or health care contract agencies
Early pandemic challenge 271 50.9% 45.1-56.8%
Pandemic challenge as of fall 2021 271 40.2% 34.6-46.1%
p-value <0.0001
Recruiting new clinical staff due to increased competition from other health care facilities or health care
contract agencies
Early pandemic challenge 271 70.8% 65.2-75.9%
Pandemic challenge as of fall 2021 271 62.4% 56.5-67.9%
p-value=0.0018
Paying contracted clinical staff due to higher contracting costs during the pandemic
Early pandemic challenge 271 48.7% 42.9-54.6%
Pandemic challenge as of fall 2021 271 43.5% 37.8-49.4%
p-value=0.0475
Limited staff availability to work due to personal circumstances related to the pandemic (e.g., lack of
childcare due to school closures)
Early pandemic challenge 271 84.5% 79.8-88.3%
Pandemic challenge as of fall 2021 271 55.4% 49.5-61.1%
p-value <0.0001
Limited staff availability to work because of self-quarantine/isolation due to COVID-19 exposure
Early pandemic challenge 271 85.2% 80.6-88.9%
Pandemic challenge as of fall 2021 271 55.4% 49.5-61.1%
p-value <0.0001
Strategies used to address challenges with HHAs’ staffing during the COVID 19 pandemic
Provided staff benefits to address COVID-19-related concerns (e.g., childcare, flex time, transportation
assistance)
Used and found helpful 271 59.4% 53.5-65.0%
Used but did not find helpful 271 6.3% 4.0-9.8%
Did not use 271 34.3% 29.0-40.1%
Trained staff to perform tasks outside of their usual duties (e.g., administrative work or duties in a different
clinical area)
Used and found helpful 271 57.6% 51.7-63.2%
Used but did not find helpful 271 4.4% 2.6-7.6%
Did not use 271 38.0% 32.5-43.8%
Provided paid and/or unpaid leaves of absence to retain staff that are unable to work
Used and found helpful 271 64.6% 58.8-70.0%
Used but did not find helpful 271 10.0% 7.0-14.1%
Did not use 271 25.5% 20.7-30.9%
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Created specialized care teams of clinical staff who only treat COVID-19 patients
Used and found helpful 271 39.9% 34.3-45.7%
Used but did not find helpful 271 5.2% 3.1-8.5%
Did not use 271 55.0% 49.1-60.7%
Developed new or used existing partnerships with other HHAs or health care facilities to share staff to fill
staffing gaps
Used and found helpful 271 26.6% 21.7-32.1%
Used but did not find helpful 271 6.6% 4.3-10.2%
Did not use 271 66.8% 61.0-72.1%
Use of CMS regulatory flexibilities and supports to help address staffing challenges
Extend the 5-day completion requirement for the comprehensive assessment to 30 days
Used and found helpful 271 54.2% 48.4-60.0%
Used but did not find helpful 271 3.7% 2.0-6.7%
Did not use 271 42.1% 36.4-47.9%
Authorize additional practitioners to certify beneficiaries for eligibility, order home health services, and
establish and review the care plan
Used and found helpful 271 80.1% 75.0-84.4%
Used but did not find helpful 271 1.5% 0.6-3.8%
Did not use 271 18.5% 14.3-23.4%
Waive requirement for onsite visits by a nurse every 2 weeks
Used and found helpful 271 48.0% 42.2-53.8%
Used but did not find helpful 271 3.3% 1.8-6.2%
Did not use 271 48.7% 42.9-54.6%
Allow occupational therapists, physical therapists, and speech language pathologists to perform initial and
comprehensive assessment for all patients receiving therapy services
Used and found helpful 271 64.2% 58.4-69.6%
Used but did not find helpful 271 4.8% 2.8-8.0%
Did not use 271 31.0% 25.8-36.7%
Postpone deadline to completing requirement that each home health aide receives 12 hours of in-service
training in a 12-month period
Used and found helpful 271 40.6% 35.0-46.5%
Used but did not find helpful 271 3.0% 1.5-5.7%
Did not use 271 56.5% 50.6-62.2%
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HHA experiences with infection control during the COVID-19 pandemic
95%
Point
Description Sample size confidence
estimate
interval
Challenges with infection control during the COVID 19 pandemic
Unclear State/Federal guidance about how to treat COVID-19 patients
Early pandemic challenge 271 88.6% 84.3-91.8%
Pandemic challenge as of fall 2021 271 19.6% 15.3-24.6%
p-value <0.0001
Navigating evolving guidance about how to treat COVID-19 patients
Early pandemic challenge 271 87.1% 82.6-90.5%
Pandemic challenge as of fall 2021 271 25.5% 20.7-30.9%
p-value <0.0001
Unclear or conflicting State/Federal guidelines about COVID-19 infection prevention and control
Early pandemic challenge 271 88.2% 83.8-91.5%
Pandemic challenge as of fall 2021 271 24.4% 19.7-29.7%
p-value <0.0001
Access to masks (not other types of personal protective equipment (PPE))
Early pandemic challenge 271 92.6% 88.9-95.2%
Pandemic challenge as of fall 2021 271 13.7% 10.1-18.2%
p-value <0.0001
Access to other types of PPE (not masks)
Early pandemic challenge 271 91.1% 87.2-94.0%
Pandemic challenge as of fall 2021 271 15.1% 11.4-19.8%
p-value <0.0001
Access to sanitizing products (e.g., sanitizing wipes, hand sanitizer)
Early pandemic challenge 271 94.5% 91.1-96.6%
Pandemic challenge as of fall 2021 271 8.9% 6.0-12.8%
p-value <0.0001
High cost of PPE during the pandemic
Early pandemic challenge 271 88.6% 84.3-91.8%
Pandemic challenge as of fall 2021 271 42.4% 36.8-48.3%
p-value <0.0001
