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Anne Koepsell, RN, BSN, MHA, CLNC Executive Director WA State Hospice & Palliative Care Org. 1.

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Presentation on theme: "Anne Koepsell, RN, BSN, MHA, CLNC Executive Director WA State Hospice & Palliative Care Org. 1."— Presentation transcript:

1 Anne Koepsell, RN, BSN, MHA, CLNC Executive Director WA State Hospice & Palliative Care Org. 1

2 Course Objectives Learner will be able to: Identify the components of certification/recertification. Identify the elements of the Comprehensive Assessment. Describe how the IDT care planning process improves patient care. Describe the cycle of care process. Restate the role of the Medical Director. 2

3 Focus of CoPs Patient centered Emphasizes quality improvement Emphasizes patient outcomes Non-prescriptive, organization policy determines process 3

4 Components of Rule List of Subjects/Authority Subpart A. General Provision and Definitions Subpart B. Eligibility, Election and Duration of Benefits Applies to Medicare patients only Subpart C. Patient Care Applies to all patients served Subpart D. Organizational Environment Applies to all patients served 4

5 State Operations Manual Part I – Investigative Procedures Read thoroughly Review regularly Will guide you through survey experience Defines what surveyors will be looking for Part II – Interpretive Guidelines Subpart C. Patient Care Subpart D. Organizational Environment Guidance/Guidance/Manuals/downloads/som107ap_m_hospice.pdf 5

6 SUBPART A: General Provisions Section Definitions Always review definitions and refer back to them when reading a condition or standard Bereavement counseling means emotional, psychosocial, and spiritual support and services provided before and after the death of the patient to assist with issues related to grief, loss, and adjustment. 6

7 Section Definitions – cont Clinical note: Clinical note means a notation of a contact with the patient and/or the family that is written and dated by any person providing services and that describes signs and symptoms, treatments and medications administered, including the patient's reaction and/or response, and any changes in physical, emotional, psychosocial or spiritual condition during a given period of time. 7

8 Section Definitions – cont Employee: Employee means a person who works for the hospice and for whom the hospice is required to issue a W–2 form on his or her behalf, or if the hospice is a subdivision of an agency or organization, an employee of the agency or organization who is appropriately trained and assigned to the hospice or is a volunteer under the jurisdiction of the hospice. 8

9 Section Definitions – cont Hospice care: Hospice care means a comprehensive set of services described in 1861(dd)(1) of the Act, identified and coordinated by an interdisciplinary team to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care. 9

10 Section Definitions – cont Licensed professional: Licensed professional means a person licensed to provide patient care services by the State in which services are delivered. No list of examples because CMS felt it was unnecessary and may be confusing. States vary in titles and licensure requirements Must be familiar with state requirements 10

11 Section Definitions – cont Multiple location means a Medicare-approved location from which the hospice provides the same full range of hospice care and services that is required of the hospice issued the certification number. A multiple location must meet all of the conditions of participation applicable to hospices. 11

12 Section Definitions – cont Restraint (1) Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely, not including devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort); or (2) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. 12

13 Section Definitions – cont Seclusion: Seclusion means the involuntary confinement of a patient alone in a room or an area from which the patient is physically prevented from leaving. 13

14 Section Definitions Comprehensive assessment: Comprehensive assessment means a thorough evaluation of the patient’s physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions. This includes a thorough evaluation of the caregiver’s and family’s willingness and capability to care for the patient. 14

15 Section Definitions Dietary counseling: Dietary counseling means education and interventions provided to the patient and family regarding appropriate nutritional intake as the patient’s condition progresses. Dietary counseling is provided by qualified individuals, which may include a registered nurse, dietitian or nutritionist, when identified in the patient’s plan of care. 15

16 Section Definitions Initial assessment: means an evaluation of the patient’s physical, psychosocial and emotional status related to the terminal illness and related conditions to determine the patient’s immediate care and support needs. 16

17 Section Definitions Physician designee: means a doctor of medicine or osteopathy designated by the hospice who assumes the same responsibilities and obligations as the medical director when the medical director is not available. 17

18 SUBPART B: Eligibility, election and duration of benefits Eligibility requirements Duration of hospice care coverage – Election periods Certification of terminal illness Election of hospice care 18

19 Section & – Eligibility requirements Entitled to Medicare Part A Certified as Terminally Ill in accordance with – Election periods Initial 90-day period Subsequent 90-day period Unlimited number of subsequent 60-day periods 19

20 Section Certification of Terminal Illness (a) Timing Written certification for each of the periods in Must be obtained before submitting claim Exceptions: If not obtained within 2 calendar days after period begins, must obtain oral certification within 2 days and written prior to submitting claim Certs/Recerts may be completed no more than 15 days prior to effective date of election or start of subsequent period 20

21 Section Certification of Terminal Illness – cont. (a) Timing – cont. Face-to-Face encounter Hospice Physician or NP must have F2F with each hospice patient whose total stay across all hospice is anticipated to reach the 3 rd benefit period. No more than 30 calendar days prior to recertification thereafter To gather clinical findings to determine continued eligibility for hospice care (my emphasis) Can occur on the first day of the 3 rd benefit period (clarified in 2012) 21

22 Section Certification of Terminal Illness – cont. (b) Content Based on the physician/medical director’s clinical judgment regarding the normal course of illness. Cert must conform to the following: Specify that the individual’s prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course Clinical information that supports the medical prognosis must accompany certification Initial certification requires two signatures – hospice medical director/physician AND attending. Recertifications only require one signature 22

23 Section Certification of Terminal Illness – cont. (b) Content – cont. Brief Narrative explanation of clinical findings that supports a life expectancy of 6 months or less Can be on form or as an addendum If part of form, narrative must be immediately prior to the physician’s signature If addendum, physician must also sign immediately following the narrative. Addendum creates need for two signatures – one with certification statement and one with brief narrative addendum 23

24 Section Certification of Terminal Illness – cont. (b) Content – cont. Brief Narrative explanation of clinical findings that supports a life expectancy of 6 months or less Narrative shall have statement directly above the signature attesting that physician composed narrative based upon his/her review of medical record or examination of patient. Narrative must reflect the patient’s individual clinical circumstances and cannot contain check boxes or standard language used for all patients 24

25 Section Certification of Terminal Illness – cont. (b) Content – cont. Face-to-Face Encounter if entering third benefit period More than one physician can be involved. MD or NP must attest in writing that he/she had a face to face encounter with the patient, including the date of that visit. If different NP or MD performs F2F, they shall state the clinical findings were provided to MD for use in determining prognosis. Attestation, signature, and date must be a separate and distinct section of addendum or form and must be clearly titled. CMS change in position memo dated 25 Mar

26 SUBPART C: PATIENT CARE Conditions: Patient Rights Initial and Comprehensive Assessment Interdisciplinary Group, Care Planning, and Coordination of Services Quality Assessment and Performance Infection Control Licensed Professional Services Core Services Nursing Services Waiver 26

