1. DOH Hospice update October 10, 2016

2. In-Home Services Rules The In-Home Services (IHS) rules (chapter 246-335 WAC) are open for updating. The IHS rules includes regulations for Home Care, Home Health, and Hospice agencies. Also Hospice Care Centers. The last time the rules were thoroughly reviewed and updated was 2002.

3. In-Home Services Rules Why are we updating the rules? In recent years, the department has implemented a process to regularly review all of its rules and to determine if any rules require updating. We reviewed the IHS rules and determined that updating was needed to provide necessary clarifications and to reflect changes in technology and industry practices.

4. In-Home Services Rules The department has hosted a total of eight public rules workshops in 2016. Our final workshop was completed on October 3 rd. At the workshops, department staff reviewed each section of the In-Home Services rules and lead group discussions on how best to clarify or update the requirements. We’ve had a good cross-section of participation from licensees, association representatives, DSHS representatives, and department staff.

5. In-Home Services Rules The October 3 rd workshop was focused on Hospice agencies and Hospice Care Centers. I’d like to share some of the key Hospice rule changes: 1.? 2.? 3.? 4.?

6. In-Home Services Rules Next steps:  We are preparing a final draft rule and will send it out on the department’s IHS ListServ for your review and comments.  We will consider all comments and make any final changes that are deemed appropriate/necessary.  Once we’ve finalized the rule language, we will file a CR-102 which announces the official public hearing date.  At the public hearing, interested parties are encouraged to attend and provide written or oral testimony regarding the proposed rules.

7. In-Home Services Rules  All comments and testimony from the public hearing will be considered and last minute, minor changes to the rules may occur.  Shortly after the public hearing, we will file the CR-103 which will announce the final version of the rules.  We plan to have a public hearing in December 2016 or January 2017 and to then file the CR-103 around February/March 2017.  The new rules would become effective 31 days after filing the CR-103.

8. In-Home Services Rules The department has primarily communicated with stakeholders through the In-Home Services ListServ – so please sign up! The link to the IHS ListServ is: http://listserv.wa.gov/cgi- bin/wa?A0=IN-HOME-SERVICEShttp://listserv.wa.gov/cgi- bin/wa?A0=IN-HOME-SERVICES This link is also on the Hospice Agencies webpage on the DOH website.

9. Any Questions about the rules updating process?

10. Navigating the Medicare Certification Process Presented by: Valerie Vajda, DOH NLTC Medicare Certification Specialist

11. STATE OF WASHINGTON DEPARTMENT OF HEALTH MAC AGENCY SA Tie In Notice

12. Agency Responsibilities for Medicare Hospice Certification Be approved by DOH Certificate of Need Have a DOH, IHS license for Hospice If building a Hospice Care Center, go through DOH Construction Review Process Request participation in voluntary Medicare program Comply with Conditions of Participation Notify MAC of any operational/organizational changes

13. Medicare Administrative Contractor (MAC) National Government Services 855-834-5596 Assist agency with filling out 855 paper application or with PECOS (Provider, Enrollment, Chain, and Ownership System) Represent their organization as Medicare but are contracted by Medicare – commonly confuses people

14. Medicare Administrative Contractor (MAC) Approve or deny certification information and will send recommendation letter and application documents to State Agency. Agency should notify their MAC of any and all operational/organizational structure changes.

15. State Agency – (SA) The Washington State Department of Health is the State Regulatory Agency for Non-Long Term Care facilities. We review MAC recommendation letter, application, and supporting documentation for completeness and to make sure all required elements received. Verify with agency Certificate of Need and when applicable Construction Review departments that state requirements met.

16. State Agency – (SA) Certificate of Need contacts are: Karen Nidermeyer - 360-236-2957 Beth Harlow – 360-236-2931 Licensing Department contact: Kathi Miller – 360-236-4897 Construction Review contact for Hospice Care Centers Clynn Wilkinson – 360-236-2951

17. State Agency – (SA) Notifies agency contact listed on application material of additional certification documents required prior to SA recommendation and need for survey. Once all documentation received, creates agency in Federal Database for CMS to assign the CMS Certification Number (CCN).

18. State Agency – (SA) SA compiles all the documents and forwards with their recommendation for certification. SA continues to monitor facilities information by way of notification from CMS, agency, MAC, Accrediting Organization or by way of recertification survey.