Strategies used to address infection control challenges during the COVID 19 pandemic
Developed internal COVID-19 infection control protocols for staff
Used and found helpful 271 96.7% 93.8-98.2%
Used but did not find helpful 271 1.5% 0.6-3.8%
Did not use 271 1.8% 0.8-4.3%
Increased or improved clinical staff training on COVID-19 treatment
Used and found helpful 271 94.8% 91.5-96.9%
Used but did not find helpful 271 3.3% 1.8-6.2%
Did not use 271 1.8% 0.8-4.3%
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Provided PPE training for clinical staff
Used and found helpful 271 95.9% 92.9-97.7%
Used but did not find helpful 271 1.5% 0.6-3.8%
Did not use 271 2.6% 1.2-5.3%
Found nontraditional sources for PPE (e.g., nail salons, tattoo parlors)
Used and found helpful 271 31.4% 26.2-37.1%
Used but did not find helpful 271 4.8% 2.8-8.0%
Did not use 271 63.8% 58.0-69.3%
Conserved PPE (e.g., re-used PPE normally meant for single use, prioritized certain types of PPE for
highest-risk activities)
Used and found helpful 271 57.2% 51.3-62.9%
Used but did not find helpful 271 8.5% 5.7-12.4%
Did not use 271 34.3% 29.0-40.1%
Developed new or used existing partnerships with other HHAs or health care facilities to obtain or pool
supplies
Used and found helpful 271 42.4% 36.8-48.3%
Used but did not find helpful 271 7.4% 4.8-11.1%
Did not use 271 50.2% 44.3-56.0%
Postponed accepting patients with positive COVID-19 diagnosis until HHA had adequate infection control
protocols
Did not use 271 44.3% 38.6-50.2%
Used (combined) 271 55.7% 49.8-61.4%
Telehealth use during the COVID-19 pandemic
Point 95% confidence
Description Sample size
estimate interval
HHA used telehealth during the pandemic 271 72.7% 67.2-77.6%
HHA did not use telehealth during the pandemic 271 27.3% 22.4-32.8%
HHAs that provided telehealth services during the COVID 19 pandemic
Mode of telehealth services during the pandemic
Live, real-time services between a patient and a health care provider (in the HHA)
Used 197 78.2% 72.0-83.3%
Did not use 197 21.8% 16.7-28.0%
Patient health information is electronically transmitted to a health care provider for their assessment at a
different time
Used 197 44.2% 37.5-51.1%
Did not use 197 55.8% 48.9-62.5%
HHA providers helped patients set up or participate in telehealth services with another provider (outside of the
HHA)
Used 197 62.9% 56.1-69.3%
Did not use 197 37.1% 30.7-43.9%
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Challenges using telehealth during the pandemic
High cost of providing telehealth services
Challenge 197 44.2% 37.5-51.1%
Not a challenge 197 55.8% 48.9-62.5%
Insufficient internet access in patients’ homes
Challenge 197 66.5% 59.7-72.7%
Not a challenge 197 33.5% 27.3-40.3%
Lack of direct reimbursement for telehealth services (other than for administrative costs)
Challenge 197 67.5% 60.8-73.6%
Not a challenge 197 32.5% 26.4-39.2%
Most care required physical contact with patient
Challenge 197 63.5% 56.6-69.8%
Not a challenge 197 36.5% 30.2-43.4%
Will this HHA continue to use telehealth after the pandemic?
Yes 197 56.9% 49.9-63.5%
No 197 43.1% 36.5-50.1%
Note: In the survey, we used the term “telemedicine” rather than “telehealth.”
Emergency preparedness and response
Point 95% confidence
Description Sample size
estimate interval
COVID 19-specific response plans
HHAs that had a COVID-19 response plan
HHA had a COVID-19 response plan 271 84.9% 80.2-88.6%
HHA did not have a COVID-19 response plan 271 15.1% 11.4-19.8%
CMS required emergency preparedness (EP) plan
Overall, EP plan helpfulness in responding to the pandemic (of those with an EP plan during the pandemic)
Helpful 267 98.1% 95.6-99.2%
Not helpful 267 1.9% 0.8-4.4%
EP plan helpfulness in responding to infection control challenges due to the pandemic (of those with an EP
plan during the pandemic)
Helpful 267 90.6% 86.6-93.6%
Not helpful 267 3.7% 2.0-6.8%
Not applicable 267 5.6% 3.4-9.1%
EP plan helpfulness in responding to supply challenges due to the pandemic (of those with an EP plan
during the pandemic)
Helpful 267 80.9% 75.8-85.1%
Not helpful 267 12.7% 9.3-17.2%
Not applicable 267 6.4% 4.0-9.9%
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist
OEI-01-21-00110 Appendix D | 41
EP plan helpfulness in responding to staffing challenges due to the pandemic (of those with an EP plan
during the pandemic)
Helpful 267 74.2% 68.7-79.0%
Not helpful 267 14.6% 10.9-19.3%
Not applicable 267 11.2% 8.0-15.5%
HHAs that experienced the challenge that their EP plan was more suitable to a local emergency than a
national or global emergency such as the pandemic (of those with an EP plan during the pandemic)
Challenge 267 50.6% 44.7-56.4%
Not a challenge 267 49.4% 43.6-55.3%
HHAs that will modify or have modified their EP plan to include lessons learned from the COVID-19
pandemic (of those with an EP plan during the pandemic)
HHA has already modified OR will modify its EP plan to
267 96.6% 93.7-98.2%
include lessons learned from the pandemic
HHA has not modified and will not modify its EP plan to
267 3.4% 1.8-6.3%
include lessons learned from the pandemic
HHAs with an EP plan that included an infectious disease component prior to the pandemic.
Note: Among HHAs that had an EP plan prior to the pandemic.