27 SUBPART C: PATIENT CARE – Cont. Conditions, cont. Furnishing of non-core services PT, OT, Speech Waiver of requirement – PT, OT, Speech, Dietary Hospice Aide and Homemaker services Volunteers 27

28 Subpart C – Patient Rights SEC : PATIENT RIGHTS While not a new rule, it is new to Hospice rules Determine how you will demonstrate compliance during a survey Train staff on reviewing as part of assessment Obtain a signature that acknowledged receipt of Notice Look at P&P on communication barriers with persons of limited English proficiency Family members should not be first choice 28

29 Patient’s rights (a) Standard: Notice of rights and responsibilities. Verbally and in writing; make all reasonable efforts to have written copies of the notice of rights available in the language(s) that are commonly spoken in the hospice’s service area. In a language and manner that the patient understands; and make all reasonable efforts to secure a professional, objective translator for hospice-patient communications, including those involving the notice of patient rights. During the initial assessment visit in advance of furnishing care. 29

30 Patient’s rights Interpretive Guidelines (IG) Pt refers to patient or patient representative Family members can serve as interpreters only when an objective translator cannot be obtained or the patient requests it. Procedures and Probes (PP) Ask for copies of material Ask patients if, who and when informed 30

31 Patient’s rights (a) Standard: Notice of rights and responsibilities. Advance directives ‘‘The hospice must obtain the patient’s or representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities.’’ Interpretive Guidelines (IG) Admission does not require an advance directive Policies and Procedures Procedures and Probes (PP) Review clinical record for evidence 31

32 Patient’s rights (b) Standard: Exercise of rights and respect for property and person. Patients have the right to: exercise their rights, be treated with respect, voice grievances, and be protected from discrimination or reprisal for exercising their rights Process for dealing with alleged violations: Report violations to hospice administrator Investigate violations & complaints Take corrective action if violation is verified Report verified significant violations within 5 working days of becoming aware of incident 32

33 Patient’s rights Interpretive Guidelines (IG) Definitions of various types of abuse Procedures and Probes (PP) Review admission information for instructions on making a compliant Review prior 12 months documentation of complaints – how received, investigated, resolved Ask patient if they know how to make a complaint and treatment Determine if staff can ID various forms of abuse and if they know how to report 33

34 Patient’s rights (c) Standard: Rights of the patient Pain management and symptom control. Interpretive Guidelines Patients should not have to experience long waits for pain and symptom management, medication, interventions Hospice should have methods to assure 24 hours/7 days response in all settings and where ever pt resides Procedures and Probes Ask to describe policies Determine how hospice assures timely response Ask patients how quickly hospice responds 34

35 Patient’s rights (c) Standard: Rights of the patient Be involved in developing plan of care. Probes Ask staff how they facilitate pt/family involvement Ask patient/family if they are involved. Refuse care or treatment. Interpretive Guidelines Probes further if particular trend is identified, i.e. a majority of patients is refusing a particular service, to assure that hospice is fully prepared to provide the service with qualified personnel. 35

36 Patient’s rights (c) Standard: Rights of the patient Choose attending physician. Interpretive Guidelines Pts have right to choose physician and have this person involved in their medical care in all settings Probes Is there evidence that the hospice does not allow the patient to choose their physician? 36

37 Patient’s rights (c) Standard: Rights of the patient Confidential clinical record/ HIPAA. Interpretive Guidelines Safeguarding content, paper and electronic, from unauthorized disclosure without consent Observe whether staff shows evidence of protecting confidentiality Is patient information posted in public places Are clinical records accessible for reading or removing? 37

38 Patient’s rights (c) Standard: Rights of the patient Be free of abuse, neglect, mistreatment Interpretive Guidelines If issue identified during survey, investigate and report Ensure that the hospice addresses the incident immediately 38

39 Patient’s rights (c) Standard: Rights of the patient Receive information about hospice benefit. Interpretive Guidelines Fully inform on covered services (Medicare and non-Medicare) Procedures and Probes Is pt/family aware of all covered services? Has hospice described any services for which pt might have to pay? Consider pts ability to understand and retain information 39

40 Patient’s rights (c) Standard: Rights of the patient Receive information about scope and limitations of hospice services. Procedures and Probes Ask pt/family what services they are receiving Are they aware of any limitations to those services Hospices are required to provide all services necessary for palliation and management of terminal illness and should not accept a patient if they cannot provide all services. 40

41 Initial/Comprehensive assessment Conduct and document in writing patient-specific comprehensive assessment and pts need for physical, psychosocial, emotional and spiritual care The comprehensive assessment is not a single static document, a symptom and severity checklist, or a set of generic questions that all patients are asked. It is a dynamic process that needs to be documented in an accurate and consistent manner for all patients. Hospice P&Ps will serve to guide decisions about who assesses patient/family needs and how 41

42 Initial/Comprehensive assessment (a) Standard: Initial assessment. Completed by RN Election can be another IDG member Must occur within 48 hours after election of hospice care Need staffing to address needs that require a shorter than 48 hours assessment and weekends/holidays This is an initial overall assessment of the patient/family needs If there are significant issues in one area, then it is recommended that the specialty IDG member complete the comprehensive assessment 42

43 Initial/Comprehensive assessment (a) Standard: Initial assessment – cont. Initial contact cannot be substituted for initial assessment Cannot wait until comprehensive assessment is complete to formulate Plan of Care and provide services Initial assessment guides decisions about who comprehensively assesses patient/family needs Document the IDG formulation of the POC based upon initial assessment 43

44 Initial/Comprehensive assessment (a) Standard: Initial assessment – cont. Interpretive Guidelines Purpose is to gather critical information necessary to treat immediate care needs In the location where the hospice services are being delivered Not a ‘meet and greet’ visit RN must conduct, other IDTS can be involved Procedures and Probes Determine through interview, observation and record review if immediate care needs met Did RN complete initial assessment? 44

45 Initial/Comprehensive assessment (b) Standard: Time frame for completion of the comprehensive assessment. Completed by the hospice IDG in consultation with the attending physician. Attending not required to sign, but they do need to be involved – how to document Completed within 5 calendar days after the patient elects hospice care, based upon patient needs. – IN TOP 10 DEFIENCIES FOR THE LAST 3 YEARS Ensure imminently dying patients receive appropriate and timely assessments despite their short length of stay 45

46 Initial/Comprehensive assessment b) Standard: Time frame for completion of the comprehensive assessment. All members of the IDG do not necessarily need to visit the patient/family to complete the comprehensive assessment. Comprehensive assessment is about assessing WHAT the patient needs, not all about WHO completes the assessment. CMS does not dictate how the comprehensive assessment is completed 46