19. Centers for Medicare and Medicaid (CMS) Program administrators for anyone who certifies to participate in the voluntary Medicare program Manuel Bravo is currently the Certification Officer for all Home Health and Hospice agencies in Region 10

20. Centers for Medicare and Medicaid (CMS) Regional Office (RO) is located at 701 Fifth Avenue, Suite 1600, Seattle, WA 98104. CMS is the final decision makers for all aspects of certification and enforcement.

21. Updates from the IHS Survey Team!!

22. Updates from the IHS Survey Team Suzanne Kinchen – In-Home Services Surveyor (Eastern WA) Patricia Terry - In-Home Services Surveyor (Western WA) Jada Lynn - In-Home Services Surveyor (Western WA) Sarah Benson - In-Home Services Surveyor (Western WA) Robin Bucknell, In-Home Services Survey Manager

23. Frequent Hospice WAC Citations WAC 246-335-075 - Bill of rights (1) An in-home services licensee at the time of admission must provide each patient or client, or designated family member with a written bill of rights affirming each individual’s right to: (c) A description of the process for submitting and addressing complaints; (d) Submit complaints without retaliation and to have the complaint addressed by the licensee; (e) Be informed of the state complaint hotline number;

24. Frequent Hospice WAC Citations WAC 246-335-085 - Hospice Plan of Care (1)Hospice licensees must, except as provided in subsection (2) of this section: (b) Assure each plan of care is developed by appropriate agency personnel and is based on a patient and family assessment; (c)(vii) Assure the hospice plan of care includes: Special nutritional needs and food allergies; (c)(xii) Resuscitation status of the patient according to documentation consistent with the Natural Death Act and advance directives, chapter 70.122 RCW;

25. Frequent Hospice WAC Citations WAC 246-335-085 - Hospice Plan of Care (continued) (d)(i) Develop and implement a system to: Assure and document the plan of care is reviewed by the appropriate interdisciplinary team members within the first week of admission and every two weeks thereafter; (d)(iv) Develop and implement a system to: Inform the authorizing practitioner regarding changes in the patients condition that indicates a need to change the plan of care; (v) Obtain approval from the authorizing practitioner for additions and modifications;

26. Frequent Hospice WAC Citations WAC 246-335-100 - Supervision of hospice care (5) The licensee must document supervision including, but not limited to: (b) Licensed nurse supervision of home health aide services during an on-site visit with or without the home health aide present once a month to evaluate compliance with the plan of care an patient and family satisfaction with care;

27. Frequent Hospice L-Tags COP 418.116 – Compliance with Federal/State/local laws L798: The hospice and its staff must operate and furnish services in compliance with all applicable Federal, State, and local laws and regulations related to the health and safety of patients. If State or local law provides for licensing of hospices, the hospice must be licensed.

28. Frequent Hospice L-Tags COP 418.54(b) – Timeframe for completion of the comprehensive assessment L523: The hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after the election of hospice care in accordance with 418.24.

29. Frequent Hospice L-Tags COP 418.76(h) - Supervision of hospice aides L629: (1) A registered nurse must make an on-site visit to the patient’s home: (i) No less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meets the patient’s needs. The hospice aide does not have to be present during this visit.

30. Frequent Hospice L-Tags COP 418.54(c)(7) – Bereavement (content of comprehensive assessment) L531: An initial bereavement assessment of the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment must be incorporated into the plan of care and considered in the bereavement plan of care.

31. Frequent Hospice L-Tags COP 418.54(d) – Update of the comprehensive assessment L533: The update of the comprehensive assessment must be accomplished by the hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) and must consider changes that have taken place since the initial assessment. It must include information on the patient’s progress toward desired outcomes, as well as a reassessment of the patient’s response to care. The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days.

32. Frequent Hospice L-Tags COP 418.56(e)(2) – Ensure that the care and services are provided in accordance with the plan of care L555: Coordination of services

33. Frequent Hospice L-Tags COP 418.54 – Initial & comprehensive assessment of patient L521: The hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patient’s needs for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions.

34. Frequent Hospice L-Tags COP 418.54(e) – Patient outcome measure L534: The comprehensive assessment must include data elements that allow for measurement of outcomes. The hospice must measure and document in the same way for all patients. The data elements must take into consideration aspects of care related to hospice and palliation.

35. Frequent Hospice L-Tags COP 418.56(b) – Plan of care L543: All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient’s needs if any of them so desire.

36. Questions & Thank you!