HHA did not have an EP plan with an infectious
254 7.1% 4.5-10.9%
disease component
HHA had an EP plan with an infectious disease
254 92.9% 89.1-95.5%
component
How could CMS better support HHAs in using EP plans to respond to emerging infectious
diseases? (open ended responses)
HHA suggested information about EP plan content and/or
88 67.0% 56.8-75.9%
implementation in response to this question
HHA did not suggest information about EP plan content
88 33.0% 24.1-43.2%
and/or implementation in response to this question
Rural HHA experiences*
Rural HHA experiences with staffing challenges
Limited staff availability to work because of self-quarantine/isolation due to COVID-19 exposure
Challenge 39
Not a challenge 2
Rural HHA experiences with infection control and prevention challenges
Unclear or conflicting State/Federal guidelines about COVID-19 infection prevention and control
Early challenge 34
Not an early challenge 7
Access to masks (not other types of personal protective equipment (PPE))
Early challenge 37
Not an early challenge 4
Access to other types of PPE (not masks)
Early challenge 37
Not an early challenge 4
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist
OEI-01-21-00110 Appendix D | 42
Access to sanitizing products (e.g., sanitizing wipes, hand sanitizer)
Early challenge 38
Not an early challenge 3
Rural HHA experiences with telehealth during the pandemic
HHA used telehealth during the pandemic 31
HHA did not use telehealth during the pandemic 10
Challenges with insufficient internal access in patients’ homes
Challenge 25
Not a challenge 6
* We were unable to project due to limited sample size.
Note: Because of rounding, not all percentages may add up to 100 percent.
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist
OEI-01-21-00110 Appendix D | 43
Appendix E: Agency Comments
Following this page are the official comments from CMS.
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist
OEI-01-21-00110 Appendix E | 44
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services
Administrator
Washington , DC 20201
DATE: September 22, 2022
TO: Suzanne Murrin
Deputy Inspector General for Evaluation and Inspections
Office of Inspector General
FROM: Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
SUBJECT: Office of Inspector General (OIG) Draft Report: Home Health Agencies Used
Multiple Strategies to Respond to the COVID-19 Pandemic, Although Some
Challenges Persist (OEI-01-21-00110)
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and
comment on the Office of Inspector General’s (OIG) draft report. CMS is committed to
supporting home health agencies (HHAs) during health emergencies so they may care for people
with Medicare in the home setting while protecting them from the spread of infectious diseases.
CMS is using lessons learned during the COVID-19 public health emergency (PHE) to improve
quality of care and equitable access to CMS benefits, services, and supports.
Throughout the COVID-19 PHE, CMS has used a combination of emergency authority waivers,
regulations, enforcement discretion, survey flexibilities, and sub-regulatory guidance to help ensure
access to care, give health care providers the flexibilities needed to respond to COVID-19, and help
keep people safer. Flexibilities offered during the COVID-19 PHE supported HHAs in addressing
staffing challenges, especially early on in the COVID-19 PHE. For example, a statutory change
enabled CMS to allow additional practitioners to certify beneficiaries for eligibility, order home
health services, and establish and review care plans. The use of telehealth to furnish home health
services was finalized on a permanent basis in the calendar year (CY) 2021 Home Health
Prospective Payment System final rule. 1 However, such services cannot be reported as a visit on
home health claims for the purposes of eligibility or payment.
Many of the waivers and flexibilities will terminate at the end of the COVID-19 PHE or after the
151st day after the end of the PHE, as they were intended to address the acute and extraordinary
circumstances of a rapidly evolving pandemic and not replace existing requirements. Some were
made permanent through the passage of new laws. For example, Division CC, section 115 of the
Consolidated Appropriations Act of 2021, made permanent the flexibility that occupational
therapists could conduct initial and comprehensive assessments for patients when certain
requirements relating to the plan of care are met.
1
Federal Register: “Medicare and Medicaid Programs; CY 2021 Home Health Prospective Payment System Rate
Update, Home Health Quality Reporting Program Requirements, and Home Infusion Therapy Services and Supplier
Enrollment Requirements; and Home Health Value-Based Purchasing Model Data Submission Requirements; Final
Rule (85 FR 70298) (November 4, 2020).”
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist
OEI-01-21-00110 Appendix E | 45
CMS continues to support stakeholders and the people we serve during the current phase of the
COVID-19 PHE while looking forward to a health system that successfully emerges from the
COVID-19 PHE focused on improving quality and safety. CMS is also monitoring the status of the
COVID-19 PHE and has begun phasing out certain flexibilities that are generally no longer needed.
To understand how blanket flexibilities and those specific to HHAs were used on the front lines
during the COVID-19 PHE, CMS received feedback from the HHA industry, national HHA
organizations, and from subject matter experts. This information helped inform waiver disposition
decisions and identify groups of waivers that may be helpful in future PHE response activities.
CMS recently released fact sheets to summarize the current status of Medicare blanket waivers and
flexibilities by provider type, including HHAs. 2
Long before the COVID-19 PHE began, CMS had acted to strengthen infection prevention and
control practices for HHAs and other provider types. CMS took pivotal actions in the 2016 final
rule, “Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and
Medicaid Participating Providers and Suppliers,” which outlined the need for providers to prepare
for infectious disease threats. 3 In March 2020, CMS issued guidance to HHAs encouraging them to
take appropriate action to address potential and confirmed COVID-19 cases and mitigate
transmission, including screening, treatment and transfer to higher level care (when appropriate).4
CMS also held Open Door Forum calls specific to HHAs since 2016 and added additional COVID-
19 calls during the COVID-19 PHE, which continue to date. CMS meets regularly with
stakeholders, such as the National Association for Home Care and Hospice, to discuss issues
affecting the HHA community. In addition, CMS’s Quality Safety and Education Portal provides
current trainings on various CMS survey and certification requirements. 5 These trainings are used
by surveyors but are also free of charge and available to the public by choosing the “public access”
link on the portal.
CMS thanks OIG for its efforts on this important issue and looks forward to working with OIG
on this and other issues in the future. OIG’s recommendations and CMS's responses are below.
OIG Recommendation
Evaluate how HHAs are using telehealth—specifically, the types of services provided via
telehealth and the characteristics of patients who benefit from these services.