47 Initial/Comprehensive assessment b) Standard: Time frame for completion of the comprehensive assessment. Interpretive Guidelines If no attending, hospice physician must assume role If attending, must be consulted Consultation occurs through phone calls, fax, s, text messages, etc.) Attending often has history and family dynamics Election may be signed with a later date, but not earlier May be completed earlier than 5 days 47

48 Initial/Comprehensive assessment Election of hospice Patient/ represent ative signs form Initial assessment RN completes Within 48 hours of election of hospice Comprehensive assessment All needs of patient/ family Completed within 5 days of election of hospice Update comprehensive assessment Updates identified needs of patient/family Every 15 days of as necessary 48

49 Initial/Comprehensive assessment c) Standard: Content of the comprehensive assessment. Physical, Psychosocial, Emotional, Spiritual needs related to the terminal illness and related conditions Ensure that assessment and POC address actual as well as potential problems Interpretive Guidelines Identifies minimum symptoms to be assessed Pain, dyspnea, N&V, constipation, restlessness, anxiety, sleep disorders, skin integrity, confusion, emotional distress, spiritual needs, support systems, need for counseling/education Identifies components of comprehensive pain assessment History, characteristics, physical exam, current meds, goals 49

50 Initial/Comprehensive assessment c) Standard: Content of the comprehensive assessment Must take into consideration the following 8 factors: 1) Nature and condition causing admission 2) Complications and risk factors that affect care planning 3) Functional Status including the patient’s ability to understand and participate in his/her own care (structure, function, activity) 4) Imminence of death as evidenced by…. 50

51 Initial/Comprehensive assessment c) Standard: Content of the comprehensive assessment 5) Severity of symptoms Use rating scales for consistency Document pt’s self-identified threshold (SIT score) All IDG members need to ask and report symptoms at every visit Procedures and Probes Ask staff how they complete comprehensive assessment Evidence in clinical record? 51

52 Initial/Comprehensive assessment c) Standard: Content of the comprehensive assessment 6) Drug profile – includes effectiveness, side effects, interactions, duplicate drug therapy, therapy associated with clinical monitoring Interpretive Guidelines Include non pharmacological interventions Includes definitions Procedures and Probes Ask staff to describe process/policy of medication review Complete medication reconciliation on home visit and compare IN TOP 10 DEFIENCIES FOR THE LAST 3 YEARS 52

53 Initial/Comprehensive assessment c) Standard: Content of the comprehensive assessment 7) Bereavement incorporated into POC and considered in the bereavement POC Interpretive Guidelines Assess grief/loss issues through-out care Scope of assessment – history of previous losses, family problems, legal/financial concerns, communication issues, drug/alcohol abuse, health concerns, support system, mental health issues Procedures and Probes What evidence is present in assessment and POC? 53

54 Initial/Comprehensive assessment c) Standard: Content of the comprehensive assessment 8) Need for referrals For further evaluation by appropriate health professionals Related/Unrelated Procedures and Probes Ask staff how they determine need for referral 54

55 Initial/Comprehensive assessment (d) Standard: Update of the comprehensive assessment. Updated by the IDG As frequently as the patient’s condition requires At a minimum every 15 days Update those sections of the comprehensive assessment that require updating. Patient condition change - comprehensive assessment must be updated to reflect changes. 55

56 Initial/Comprehensive assessment (d) Standard: Update of the comprehensive assessment. Interpretive Guidelines Hospices are free to choose the method that best suits their needs when documenting the comprehensive assessment and the updates to that assessment. Assessment updates should be easily identified Only update those areas of change Identify if there are no changes Procedures and Probes Determine through interview, observation and record review evidence of IDG active involvement 56

57 Initial/comprehensive assessment cycle Change in patient status Update the comprehensive assessment Update of patient plan of care 57

58 Initial/Comprehensive assessment (e) Standard: Patient outcome measures. Patient level data elements must be included in each patient assessment Data elements must be used in patient care planning and evaluation AND in the hospice’s QAPI program Data elements must be integral part of comprehensive assessment Data elements must be collected and documented in a consistent, systematic, and retrievable way. Interpretive Guidelines Data elements for patient reported outcomes on symptoms Procedures Interview key staff and have them explain 58

59 Initial/Comprehensive assessment Documentation – SOAPIER clinical notes Subjective Objective Assessment Plan Intervention Evaluate Reassess * Weatherbee Resources, Inc. 59

60 Initial/Comprehensive assessment Techniques for compliance WHAT HAS WORKED FOR YOUR HOSPICE PROGRAM? 60

61 IDG, care planning, and coordination of services Interpretive Guidelines Physician member may be hospice medical director Nurse, social worker and counselor members must be hospice employees If hospice is sub-division of organization, must be appropriately trained and assigned to hospice Probes Ask how POC is developed by full IDG with attending Request documentation that verifies 4 L-tags in this condition were in the TOP 10 DEFICIENCES IN

62 IDG, care planning, and coordination of services (a) Standard: Approach to service delivery Hospice designates an IDG who work together to meet the needs of the patient and family. IDG in entirety must supervise care and services Interpretive Guidelines Supervision may be accomplished by face-to-face, telephone, conferences, evaluations, discussions, general oversight, direct observations Procedures Ask RN Coordinator to describe developing goals, facilitating exchange of information with pt and IDG 62

63 IDG, care planning, and coordination of services (a) Standard: Approach to service delivery The hospice designates a registered nurse who is member of the IDG to provide program coordination, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation and revision of the plan of care. Procedures and Probes Ask administrator to identify RN coordinators How does this person assure coordination of care with IDG? 63

64 IDG, care planning, and coordination of services (a) Standard: Approach to service delivery Required members of the IDG: Doctor of medicine or osteopathy (employee/contract) Registered nurse; Social worker; and Pastoral or other counselor Interpretive Guidelines Number of individuals is not important, it is qualifications – i.e., dually licensed individuals Procedures Determine that all disciplines contribute to assessments and POC 64

65 IDG, care planning, and coordination of services If there is more than one IDG, the hospice must identify a specifically designated IDG to establish day-to-day policies and procedures. Interpretive Guidelines Does not need to be the same group that works together to care for patients. 65

66 IDG, care planning, and coordination of services (b) Plan of Care When establishing the written plan of care, IDG consults with the following: Attending physician (if any); Patient or representative; and Primary caregiver All hospice services furnished to patients and their families must follow an individualized written plan of care. Patient and primary caregiver(s) receive education and training related to their care responsibilities identified in the plan of care. MOST FREQUENT DEFICIENCY FOR LAST 3 YEARS 66

67 IDG, care planning, and coordination of services (c) Standard: Content of the plan of care Reflects patient and family goals Includes interventions for problems identified throughout the assessment process Includes all services necessary for palliation and management of terminal illness and related conditions Individualized written POC for each patient TOP 10 DEFICIENCES FOR THE PAST 3 YEARS 67

