Frequently Cited Deficiencies and Common Compliance Strategies - Governing Body Responsibilities for Class A Agencies
This is for informational purposes only. Following this guidance does not guarantee you will pass the survey visit. What follows are examples of some, but not all causes for deficient practice. This guidance is not intended to be the best or the only way to be compliant.
Governing Body Regulations for Class A Agencies
6 CCR 1011, Chapter 26, Section 7.1
"(A) A home care agency shall have an organized governing body.
(1) The body shall consist of members who singularly or collectively have business and healthcare experience sufficient to oversee the services provided by the home care agency.
(B) The governing body shall have a process for review of agency operations at least quarterly and meet at least annually.
(C) The governing body shall assume responsibility for:
(1) Compliance with all federal regulations, state rules, and local laws;
(2) Quality consumer care;
(3) Policies and procedures which describe and direct functions or services of the home care agency and protect consumer rights;
(4) Bylaws that shall include, at a minimum:
(a) A description of functions and duties of the governing body, officers, and committees;
(b) A statement of the authority and responsibility delegated to the administrator;
(c) Meet as stated in bylaws, at least annually;
(d) Appoint in writing a qualified administrator who is responsible for the agency's overall functions.
(5) Review of the written agency evaluation report and other communications from the administrator or group of professional personnel with evidence of written response;
(6) Establish and ensure the maintenance of a system of financial management and accountability; and
(7) Organization, services furnished, administrative control and lines of authority for the delegation of responsibility down to the consumer care level that are clearly set forth in writing and are readily identifiable."
Policy and Procedure Requirements
A common cause of deficient practice by the governing body is failure to assume responsibility for the agency's policies and procedures which describe and direct its functions. Chapter 26 requires the agency have a policy or procedure on a number of topics. The governing body may be cited with deficient practice when an agency does not have a required written policy at all; a policy is in place but is inadequate; a policy is in place but is not followed by staff; or a policy has not been reviewed as a part of an annual agency evaluation.
Below is a list of written policies and procedures required in Chapter 26 rules for home care. Although these are minimum requirements, each agency is advised to compose policies, procedures, protocols and other formal documents to describe and direct the numerous aspects of its operations.
At a minimum, a Class A agency should have written policies on the following general topics and topics specific to Class A agencies.
General Policy Requirements:
Section 6.3(E): Policy or procedure regarding the employment of any individual who is convicted of a felony or misdemeanor to ensure that the individual does not pose a risk to the health, safety and welfare of the consumer.
Section 6.4: Policy or procedure regarding the rights of consumers, how they will be informed of their rights, how they will be protected from discrimination and how the agency will protect and promote consumer rights.
Section 6.9: Policy regarding complaint processing.
Section 6.11(A): Policy directing services provided directly or under arrangement be provided in accordance with each consumer's plan of care.
Section 6.12(A): A written emergency preparedness plan including elements required in the rule, reviewed on an annual basis and after an incident response.
Section 6.16: Policy concerning pre-employment physical examinations and employee health including work restrictions for sick employees.
Section 6.17: Policy regarding missed visits and how coverage will be assured in the event of employee illness, vacation, holidays, etc.
Section 6.19: Policy or procedure regarding effective paper and electronic information management systems that assure privacy, confidentiality, organization of the record, how accuracy of documentation is validated, and how record recovery plans in the event of a system failure.
Requirements Specific to Class A Agencies:
Section 7.2(C): For agencies that provide equipment to consumers, policies and procedures for the management of medical equipment including selection, acquisition, delivery and maintenance of equipment.
Section 7.2(E): Policy describing how consumers will contact the agency after hours and how on-call staff will have access to consumer information when needed.
Section 7.3(C): Policy and procedure to establish criteria for calling a meeting of the group of professional personnel more frequently than the annual minimum.
Section 7.9(C): Policy regarding nurse delegation, delineating what tasks can and cannot be delegated, the process for delegation and how delegation will be supervised. If the agency prohibits delegation, there shall be a policy that specifies such prohibition.
Section 7.10(E): Policy about how the agency will intervene with an attending physician care provider cannot be contacted or does not respond timely.
Section 7.11(C): A policy for how controlled drugs will be administered and monitored.