CMS Response
CMS concurs with this recommendation. CMS finalized policy changes regarding the use of
services furnished via telecommunications systems in the CY 2021 Home Health Prospective
Payment System final rule.6 HHAs can utilize telecommunications technologies in providing care to
beneficiaries under the Medicare home health benefit, as long as any provision of remote patient
monitoring or other services furnished via a telecommunications system or audio-only technology
are included on the plan of care. The use of such telecommunications technology or audio-only
2
CMS, Home Health Agencies: CMS Flexibilities to Fight COVID-19. August, 18, 2022. Accessed at
https://www.cms.gov/files/document/home-health-agencies-cms-flexibilities-fight-covid-19.pdf
3
Medicare and Medicaid Programs; Emergency Preparedness Requirements, 81 FR 63860, 63862 (Sept. 16, 2016).
Accessed at https://www.federalregister.gov/documents/2016/09/16/2016-21404/medicare-and-medicaid-programs-
emergency-preparedness-requirements-for-medicare-and-medicaid
4
CMS, Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Home
Health Agencies (HHAs). March 10, 2020. Accessed at https://www.cms.gov/files/document/qso-20-18-hha.pdf
5
CMS, Quality, Safety & Education Portal (QSEP). Accessed at https://qsep.cms.gov/
6
Federal Register: “Medicare and Medicaid Programs; CY 2021 Home Health Prospective Payment System Rate
Update, Home Health Quality Reporting Program Requirements, and Home Infusion Therapy Services and Supplier
Enrollment Requirements; and Home Health Value-Based Purchasing Model Data Submission Requirements; Final
Rule (85 FR 70298) (November 4, 2020)”
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist
OEI-01-21-00110 Appendix E | 46
technology must be tied to patient-specific needs as identified in the comprehensive assessment,
and may not substitute for an in-person home visit that is ordered on the plan of care. In addition,
the law 7 explicitly states that home health services furnished via telecommunications technology
cannot be considered a visit for the purpose of patient eligibility or payment.
Currently, the collection of data on the use of telecommunications technology under the home
health benefit is limited to a broad category of telecommunications technology costs under
administrative costs on the HHA cost reports (reported at the agency level). The CY 2023 Home
Health Prospective Payment System proposed rule solicited comments on the collection of data on
the use of such services furnished using telecommunications technology on the home health claims
(at the individual beneficiary level).8 Collecting data on the use of telecommunications technology
on home health claims would allow CMS to analyze the characteristics of the beneficiaries utilizing
services furnished remotely, and could provide a broader understanding of the social determinants
that affect who benefits most from these services, including what barriers may potentially exist for
certain subsets of beneficiaries. CMS aims to collect such data on home health claims by January 1,
2023 on a voluntary basis by HHAs, and plans begin to requiring this information to be reported on
claims beginning July 2023. CMS will consider OIG’s recommendation along with comments
submitted on the proposed rule when finalizing the rule.
OIG Recommendation
To inform decision-making, evaluate how regulatory flexibilities offered during the COVID-19
pandemic affect quality of home health care.
CMS Response
CMS concurs with this recommendation to evaluate the effects of waivers to the extent it is possible
to do so. While it may be difficult to make direct links from waivers to quality and health outcomes,
CMS is using lessons learned during the COVID-19 PHE to improve quality of care in home care
settings to ensure equitable access to CMS benefits, services and supports. CMS is monitoring the
status of the COVID-19 PHE and has begun phasing out certain flexibilities that are generally no
longer needed. CMS released fact sheets to summarize the current status of Medicare blanket
waivers and flexibilities by provider type, including HHAs. 9
Given the unprecedented length and scope of the COVID-19 PHE, CMS has systematically
reviewed all the emergency measures, regulatory flexibilities, and related programs enacted during
the COVID-19 PHE on an ongoing basis since 2020 to assess the appropriateness of continuing
those flexibilities or of retaining some as a permanent part of CMS programs, as permitted under
the law. To understand how HHAs used flexibilities during the COVID-19 PHE, CMS received
feedback from the HHA industry, national HHA organizations, and from subject matter experts.
This information helped inform waiver disposition decisions and identify groups of waivers that
may be helpful in future PHE response activity. For example, as part of the CY 2022 Home Health
Prospective Payment System final rule, CMS finalized the provision for aide supervision for
7
Section 1895(e)(1)(A) of the Social Security Act. Accessed at
https://www.ssa.gov/OP_Home/ssact/title18/1895.htm
8
Federal Register: “Medicare Program; Calendar Year (CY) 2023 Home Health Prospective Payment System Rate
Update; Home Health Quality Reporting Program Requirements; Home Health Value-Based Purchasing Expanded
Model Requirements; and Home Infusion Therapy Services Requirements; Proposed Rule (87 FR 37600) (June 23,
2022)”
9
CMS, Home Health Agencies: CMS Flexibilities to Fight COVID-19, September 1, 2022. Accessed at
https://www.cms.gov/files/document/home-health-agencies-cms-flexibilities-fight-covid-19.pdf
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist
OEI-01-21-00110 Appendix E | 47
patients receiving skilled care every 14 days to now allow for one virtual visit per 60-day episode
per patient and only in rare circumstances. 10
CMS is also in the process of holding a series of listening sessions seeking feedback from
providers, including HHAs, on what specific flexibilities, if any, have been the most or least
helpful. While it is challenging to isolate the many compounding factors that affect quality of
care and conclude that individual waivers were the sole contributor to changes in patient
outcomes, especially given the unique circumstances of the COVID-19 PHE and data limitations
during this time, CMS is reviewing waivers as part of larger efforts to ensure health care quality
and safety. CMS remains steadfast in its commitment to keeping the HHA community and public
informed throughout the COVID-19 PHE.
OIG Recommendation
In collaboration with Administration for Strategic Preparedness and Response (ASPR) Technical
Resources, Assistance Center, and Information Exchange (TRACIE), apply lessons learned from
the COVID-19 PHE to update and/or develop emergency preparedness trainings and materials
for HHAs on responding to infectious disease outbreaks.