68 IDG, care planning, and coordination of services (c) Standard: Content of the plan of care Procedures and Probes Determine through interview, observation and record review if POC identifies all services needed Is there evidence of pt receiving medications ordered? Are POCs patient-specific? Does the POC integrate changes based upon the assessment? Is there evidence the POC was a collaborative effort? 68

69 IDG, care planning, and coordination of services (c) Standard: Content of the plan of care 1. Interventions to manage pain and symptoms Interpretive Guidelines Goal is quality of life Ongoing assessment of all needs Evidence of interventions, including alternative therapies Procedures and Probes Ask staff for specific patient information Is there evidence of proactively anticipating side effects Ask pt if satisfied with level of comfort? What was response when pain escalated? Investigate when not managed 69

70 IDG, care planning, and coordination of services (c) Standard: Content of the plan of care 2. Detailed statement of the scope and frequency of services to meet the patient’s and family’s needs Interpretive Guidelines May include range of visits and PRN Range must be small intervals, but 0 is not allowed IDG may exceed number in range, but documentation should support need for extra visits If requires frequent use of PRN, POC should update frequency to meet current need Standing orders must be individualized 70

71 IDG, care planning, and coordination of services (c) Standard: Content of the plan of care 2. Detailed statement of the scope and frequency of services to meet the patient’s and family’s needs Procedures and Probes Ask IDG members what criteria is used to assess need, who is involved, how does IDG decide what services, how does IDG evaluate effectiveness, how monitor contracted services Ask pt/family if aware of all services included in benefit, who comes to see them, how often, what services provided, are they satisfied? Determine if any indication that pt needs services not receiving 71

72 IDG, care planning, and coordination of services (c) Standard: Content of the plan of care 3. Measurable outcomes Interpretive Guidelines Outcomes should be measurable result of implementation of POC Using data elements to see if they are meeting goals Probes Are outcomes measurable and documented? Look for movement towards expected outcomes and revisions to POC 72

73 IDG, care planning, and coordination of services (c) Standard: Content of the plan of care 4. Drugs and treatments Interpretive Guidelines References (c) (1) – Rights of pt to effective pain & symptom management 5. Medical supplies and appliances 6. Documentation (in the clinical record) of the patient’s or representative’s level of understanding, involvement and agreement with the plan of care IG - do not need to be present at IDG meetings 73

74 IDG, care planning, and coordination of services (d) Standard: Review of the plan of care Plan of care must be reviewed as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days Revised plan of care includes: Information from the updated comprehensive assessment Information regarding the progress toward achieving specified outcomes and goals Completed by the IDG in collaboration with the attending physician (if any) TOP 10 DEFICIENCES FOR THE PAST 3 YEARS 74

75 IDG, care planning, and coordination of services (d) Standard: Review of the plan of care Interpretive Guidelines Communication with attending may be through various means according to policy and patient needs Procedures and Probes Ask the hospice to describe the POC review process How does the hospice ensure the review process occurs by the IDT no later than 15 days from the prior review? 75

76 IDG, care planning, and coordination of services (e) Standard: Coordination of services Develop and maintain a system of communication and integration Ensure the IDG maintains responsibility for directing, coordinating, and supervising the care and services provided Care and services are provided in accordance with the plan of care TOP 10 DEFICIENCES IN 2011 Care and services are based on assessments of the patient and family needs 76

77 IDG, care planning, and coordination of services (e) Standard: Coordination of services – cont. Sharing information between all disciplines providing care and services, in all settings, whether provided directly or under arrangement Sharing information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. 77

78 IDG, care planning, and coordination of services (e) Standard: Coordination of services – cont. Probes What systems are in place to facilitate exchange of information among staff and with non-hospice providers? How does the hospice ensure that coordination of care occurs between services provided directly and those under arrangement? Is there documentation of the sharing of information between all disciplines and other providers? 78

79 IDG, care planning, and coordination of services Techniques for compliance Establish methods of communication to ensure that modalities are adequate, efficient and reliable. Define term ‘change in condition’ IDG meetings IDG – “planning” - this is the time to anticipate what you expect and plan for that. It is not reviewing past care, reporting current condition. DARE format – Deaths, Admits, Recertifications (group by LCD category), Existing patients (group by diagnosis/LCD category) 79

80 IDG, care planning, and coordination of services Techniques for compliance WHAT HAS WORKED FOR YOUR HOSPICE PROGRAM? 80

81 Quality assessment and performance improvement Develop, implement and maintain an effective, ongoing, hospice-wide data-driven QAPI program. Reflect complexity of organization Involves all services Focuses in indicators to improved palliative outcomes Takes action to demonstrate improvement The hospice must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS 81

82 QAPI Interpretive Guidelines Each hospice develops its own QAPI program Methods used are flexible – documentation, direct observation, incident reports, complaints, surveys, interviews Information gathered should be based on measures generated by medical/professional staff Reflect best practices, staff performance and patient outcomes Ongoing means continuous and periodic collection and assessment of data 82

83 QAPI Interpretive Guidelines QAPI program should have following elements Program objectives All patient care disciplines Description of how administered and coordinated Method for monitoring and evaluating quality of care Priorities for resolution of problems Monitoring to determine effectiveness of action Oversight responsibility reports to governing body Documentation of review of QAPI program 83

84 QAPI Interpretive Guidelines Fundamental purpose is to set a clear expectation of proactive approach to improve performance and focus on improved care Stresses improvement in systems in order to improve processes and patient outcomes All components of QAPI in place hospice wide Must be ongoing and have written plan of implementation Performance Improvement fosters a ‘blame free’ environment 84

85 QAPI Procedures and Probes Request the following: Aggregated data and its analysis of data QAPI plan Individuals responsible for QAPI program Evidence the QAPI has been implemented and is functioning effectively Regular meetings, investigation of sentinel and adverse events Recommendations for systemic change Identified performance measures that are tracked and analyzed Regular review and use of QAPI analysis by management and governing body 85

86 QAPI Procedures and Probes Match data provided with actual experiences of hospice staff and patients Focus on how and why quality measures chosen, how it ensures consistent data collection, how it uses data in patient care planning and how it aggregates and analyzes data Documentation of analysis can be meeting minutes, reports, recommendations for change CMS Preamble – “Tools must allow hospices to document information in a systematic and retrievable way for each patient.” 86

87 QAPI Operates on 2 levels Patient Hospice Focuses on Collecting data to assess quality Using data to identify opportunities for improvement Patient focused – outcome oriented Two related process Quality Assessment Performance Improvement 87

88 QAPI (a) Standard: Program scope Show measurable improvement in indicators related to improved palliative outcomes and hospice services Must measure, analyze, and track quality indicators, including adverse pt events CMS Preamble- Failure to meet the quality assurance condition is consistently one of the top 10 deficiencies cited by Medicare surveyors nationwide. 88