Section 7.13: Develop an orientation plan for staff providing extended care involving highly technical services and a contingency plan in case staff are unavailable.
Section 7.16(C): A process for standardized, step-by-step observation and evaluation of nurse aide competency in a variety of subject areas prior to the assignment of tasks.
The governing body must review all of the agency's written policies at least annually and make revisions as necessary to keep the policies current and specific to the agency.
Sometimes agencies acquire sets of policies and policy templates from a consultant or other vendor. There is nothing wrong with that practice. In fact, it may give an agency a head-start as it begins to compile a complete set of policies. However, if the policies are not customized to reflect the unique operations of the agency or differ in the way in which care and services are actually delivered, they may be ineffective in directing operations and could lead to deficient practice being cited.
Governing Body Composition Requirements
Chapter 26, Section 7.1(A)(1) defines the required composition of a Class A agency governing body:
"The body shall consist of members who singularly or collectively have business and healthcare experience sufficient to oversee the services provided by the home care agency."
Each agency is unique. They vary in size, disciplines offered, geographic areas served, the complexity of care provided, and so on. Some agencies are small businesses, owner operated, with few administrative staff and only a handful of field staff. Others are large companies with hundreds of employees and consumers, some owned or affiliated with large healthcare systems.
For agencies with few staff members and a small census of consumers, it may be appropriate for an agency to have a governing body of one or a few individuals. If the owner/administrator is the sole governing body member, that person is still responsible for carrying out the responsibilities of the governing body, including conducting an annual evaluation and conducting policy review. To demonstrate their efforts, small and single-person governing bodies must still maintain clear documentation of their oversight efforts and their direction. Recalling governing body activity from one's memory does not suffice for tracking changes and evaluating outcomes. It also does not suffice when evaluation of compliance is conducted by surveyors. Documentation is important, even for one-person governing bodies.
The governing bodies of bigger agencies may be comprised of many people with varied backgrounds and strengths. Large or small, members of the governing body and administration should have the collective experience needed to effectively carry out its responsibility to ensure compliance, ensure quality care, review and revise policies and bylaws, conduct an annual agency evaluation, manage finances and generally exercise administrative control.
The Work of the Governing Body
Below is a list of work commonly carried out by a governing body. It is not intended to be an exhaustive list.
In addition to annually reviewing policies and procedures and evaluating operations, the governing body is responsible for ongoing oversight of agency operations.
In order to monitor services and maintain administrative control, some governing bodies meet more frequently than annually and do more than a quarterly review of operations.
Engaged governing bodies require frequent reports from Administrators on incidents like complaints, occurrences, enrollments, discharges, missed visits etc. They may require quality management activities be carried out based on what is reported and may monitor the outcome of improvement efforts during future meetings.
Following a troubling event, some governing bodies convene to draft new policies that direct agency and employee action in order to avoid similar events in the future.
To show they are aware of agency operations and overseeing services, governing bodies retain documentation of their discussions as well as the directions they give the Administrator and others. Often times the governing body will request updated reporting from the administrator and others in order to monitor progress and the effectiveness of corrective actions.
The governing body does not have to always meet in person. Ongoing oversight and collaboration can occur remotely. Administrators may send routine emailed reports to each member of the governing body on predetermined topics or as issues come to light. Emailed responses with input and direction are retained to demonstrate ongoing direction. Collaboration is important under these circumstances.
Additional Compliance Considerations
In addition to not meeting as frequently as required, a governing body may be cited for failing to provide oversight and direction when they are made aware of operational issues that warrant a response. Governing bodies should maintain thorough documentation such as meeting minutes, that detail what concerns they were made aware of, what direction they gave and what monitoring they conducted.
6 CCR 1011-1 Standards for Hospitals and Health Facilities: Chapter 26 – Home Care Agencies: https://www.sos.state.co.us/CCR/DisplayRule.do?action=ruleinfo&ruleId=3052&deptID=16&agencyID=144&deptName=Department%20of%20Public%20Health%20and%20Environment&agencyName=Health%20Facilities%20and%20Emergency%20Medical%20Services%20Division%20(1011,%201015%20Series)&seriesNum=6%20CCR%201011-1%20Chap%2026