CMS Response
CMS concurs with this recommendation. ASPR TRACIE and CMS have a long history of working
together to support providers in responding to emergencies, including emerging infectious diseases,
such as COVID-19. CMS has provided education and outreach to HHAs on CMS quality and safety
standards to support their infection prevention and control efforts. In addition, CMS has
collaborated with ASPR TRACIE on homecare related resources, including a resource on HHA
requirements relating to the emergency preparedness rule.11 This resource was updated in March
2021 to reflect updates from the COVID-19 PHE.
CMS recently published case studies of 30 providers (nursing homes and hospitals) on their
responses to challenges during the onset of COVID-19.12 The study focused on understanding how
these providers prepared for and responded to the COVID-19 PHE. The discussions and
engagement focused on whether or not the facilities had risk assessments which included emerging
infectious diseases prior to the PHE, their input on individual preparedness within their facilities,
and discussion on some of the challenges and burdens. The study found that locally developed
emergency preparedness plans and staff training were key factors in dealing with the COVID-19
PHE. While this study focused on nursing homes and hospitals, the information gained from the
study would apply across provider and supplier types.
CMS will continue to collaborate with ASPR TRACIE and share information based on lessons
learned from the COVID-19 PHE with the HHA industry. However, CMS does not provide funding
to ASPR TRACIE. While our agencies will continue to collaborate, CMS does not have the
authority over ASPR TRACIE work products.
10
Federal Register: “Medicare and Medicaid Programs; CY 2022 Home Health Prospective Payment System Rate
Update; Home Health Value-Based Purchasing Model Requirements and Model Expansion; Home Health and Other
Quality Reporting Program Requirements; Home Infusion Therapy Services Requirements; Survey and Enforcement
Requirements for Hospice Programs; Medicare Provider Enrollment Requirements; and COVID-19 Reporting
Requirements for Long-Term Care Facilities; Final Rule (86 FR 62240) (November 9, 2021)”
11
CMS, Home Health Agency Requirements CMS Emergency Preparedness Final Rule, March 26, 2021. Accessed
at https://files.asprtracie.hhs.gov/documents/aspr-tracie-cms-ep-rule-home-health-agency-requirements.pdf
12
Blackstock, S.C., Moody-Williams, J.D., Fleisher, L.A., Learnings Regarding Emergency Preparedness During
the Public Health Emergency: A Mixed-Methods Study of Hospitals and Long-Term Care Facilities, NEJM
Catalyst, August 24, 2022. Accessed at https://catalyst.nejm.org/doi/full/10.1056/CAT.22.0152
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist
OEI-01-21-00110 Appendix E | 48
ACKNOWLEDGMENTS AND CONTACT
Acknowledgments
Sarah Hijaz and Shanna Weitz served as the team leaders for this study, and Caitlin
Foster served as the lead analyst. Office of Evaluation and Inspections headquarters
staff who provided support include Joseph Chiarenzelli, Althea Hosein, Christine
Moritz, and Sara Swisher.
This report was prepared under the direction of Joyce Greenleaf, Regional Inspector
General for Evaluation and Inspections in the Boston regional office, and Danielle
Fletcher, Deputy Regional Inspector General.
Contact
To obtain additional information concerning this report, contact the Office of Public
Affairs at Public.Affairs@oig.hhs.gov. OIG reports and other information can be found
on the OIG website at oig.hhs.gov.
Office of Inspector General
U.S. Department of Health and Human Services
330 Independence Avenue, SW
Washington, DC 20201
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist
OEI-01-21-00110 Acknowledgments and Contact | 49
ABOUT THE OFFICE OF INSPECTOR GENERAL
The mission of the Office of Inspector General (OIG), as mandated by Public Law
95-452, as amended, is to protect the integrity of the Department of Health and
Human Services (HHS) programs, as well as the health and welfare of beneficiaries
served by those programs. This statutory mission is carried out through a nationwide
network of audits, investigations, and inspections conducted by the following
operating components:
The Office of Audit Services (OAS) provides auditing services for HHS,
either by conducting audits with its own audit resources or by overseeing audit work
done by others. Audits examine the performance of HHS programs and/or its
grantees and contractors in carrying out their respective responsibilities and are
intended to provide independent assessments of HHS programs and operations.
These audits help reduce waste, abuse, and mismanagement and promote economy
and efficiency throughout HHS.
The Office of Evaluation and Inspections (OEI) conducts national
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable
information on significant issues. These evaluations focus on preventing fraud, waste,
or abuse and promoting economy, efficiency, and effectiveness of departmental
programs. To promote impact, OEI reports also present practical recommendations
for improving program operations.
The Office of Investigations (OI) conducts criminal, civil, and administrative
investigations of fraud and misconduct related to HHS programs, operations, and
beneficiaries. With investigators working in all 50 States and the District of Columbia,
OI utilizes its resources by actively coordinating with the Department of Justice and
other Federal, State, and local law enforcement authorities. The investigative efforts
of OI often lead to criminal convictions, administrative sanctions, and/or civil
monetary penalties.
The Office of Counsel to the Inspector General (OCIG) provides
general legal services to OIG, rendering advice and opinions on HHS programs and
operations and providing all legal support for OIG’s internal operations. OCIG
represents OIG in all civil and administrative fraud and abuse cases involving HHS
programs, including False Claims Act, program exclusion, and civil monetary penalty
cases. In connection with these cases, OCIG also negotiates and monitors corporate
integrity agreements. OCIG renders advisory opinions, issues compliance program
guidance, publishes fraud alerts, and provides other guidance to the health care
industry concerning the anti-kickback statute and other OIG enforcement authorities.
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist
OEI-01-21-00110 About the Office of Inspector General | 50
ENDNOTES
1 National Association for Home Care and Hospice, National Study Shows How Home Care Is in a Fragile State, April 27, 2020.
Accessed at https://www.nahc.org/wp-content/uploads/2020/03/NATIONAL-STUDY-SHOWS-HOME-HEALTH-CARE-IS-IN-A-
FRAGILE-STATE.pdf on August 17, 2022.