89 QAPI (a) Standard: Program scope Interpretive Guidelines Assess quality in all areas of operations Specific requirement to track adverse events and reduce occurrence Show, using quantitative data, that quality is improved as measured by own indicators or measures Procedures and Probes Does hospice adhere to its own definition of adverse event 89

90 QAPI (b) Standard: Program data The program must utilize quality indicator data, including patient care, and other relevant data, in the design of its program Interpretive Guidelines Not limit data collection to patient assessments Examine all facets of hospice operations Procedures and Probes Is the hospice’s QAPI program data driven? Is there evidence it uses data to identify opportunities for improvement? 90

91 QAPI (b) Standard: Program data Hospice must use data collected to monitor effectiveness and safety of services and quality of care and identify opportunities and priorities for improvement Frequency and detail of the data collection must be specified by the hospice’s governing body Interpretive Guidelines Governing Body may assume hands-on control or delegate 91

92 QAPI (c) Standard: Program activities The hospice’s performance improvement activities must: Focus on high risk, high volume, problem prone areas Consider evidence, prevalence, and severity of problems in those areas Affect palliative outcomes, patient safety and quality of care Performance activities must track adverse patient events, analyze their causes and implement preventive actions and mechanisms that include feedback and learning throughout the hospice Interpretive Guidelines – hospice may choose to develop own definition for adverse event or use one developed by national accrediting organization 92

93 QAPI (c) Standard: Program activities (cont’d) Take action aimed at performance improvement Measure success of action Track performance of action to ensure that improvements are sustained Interpretive Guidelines Consider how often certain quality issues arise and severity of potential harm Procedures and Probes Determine if hospice has taken appropriate action to correct identified problems Evidence performance continually monitored? 93

94 QAPI (d) Standard: Performance improvement projects (PIP) The number and scope of projects conducted annually must reflect the scope, complexity and past performance of the hospice’s services and operations Document what quality improvement projects are being conducted, reasons for conducting the projects and measurable progress achieved on these projects Interpretive Guidelines No requirement for specific number of PIPs Procedures and Probes Do the number and scope of PIPs reflect scope, complexity and past performance of hospice? 94

95 QAPI (e) Standard: Executive responsibilities Governing body ensures: That an ongoing program for QI and patient safety is defined, implemented and maintained. (Board needs to approve details.) The QAPI efforts address quality of care and patient safety, and all improvement actions are evaluated for effectiveness. That an individual(s) is designated to lead QAPI efforts. 95

96 QAPI (e) Standard: Executive responsibilities Probes Do hospice records indicate that the hospice’s governing body is involved in oversight of the QAPI program? Is there an individual appointed by the governing body who is responsible for operating the QAPI program 96

97 QAPI Patient – level QAPI Collect data on what happened to an individual patient Assessment/reassessment (418.54) Care Plan (418.56) Visit Notes Use the data to improve quality of care and outcomes for that patient (418.56) 97

98 QAPI Hospice – level QAPI Clinically focused Aggregate patient level data Collect satisfaction data Non Clinically focused Administrative data Marketing – referral source contact Outreach to community Profitability Fund raising 98

99 QAPI Quality Assessment requires quantitative information Numbers OR Uniform variables (yes/no, increased/decreased) Performance Improvement requires qualitative information Narrative data Detail behind quantitative 99

100 QAPI Visualize – QAPI Hospice SEE – quality data is posted FEEL – culture of quality Quality of assessment is a core activity across the organization Positive questioning, not finger pointing or blaming Reliance on data for decision making PI, not criticism or punishment, is the organizational response to errors and problems. READ – QAPI plan, PIP report, Board meeting minutes WATCH - Everybody participates 100

101 QAPI Initial Steps to QAPI Appoint individual/team responsible for QAPI program Generate buzz about QAPI Educate everyone about QAPI and their role Develop a QAPI Plan – to be reviewed/evaluated yearly Implement Plan Develop Performance Improvement Project teams to address identified areas for improvement (this can take 4 – 6 months) 101

102 QAPI Act Plan Study Do Redesign 102

103 QAPI Patient Level – The Cycle of Care 103 Assess (data) ID Problems Intervention (POC) Reassess (data)/ Change POC

104 QAPI Hospice Level – The QAPI Process 104 Gather data ID areas for improvement Performance Improvement Projects (PIP) Institutionalize improvements

105 QAPI QAPI Leaders - Governing body retains responsibility Appoint one or more to manage day to day - At least part-time defined hours/days Chairs committee (CQO) Monitor compliance with the QAPI plan Manages collection of indicator data Oversee analysis and reporting Supports PI teams QAPI Committee Clinical and non-clinical (include medical records) Managers and staff Generate Buzz and Celebration 105

106 QAPI Use available quality measurement tools Agency satisfaction survey tools NHPCO – National Data Set, FEHC, STAR, QP Agency for Healthcare Research and Quality – EOL outcomes National Quality Forum – Standards for symptom management and EOL care excelleRx – pharmaceutical tools Multiview – financial OCS – QAPI snapshot Deyta – FEHC and other satisfaction surveys CMS Pilot to determine outcomes currently underway in New York 106

107 Infection control Must maintain and document effective infection control program that protects patients, families, visitors and hospice personnel by preventing and controlling infections and communicable diseases Interpretive Guidelines IC program must identify risks in all settings where pts reside System to communicate with all staff, pts/families, visitors about infection prevention and control 107

108 Infection control Interpretive Guidelines IC program may include, but not limited to: Educating staff Protocols related to infusion therapy, urinary tract care, respiratory tract care and wound care Guidelines on caring for pts with multi-drug resistant organisms Policies on protection from blood borne or airborne pathogens Monitoring for compliance Protocols for educating in standard precaution and prevention/control 108

109 Infection control Procedures and Probes Ask what steps it takes to assure staff take appropriate prevention and control precautions How does the hospice ensure timely instructions regarding standard precautions If providing inpatient care directly, observe for appropriate infection prevention and control precautions including signage or other posted information or materials in pt rooms or staff area. 109

110 Infection control (a) Standard: Prevention Follow accepted standards of practice to prevent transmission, including standard precautions Interpretive Guidelines Accepted standards of practice are typically developed by government agencies, professional organizations and associations Standard Precautions are based on principle that all body fluids may contain transmissible infectious agents These include hand hygiene, gloves, mask, gown, eye protection, face shield and safe injection practices Procedures During home visit, observe practices 110

111 Infection control (b) Standard: Control Maintain a coordinated, agency-wide program for surveillance, identification, prevention, control, and investigation of infectious and communicable diseases That is an integral part of QAPI program Includes method of identify infectious and communicable disease problems and A plan for implementing appropriate actions that are expected to result in improvement and disease prevention 111

112 Infection control (b) Standard: Control Interpretive Guidelines Examples of infection control practices are monitoring work related employee illness and infections Analyzing them in relation to patient infections Taking appropriate actions when an infection or communicable disease is present to prevent spread Procedures and Probes Ask hospice to explain methods it uses to ID problems Does the hospice redesign its strategies to improve when it identifies problems? 112

113 Infection control (c) Standard: Education Infection control education provided to staff, patients, families, and other caregivers Probes Is hospice staff aware of infection control principles and procedures? Do they demonstrate this knowledge during home visits? During home visit ask pt/family to describe infection control education they have received. 113

114 Licensed professional services (a) Standard: Services, whether provided directly or under arrangement, must be authorized, delivered, and supervised by qualified personnel (b) Standard: Professionals must actively participate in coordinating patient care (includes: patient assessment; care planning and evaluation; and patient and family counseling and education) (c) Standard: Professionals must participate in the hospice’s QAPI and in-service training programs 114

115 Licensed professional services Interpretive Guidelines Would include, but not be limited to: skilled nursing care, physical therapy, speech language pathology, occupational therapy and medical social services Procedures and Probes Interview key staff to determine how hospice ensures the licensed professionals participate in QAPI and in-service training What evidence is there that all employees have been properly oriented to tasks, participate in in-service training programs and demonstrate appropriate skills 115

116 Core services Routinely provide substantially all core services directly by hospice employees. These services include nursing, medical social services and counseling. May use contracted staff, if necessary, to supplement hospice employees in order to meet needs of pts under extraordinary or other non-routine circumstances. May also enter into an agreement with another Medicare certified hospice Reasons: unanticipated periods of high patient loads 116

117 Core services Reasons to contract Unanticipated periods of high patient loads or CC level Staffing shortages due to illness or other short-term temporary situations Pts evacuated due to disaster Temporary travel of a patient outside the service area Interpretive Guidelines Employee definition – works for hospice/organization and receives a W-2 or is a volunteer Probes How does hospice assure that all contract providers receive training in hospice philosophy and care before providing services 117

118 Core services (a) Standard: Physician services Employee or contracted Responsible for the palliation and management of the terminal illness and related conditions Supervised by the hospice medical director Meets the medical needs of the patient when the attending physician is not available Probe Is there evidence that the medical needs of pts are being met by hospice physician when no attending or attending unavailable? 118

119 Core services (b) Standard: Nursing services Care provided by or under the supervision of a registered nurse If state law permits ARNPs to treat and write orders, then ARNPs may provide services Highly specialized nursing services maybe provided under contract – i.e., complex wound, infusion, peds Interpretive Guidelines Services provided by ARNP who is not the pt’s attending are included under nursing care (i.e., cannot be billed) TOP 10 DEFICIENCES IN

120 Core services (c) Standard: Medical social services Provided by a qualified social worker under the direction of a physician Services to patient and family based on psychosocial assessment and pt/family needs and acceptance of services Interpretive Guidelines Assessment should include adjustment to terminal illness, social/emotional factors, coping mechanisms, family dynamics, communication patterns, financial resources, caregiver’s ability, risk factors, support systems 120

121 Core services (c) Standard: Medical social services Probes How does the hospice introduce and offer medical social services? Ask the SW or CM to describe factors included in psychosocial assessment, how is info used in care planning Is there evidence that each patient receives SW services, unless refused? 121

122 Core services (d) Standard: Counseling services Counseling services must be available to pt/family to assist in minimizing the stress and problems that arise from terminal illness, related conditions and dying process Include, but are not limited to: Bereavement Dietary Spiritual Broad language includes CAM therapy providers 122

123 Core services (d) Standard: Counseling services - Bereavement Bereavement counseling: under the supervision of a qualified professional with experience or education in grief or loss counseling Available to family and other individuals, including residents of a SNF/NF or ICF/MR, when appropriate and identified in the bereavement plan of care Development of the bereavement plan of care starts before the patient’s death. TOP 10 DEFICIENCES IN

124 Core services (d) Standard: Counseling services – Bereavement Interpretive Guidelines Supervisor may be IDG social worker or other professional with documented evidence of experience or education in grief or loss counseling Procedures and Probes Ask the hospice to explain how and when they incorporate bereavement assessment into comprehensive assessment What services are provided to reflect needs of pt/family? How does hospice evaluate outcomes and effectiveness of bereavement services? Select and sample 2 – 3 bereavement POC from pts who have died in past 12 months. Determine if bereavement follow-up was appropriate. 124

125 Core services d) Standard: Counseling services - Dietary Dietary counseling: preformed by a qualified individual such as dieticians and nurses Interpretive Guidelines RN can provide dietary counseling within scope of practice If needs exceed RN expertise, then must have an appropriately trained and qualified registered dietician or nutritionist 125

126 Core services d) Standard: Counseling services - Dietary Procedures and Probes Ask the clinical manager how hospice meets the needs of pts/family who experience challenges and conflict with EOL dietary issues. Ask clinical manager how hospice meets the needs of pts who experience dysphasia, problematic enteral feedings, unresolved nutritional issues secondary to N&V or the dying process. 126

127 Core services d) Standard: Counseling services - Spiritual counseling Spiritual counseling: Make all reasonable efforts to facilitate visits from local clergy, pastoral counselors, or other individuals who support the patient’s spiritual needs. Interpretive Guidelines Evidence in record that spiritual counseling was offered and/or provided in accordance with pt/family desires. 127

128 Core services d) Standard: Counseling services - Spiritual counseling Procedures and Probes Determine through record review, interview and home visits how the hospice addresses the spiritual needs of pt/family How does the hospice introduce the availability of spiritual counseling? What mechanisms are in place to meet the spiritual needs? 128

129 Nursing services – Waiver Applies only to hospices in existence on or before Jan. 1, 1983 in non-urbanized areas 129

130 Non-core services Services in thru are provided directly or under arrangements. Services must be consistent with current standards of practice Interpretive Guidelines Must ensure all staff are aware of and follow professional standards, laws, policies, procedures. If question arises during home visit, ask staff what the policies are regarding the issue Procedure Ask how hospice monitors professional skills to determine if appropriate and adequate for its patients. 130

131 PT, OT, and SLP PT, OT, SLP services must be available and provided in a manner consistent with accepted standards of practice. Interpretive Guidelines: Rehab services, i.e., use of adaptive equipment, home safety assessment, caregiver instructions in good body mechanics, may be appropriate/beneficial for the pt. 131

132 Waiver of requirement- PT, OT, SLP, and dietary counseling Waives 24 hour requirement for non-urbanized programs Unlimited 1 year extensions 132

133 Hospice aide & homemaker services All hospice aide services must be provided by individuals who meet requirements in paragraph (a) Homemaker services must be provided by individuals who meet requirements in paragraph (j) 133

134 Hospice aide & homemaker services (a) Standard: Hospice aide qualifications Qualified aide has successfully completed one of the following: Hospice aide training and competency evaluation as specified in (b) and (c) Competency evaluation as specified in (c) Nurse aide training and competency evaluation approved by state and is in good standing State licensure program that meets requirements of (b) and (c) If there has been a 24 month lapse in furnishing services, individual must complete another program 134