2 Robert Holly, “Small Home Health Agencies Fighting to Stay Afloat Amid COVID-19 Crisis, Regulatory Uncertainty,” Home
Health Care News, April 19, 2020. Accessed at https://homehealthcarenews.com/2020/04/small-home-health-agencies-
fighting-to-stay-afloat-amid-covid-19-crisis-regulatory-uncertainty/ on March 8, 2022.
3 Jingding Shang, Ashley M. Chastain, Uduwanage Gayani E. Perera, et al., “COVID-19 Preparedness in US Home Health Care
Agencies,” Journal of the American Medical Directors Association, July 2020, Vol. 21, Issue 7, pp. 924-927, DOI:
10.1016/j.jamda.2020.06.002. Accessed at https://pubmed.ncbi.nlm.nih.gov/32674820/ on May 2, 2022.
4 Andrew Donlan, “House Passes CARES Act, Fast Forwarding Home Health Care Innovation Beyond COVID-19,” Home Health
Care News, March 27, 2020. Accessed at https://homehealthcarenews.com/2020/03/house-passes-cares-act-fast-forwarding-
home-health-care-innovation-beyond-covid-19/ on March 8, 2022.
5 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, updated May 24, 2021.
Accessed at
https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf on March 8, 2022.
6 Adara Home Health, Inc., COVID-19 Preparedness Plan.
Accessed at https://adarahomehealth.com/wp-
content/uploads/2020/07/Adara-COVID-19-Plan_6-29-20.pdf on March 8, 2022.
7 Courtney Harold Van Houtven and Walter D. Dawson, “Medicare and Home Health: Taking Stock in the COVID-19 Era,” The
Commonwealth Fund, October 21, 2020. Accessed at https://www.commonwealthfund.org/publications/issue-
briefs/2020/oct/medicare-home-health-taking-stock-covid-19-era on March 8, 2022.
8 CMS, “Chapter 7 - Home Health Services.” Medicare Benefit Policy Manual.
Accessed at https://www.cms.gov/Regulations-
and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf on April 29, 2022.
9 CMS, “Chapter 7 - Home Health Services,” Medicare Benefit Policy Manual.
Accessed at https://www.cms.gov/Regulations-
and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf on April 29, 2022.
10 Social Security Act (the Act) §§ 1814(a)(2)(C) and (a)(concluding paragraph), and 1835(a)(2)(A) and (a)(concluding
paragraph); 42 CFR § 409.42(a).
11 The Act §§ 1814(a)(2)(C) and (a)(concluding paragraph), and 1835(a)(2)(A) and (a)(concluding paragraph); 42 CFR §
424.22(a)(1)(v).
12 The Act §§ 1814(a)(2)(C) and (a)(concluding paragraph), and 1835(a)(2)(A) and (a)(concluding paragraph); 42 CFR §
424.22(c)).
13 MedPAC, “Chapter 8 - Home health care services,” Report to the Congress: Medicare Payment Policy, March 2022, pp. 275,
279, 282. Accessed at https://www.medpac.gov/wp-content/uploads/2022/03/Mar22_MedPAC_ReportToCongress_SEC.pdf
on August 17, 2022.
14 42 CFR § 484, subparts A-C.
15 CMS, “Appendix B- Guidance to Surveyors: Home Health Agencies,” State Operations Manual, Rev. 200, February 21, 2020.
Accessed at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_b_hha.pdf on March
8, 2022.
16 42 CFR § 488, subpart I.
17 CMS, “Chapter 2 - The Certification Process,” State Operations Manual, Rev. 205, March 11, 2022.
Accessed at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107c02.pdf on April 11, 2022.
Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist
OEI-01-21-00110 Endnotes | 51
18 Jingding Shang, Ashley M. Chastain, Uduwanage Gayani E. Perera, et al., “COVID-19 Preparedness in US Home Health Care
Agencies,” Journal of the American Medical Directors Association, July 2020, Vol. 21, Issue 7, pp. 924-927, DOI:
10.1016/j.jamda.2020.06.002. Accessed at https://pubmed.ncbi.nlm.nih.gov/32674820/ on May 2, 2022.
19 CDC, Symptoms of COVID-19, updated March 22, 2022. Accessed at https://www.cdc.gov/coronavirus/2019-
ncov/symptoms-testing/symptoms.html on July 11, 2002.
20 CDC, Symptoms of COVID-19, updated March 22, 2022. Accessed at https://www.cdc.gov/coronavirus/2019-
ncov/symptoms-testing/symptoms.html on July 11, 2022.
21 CDC, CDC Museum COVID-19 Timeline. Accessed at https://www.cdc.gov/museum/timeline/covid19.html on March 8,
2022.
22 HHS, Determination That A Public Health Emergency Exists, January 31, 2020. Accessed at
https://aspr.hhs.gov/legal/PHE/Pages/2019-nCoV.aspx on September 29, 2022.
23 World Health Organization, Timeline: WHO’s COVID-19 response.Accessed at
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/interactive-timeline#! on March 8, 2022.
24 CDC, Lesson 1: Introduction to Epidemiology, Section 11: Epidemic Disease Occurrence. Accessed at
https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section11.html on August 18, 2022.
25 85 Fed. Reg. 15337 (March 18, 2020).
26 CDC, Trends in Number of COVID-19 Cases and Deaths in the US Reported to CDC, by State/Territory. Accessed at
https://covid.cdc.gov/covid-data-tracker/#trends_dailycases on September 23, 2022.
27 Satyaki Roy and Preetam Ghosh, “Factors affecting COVID-19 infected and death rates inform lockdown-related
policymaking,” PLOS One, October 23, 2020. Accessed at https://doi.org/10.1371/journal.pone.0241165 on March 8, 2022.
28 CDC, CDC COVID-19 Study Shows mRNA Vaccines Reduce Risk of Infection by 91 Percent for Fully Vaccinated People, June 7,
2021. Accessed at https://www.cdc.gov/media/releases/2021/p0607-mrna-reduce-risks.html on March 8, 2022.
29 42 CFR § 484.70.