135 Hospice aide & homemaker services (b) Standard: Content and duration of hospice aide training Classroom and supervised practical training Minimum of 16 classroom hours Minimum of 16 supervised practical trainings with person, not mannequin Total of at least 75 hours 13 training subject areas identified Maintain documentation that demonstrates requirements are met 135

136 Hospice aide & homemaker services (b) Standard: Content and duration of hospice aide training Interpretive Guidelines May receive training from different organizations if amount of training totals 75 hours, content addresses all subject areas and all requirements of regulation are met. Document that requirements of standard are met Documentation should include: descriptions of program, qualification of instructors, record that distinguishes between classroom and practical training, how additional skills are taught is hospice requires more complex procedures 136

137 Hospice aide & homemaker services (c) Standard: Competency evaluation Individual may furnish services only after successfully completed a competency evaluation program. Competency evaluation must address all 13 subjects of (b). Specific subjects are to be with a patient, remaining subjects can be written, oral or observation May be provided by any organization, except those identified in (f) TOP 10 DEFICIENCES IN

138 Hospice aide & homemaker services (c) Standard: Competency evaluation Interpretive Guidelines: Must ensure that skills learned elsewhere can be successfully transferred in all settings Review of skills can be done when nurse installs new aide in patient care situation or during supervisory visit Mannequin may not be used for this evaluation 138

139 Hospice aide & homemaker services (c) Standard: Competency evaluation Must be performed by RN in consultation with other professionals, as appropriate Hospice aide not considered competent in any task evaluated as unsatisfactory and must not perform task without direct supervision until retrained If rated unsatisfactory in more than one area, not considered to have successfully completed competency evaluation. IG – precluded from functioning as aide Interpretive Guidelines: No restrictions on number of times or timeframe for testing in deficient area. Documentation must demonstrate that requirements of standard are met 139

140 Hospice aide & homemaker services (d) Standard: In-service training (same) 12 hours of in-service training during each 12 month period. May occur while furnishing care. Interpretive Guidelines: May be calendar year, employment anniversary or rolling 12 month basis Training that occurs with pt in place of residence, supervised by RN, may occur as part of supervisory visit Should not be repetition of basic skill Procedures and Probes: Ask how the hospice schedules training to assure the 12 hours within 12 months 140

141 Hospice aide & homemaker services (d) Standard: In-service training (same) Training may be offered by any organization and must be supervised by a registered nurse. Interpretive Guidelines: May be calendar year, employment anniversary or rolling 12 month basis Training that occurs with pt in place of residence, supervised by RN, may occur as part of supervisory visit Should not be repetition of basic skill 141

142 Hospice aide & homemaker services (d) Standard: In-service training (same) Procedures and Probes: Ask how the hospice schedules training to assure the 12 hours within 12 months Training may be offered by any organization and must be supervised by a RN Hospice must maintain documentation demonstrating requirements of standard are met Procedures and Probes: Review a sample of 3 – 4 hospice aides training files to validate aides are receiving required number of hours. If concerns arise, interview aides regarding in-service training 142

143 Hospice aide & homemaker services (e) Standards: Qualifications for instructors conducting classroom and supervised practical training Training performed by RN, at least 2 years experience, with at least 1 year in homecare (home health or hospice) Interpretive Guidelines: 2 years experience should be “hands-on” clinical experience such as providing care or supervising nursing services or teaching nursing skills in an organized curriculum or in-service program Other individuals may help with training 143

144 Hospice aide & homemaker services (f) Eligible competency evaluation organizations May be offered by any organization except one that has one of the identified deficiencies in the prior 2 years (g) Hospice Aide assignments and duties Assigned specific pt by IDT RN, written patient care instructions must be prepared by RN who is responsible for supervision of aide Interpretive Guidelines: Written instructions must be patient specific and not generic 144

145 Hospice aide & homemaker services (g) Hospice Aide assignments and duties Procedures and Probes: Interview key staff to determine: if aides are employees or under arrangement, if under arrangement how ensure competency How hospice ensures aides are proficient to carry out assignments in safe, efficient, effective manner How hospice monitors the assignments of aides to match skills needed for individual pts If questions arise as a result of home visits or interviews, ask clinical managers to respond to specific issues 145

146 Hospice aide & homemaker services (g) Hospice Aide assignments and duties Hospice Aide provides services that are ordered by IDG, included plan of care, permitted by State and consistent with hospice training Duties of hospice aid include: provision of hands-on personal care, performance of simple procedures as extension of therapy or nursing services, assistance in ambulation or exercises, assistance in administering medications that ordinarily self-administered. 146

147 Hospice aide & homemaker services (g) Hospice Aide assignments and duties Interpretive Guidelines: Administering medication is based upon needs of pt/family, training/competency of aide, policies, state law and rules. If allowed, hospice is required to provide training in medication administration and assure that aide is competent before assigned to patient 147

148 Hospice aide & homemaker services (g) Hospice Aide assignments and duties Hospice Aides must report changes in pt’s medical, nursing, rehab or social needs to RN, as changes related to POC and QAPI Must complete documentation in compliance with P&P Procedures: During home visit, be observant for changes in pts needs that aide should be reporting to RN Through record review, look for documentation by aide describing changes and to whom reported Clinical notes should be dated and signed 148

149 Hospice aide & homemaker services (h) Standard: Supervision of hospice aides RN onsite visit to pt’s home to assess the quality of care and services provided by the hospice aide Every 14 days Ideally is same RN that oversee care, if substitute used should be noted in documentation (see (g)) Hospice aide does not have to be present during this visit If concerns related to care and services provided by the hospice aide are noted by the supervising RN, the hospice must make an on-site visit while the patient receives care (observation of aide) If concerns are verified, the aide must complete a competency evaluation 149

150 Hospice aide & homemaker services (h) Standard: Supervision of hospice aides The RN must make an annual onsite visit to observe and assess each aide while performing care Interpretive Guidelines: Aide must be directly supervised one time annually on one patient (no requirement to assess each patient annually) Procedures and Probes: Interview key staff to determine how hospice assures all aides are supervised on-site annually 150

151 Hospice aide & homemaker services (h) Standard: Supervision of hospice aides Assess and document satisfactory performance in meeting outcomes that include, but not limited to: Following plan of care Creating successful interpersonal relationship with pt Demonstrating competency with assigned tasks Complying with infection control P&P Reporting changes in pt’s condition Interpretive Guidelines: Supervisory visits may be made in conjunction with professional visit 151