30 CMS, Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Home Health
Agencies (HHAs) and Religious Nonmedical Healthcare Institutions (RNHCIs), March 10, 2020, revised April 23, 2020. Accessed
at https://www.cms.gov/files/document/qso-20-18-hha-revised.pdf on March 8, 2022.
31 The Secretary may exercise this authority under section 1135 of the Social Security Act.
32 85 Fed. Reg. 15337 (March 18, 2020).
33 Seema Verma, “Early Impact Of CMS Expansion Of Medicare Telehealth During COVID-19,” Health Affairs Forefront, July 15,
2020, DOI: 10.1377/forefront.20200715.454789. Accessed at
https://www.healthaffairs.org/do/10.1377/forefront.20200715.454789/full/ on March 8, 2022.
34 85 Fed. Reg. 19230 (April 6, 2020).
35 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, updated May 24, 2021.
Accessed at
https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf on March 8, 2022.
36 85 Fed. Reg. 19230 (April 6, 2020).
37 P.L. No. 116-136, § 3708, March 27, 2020.
38 CMS, Medicare Telemedicine Health Care Provider Fact Sheet, March 17, 2020.
Accessed at
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet on August 18, 2022.
39 OIG, Telehealth Was Critical for Providing Services to Medicare Beneficiaries During the First Year of the COVID-19 Pandemic,
OEI-02-20-00520, March 15, 2022. Accessed at https://oig.hhs.gov/oei/reports/OEI-02-20-00520.asp on March 29, 2022.
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OEI-01-21-00110 Endnotes | 52
40 Videoconferencing involves live audiovisual communication between participants, in this case the health care provider and
the patient. Examples include Facetime or Zoom video calls.
41 HHS, What is telehealth? Accessed at https://telehealth.hhs.gov/patients/understanding-telehealth/ on May 17, 2022.
42 CMS, Medicare Telemedicine Health Care Provider Fact Sheet, March 17, 2020.
Accessed at
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet on March 18, 2022.
43 42 CFR § 409.43(a)(3)(i)(B); 42 CFR § 409.46(e).
44 85 Fed. Reg. 70298, 70322-70325 (November 4, 2020).
45 P.L. No. 116-136, § 3707, March 27, 2020.
46 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, updated May 24, 2021.
Accessed at
https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf on March 18, 2022.
47 CMS, Medicare Telemedicine Health Care Provider Fact Sheet, March 17, 2020.
Accessed at
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet on March 18, 2022;
CMS, COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing, § AA, Question 1, updated
February 28, 2022.
48 85 Fed. Reg. 19230, 19285 (April 6, 2020).
49 CMS, COVID-19 Frequently Asked Questions (FAQ) on Medicare Fee-for-Service (FFS) Billing, § AA, Question 2, updated
January 7, 2021, p. 116. Accessed at https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-
faqs-31720.pdf on March 8, 2022.
50 85 Fed. Reg. 70298, 70354 (November 4, 2020).
51 Social Security Act § 1895(e)(1).
52 42 CFR § 409.46(e).
53 Cost reports are reports submitted to CMS that include important statistical and financial data.
CMS uses cost reports to
understand each HHA’s financial situation, among other purposes. CMS requires HHAs to submit cost reports annually.
Providers must submit them no later than 5 months after the end of the year covered.
54 85 Fed. Reg. 70298, 70312 (November 4, 2020).
55 Accessed at https://telehealth.hhs.gov/patients/understanding-telehealth on July 25, 2022.
56 Accessed at https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf on July
29, 2022.
57 Seema Verma, “Early Impact Of CMS Expansion Of Medicare Telehealth During COVID-19,” Health Affairs Forefront, July 15,
2020, DOI: 10.1377/forefront.20200715.454789. Accessed at
https://www.healthaffairs.org/do/10.1377/forefront.20200715.454789/full/ on March 8, 2022.
58 OIG, Telehealth Was Critical for Providing Services to Medicare Beneficiaries During the First Year of the COVID-19 Pandemic,
OEI-02-20-00520, March 15, 2022. Accessed at https://oig.hhs.gov/oei/reports/OEI-02-20-00520.asp on August 19, 2022.
59 MedPAC, “Chapter 8 - Home health care services,” Report to the Congress: Medicare Payment Policy, March 2022, pp. 285-
286. Accessed at https://www.medpac.gov/wp-content/uploads/2022/03/Mar22_MedPAC_ReportToCongress_SEC.pdf on
August 17, 2022.
60 OIG, Telehealth Was Critical for Providing Services to Medicare Beneficiaries During the First Year of the COVID-19 Pandemic,
OEI-02-20-00520, March 2022. Accessed at https://oig.hhs.gov/oei/reports/OEI-02-20-00520.pdf on April 29, 2022.
61 MedPAC, “Chapter 4 – Physician and other health professional services,” Report to the Congress: Medicare Payment Policy,
March 2022, pp. 129-130. Accessed at https://www.medpac.gov/wp-
content/uploads/2022/03/Mar22_MedPAC_ReportToCongress_SEC.pdf on August 17, 2022.
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OEI-01-21-00110 Endnotes | 53
62 81 Fed. Reg. 63860 (September 16, 2016).
63 CMS, “Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types, Interpretive Guidance,” State
Operations Manual, Rev. 204, April 16, 2021. Accessed at https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/som107ap_z_emergprep.pdf on April 11, 2022.
64 42 CFR § 484.102.
65 Accessed at https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertEmergPrep/Downloads/CMS-Understanding-the-EP-Final-Rule-Update-BRIII-2019.pdf and
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/FAQ-Round-Four-
Definitions.pdf on April 29, 2022.
66 CMS, “Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types, Interpretive Guidance,” State
Operations Manual, Rev. 204, April 16, 2021. Accessed at https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/som107ap_z_emergprep.pdf on April 11, 2022.
67 CMS, “Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types, Interpretive Guidance,” State
Operations Manual, Rev. 204, April 16, 2021. Accessed at https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/som107ap_z_emergprep.pdf on April 11, 2022.
68 CMS, Emergency Preparedness: Provider Readiness (EP_PR).
Accessed at
https://qsep.cms.gov/pubs/ClassInformation.aspx?cid=0CMSEPPR_WEB on July 27, 2022.
69 CMS, Emergency Preparedness Basic Training.
Accessed at
https://qsep.cms.gov/pubs/CourseMenu.aspx?cid=0CMSEmPrep_ONL on July 27, 2022.
70 ASPR was formerly known as the Office of the Assistant Secretary for Preparedness and Response.
71 OIG, Six of Eight Home Health Agency Providers Had Infection Control Policies and Procedures That Complied With CMS
Requirements and Followed CMS COVID-19 Guidance To Safeguard Medicare Beneficiaries, Caregivers, and Staff During the
COVID-19 Pandemic, A-01-20-00508, September 24, 2021. Accessed at
https://oig.hhs.gov/oas/reports/region1/12000508.asp on March 8, 2022.
72 OIG, Audit of Home Health Services Provided as Telehealth During the COVID-19 Public Health Emergency.
Accessed at
https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000553.asp on March 8, 2022.
73 OIG, Reliance on Unverified Patient Lists Creates a Vulnerability in Home Health Surveys, OEI-05-16-00510, March 5, 2018.
Accessed at https://oig.hhs.gov/oei/reports/oei-05-16-00510.asp on March 8, 2022.
74 OIG, Nationwide Analysis of Common Characteristics in OIG Home Health Fraud Cases, OEI-05-16-00031, June 21, 2016.
Accessed at https://oig.hhs.gov/oei/reports/oei-05-16-00031.asp on March 8, 2022.
75 Of the 400 sampled HHAs, 19 were closed and 4 did not participate in Medicare at the time of our survey.
76 The HHS Health Resources and Services Administration (HRSA) administers the Provider Relief Fund, which is funding that
is distributed to health care providers affected by the COVID-19 pandemic. Any HHA may apply to receive financial
assistance. HRSA, Provider Relief Fund. Accessed at https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/phase4-arp-
toolkit.pdf on August 18, 2022.
77 86 Fed. Reg. 62240, 62421 (November 9, 2021).
78 85 Fed. Reg. 70298, 70354 (November 4, 2020).
79 All references to telehealth in this section are specific to HHAs that used telehealth during the pandemic.
80 85 Fed. Reg. 70298, 70325 (November 4, 2020).
81 HHAs submit their cost reports no later than 5 months after the end of the year that the cost report covers.For example,
an HHA may submit a cost report covering January 1, 2021, to December 31, 2021, in May 2022. After submission, Medicare
Administrative Contractors audit the cost reports, which regulations specify should happen within one year of receiving the
cost report. (42 CFR § 413.24(f)(2)(i) and 42 CFR § 405.1835(c)(1).)
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OEI-01-21-00110 Endnotes | 54
82 87 Fed. Reg. 37600, 37658-37659 (June 23, 2022).
83 We removed five HHAs from our scope because of their concurrent involvement in another OIG study.
84 We considered an HHA closed if either (1) the HHA’s corporate office told us that the HHA was closed or (2) the HHA’s
number was disconnected and mail sent to the HHA was returned to us.
85 During our contact attempts, we noted that at least 21 nonresponding HHAs had changed their address and 13 had phone
connection issues (e.g., disconnected phone line). Challenges accessing these HHAs may at least partially explain our
response rate.
86 We identified 314 HHAs that submitted 2019 Medicare claims in our sample, 225 of which responded to the survey.
87 We based our definition of rural HHAs on MedPAC’s analysis of “majority rural” freestanding HHAs in the March 2021
Medicare Payment Policy report. MedPAC calculated that 18 percent of freestanding HHAs were majority rural in 2019, the
same percentage of rural HHAs with 2019 Medicare claims that responded to our survey. For MedPAC’s definition of
“majority rural” HHAs: MedPAC, “Chapter 8 - Home health care services,” Report to the Congress: Medicare Payment Policy,
March 2021, p. 243, table 8-7. Accessed at https://www.medpac.gov/wp-
content/uploads/import_data/scrape_files/docs/default-source/reports/mar21_medpac_report_to_the_congress_sec.pdf on
August 17, 2022.
88 Of the 314 HHAs with 2019 Medicare claims in our sample, 53 were rural (17 percent).
89 42 CFR § 484.70 and 86 Fed. Reg. 61555, 61621-61622 (November 5, 2021).
90 42 CFR § 484.70 and 86 Fed. Reg. 61555, 61621-61622 (November 5, 2021).
91 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022.
92 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022.
93 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022.
94 CMS, Medicare Telemedicine Health Care Provider Fact Sheet, March 17, 2020.Accessed at
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet on July 11, 2022; CMS,
COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing, § AA, Question 1, updated February 28,
2022.
95 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022.
96 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022.
97 P. L No. 116-136, § 3708(f), March 27, 2020.
98 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022.
99 P.L. No. 116-260, division CC, § 115, December 27, 2020.
100 85 Fed. Reg. 70298, 70354 (November 4, 2020).
101 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022.
102 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022.
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OEI-01-21-00110 Endnotes | 55
103 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022.
104 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022.
105 CMS, Home Health Quality Reporting Program (HH QRP) COVID-19 Public Health Emergency (PHE) Tip Sheet. Accessed at
https://www.cms.gov/files/document/hhqrp-covid19phetipsheet-july2020v2.pdf on January 26, 2022.
106 85 Fed. Reg. 27550, 27629 (May 8, 2020).
107 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 7, 2022, updated August 18, 2022.
Accessed at https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on October 4, 2022.
108 CMS, Review Choice Demonstration for Home Health Services: Resumption of Demonstration Activities Update: 07/07/2020.
Accessed at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-
Programs/Review-Choice-Demonstration/Review-Choice-Demonstration-for-Home-Health-Services on January 22, 2022.
109 CMS, COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing, § V, Question 1, updated
February 28, 2022.
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OEI-01-21-00110 Endnotes | 56
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