152 Hospice aide & homemaker services (h) Standard: Supervision of hospice aides TOP 10 DEFICIENCES SINCE??? 152

153 Hospice aide & homemaker services (i) Standard: Individuals furnishing Medicaid personal care aide-only services under a Medicaid personal care benefit (COPES) May be provided on behalf of the hospice agency – must demonstrate competency in services provided Medicaid personal care benefit services are used to the extent that the hospice would use the patient’s family in delivering care Coordinate hospice aide services with Medicaid personal care benefit 153

154 Hospice aide & homemaker services (i) Standard: Individuals furnishing Medicaid personal care aide-only services under a Medicaid personal care benefit (COPES) Interpretive Guidelines: State defines optional Medicaid personal services benefit and determines if benefit is more extensive that H/HA benefit provided under Medicare hospice benefit State pays for covered Medicaid personal care services that exceed scope of Medicare hospice benefit 154

155 Hospice aide & homemaker services (j) Standard: Homemaker qualifications A qualified homemaker is an: Individual who meets the standards in (g) and has successfully completed hospice orientation OR A hospice aide as described in Interpretive Guidelines: Homemaker services may include assistance in maintaining a safe and healthy environment and services to help the pt/family carry out the treatment plan 155

156 Hospice aide & homemaker services (j) Standard: Homemaker qualifications (g) Home health aide services furnished by qualified aides as designated in Sec. § and homemaker services. Home health aides (also known as hospice aides) may provide personal care services as defined in §409.45(b) of this chapter. Aides may perform household services to maintain a safe and sanitary environment in areas of the home used by the patient, such as changing bed linens or light cleaning and laundering essential to the comfort and cleanliness of the patient. Aide services may include assistance in the maintenance of a safe and healthy environment and services to enable the individual to carry out the treatment plan. 156

157 Hospice aide & homemaker services (k) Standard: Homemaker supervision and duties Homemaker services must be coordinated and supervised by a member of the IDG Instructions for homemaker duties must be prepared by a member of the IDG Homemakers must report all concerns to member of IDG who is coordinating homemaker services 157

158 Hospice aide & homemaker services (k) Standard: Homemaker supervision and duties Procedures and Probes: Interview key adm staff regarding which member of the IDG is responsible for coordination and supervision of homemaker services Through interview, home visits and record reviews assure that there are written instructions and that concerns are being reported Duties and services must be documented 158

159 Volunteers Must use volunteers to the extent specified in section (e). Must be used for defined roles and under supervision of designated hospice employee Interpretive Guidelines Volunteers are considered hospice employees to facilitate compliance with the core services requirement (418.64) Procedures and Probes Conduct an interview with the individual designated to supervise the volunteers regarding use, training and supervision of volunteers. 159

160 Volunteers (a) Standard: Training The hospice must maintain, document and provide volunteer orientation and training that is consistent with industry standards. Interpretive Guidelines All required volunteer training should be consistent with specific tasks that volunteers perform 160

161 Volunteers (a) Standard: Training Probes How does the hospice supervise volunteers? Is there documentation supporting that all volunteers have received training and orientation before being assigned to a patient/family? What evidence is there that the volunteers are aware of: Duties/responsibilities; person to whom they report or contact for concerns; hospice goals/philosophy; confidentiality; HIPAA, family dynamics, coping mechanisms and psychological issues surrounding terminal illness, death and bereavement; procedures to follow in emergency or after death of pt; guidance related to individual responsibilities 161

162 Volunteers (b) Standard: Role Volunteers must be used in day-to-day administrative and/or direct patient care roles Interpretive Guidelines: Qualified volunteers who provide professional services must meet all requirements associated with their specialty area Duties of volunteers in direct patient care services must be evident in plan of care There should be documentation of time spent and services provided Probes: What evidence exists that the IDG conducts an assessment of the pt/family’s need for a volunteer? 162

163 Volunteers (c) Standard: Recruiting and retaining Must document and demonstrate viable and ongoing efforts to recruit and retain volunteers (d) Standard: Cost savings Must document the cost savings achieved through the use of volunteers. Must include: ID of each position that is occupied by volunteer Work time spent in occupying these positions Estimates of the dollar costs that the hospice would have incurred if filled by paid employees Interpretive Guidelines : There is no requirements for what the costs savings must be, only on how it is computed 163

164 Volunteers (e) Standard: Level of activity Volunteers must provide a minimum hours worked that of equals 5% of total patient care hours of all paid and contract staff Hospice must maintain records on use of volunteers including type of service and time worked Hospices may count volunteer driving hours in the 5% calculation as long as they count staff driving hours. Board and fund raising hours do not count. Total paid hours (minus fund raising) x 1.05 = number of hours needed to meet 5% calculation. 164

165 SUBPART D: ORGANIZATIONAL ENVIRONMENT Conditions: Organization and administration of services Medical Director Clinical Records Drugs, Biologicals, Medical Supplies, DME Short Term Inpatient Care Hospices that provide inpatient care directly Hospice that provide care to residents in SNF/NF Personnel qualifications Compliance 165

166 Organization & administration of services Hospice must organize, manage, and administer its resources to provide hospice care and services for palliation and management of terminal illness and related conditions (a) Standard: Serving the patient and family Optimizes comfort and dignity Consistent with patient and family goals Patient’s needs and goals are hospices primary consideration 166

167 Organization & administration of services (b) Standard: Governing body and administrator Governing body (or designated person) assumes full legal authority and responsibility Qualified Administrator is appointed by and reports to the governing body Must be employee and possess education and experience required by governing body 167

168 Organization & administration of services (b) Standard: Governing body and administrator Interpretive Guidelines: If hospice part of larger organization and the governing body is the same, there must be documented evidence that the governing body is assuming full authority and responsibility for operations, services and QAPI program If Administrator not available, must identify another individual to assume assigned duties Procedures and Probes How is governing body informed of ongoing operations, service delivery issues and QAPI activities? Ask administrator/clinical supervisor to describe relationship between governing body, management and staff 168

169 Organization & administration of services (c) Standard: Services Hospice must be primarily engaged in providing: Nursing, medical social, and physician Counseling (spiritual, dietary and bereavement) Hospice aide, volunteer, homemaker PT, OT, SLP Short-term inpatient care Medical supplies (including drugs) and medical appliances Nursing, physician and drugs must be provided 24/7 Other services on 24 hour basis when reasonable and necessary 169

170 Organization & administration of services (d) Standard: Continuation of care Hospice may not discontinue or reduce care provided to a Medicare or Medicaid beneficiary because of beneficiary’s inability to pay for that care Interpretive Guidelines: Applies to Medicare and Medicaid beneficiaries only 170

171 Organization & administration of services (e) Standard: Professional management responsibility Must retain oversight of staff and services for all arranged services Arranged services must be supported by written agreements that require all services be: Authorized by hospice Furnished in safe and effective manned by qualified personnel Delivered in accordance with pt’s POC 171

172 Organization & administration of services (e) Standard: Professional management responsibility Interpretive Guidelines: Hospice must retain administrative, financial management and oversight of staff and services provided under arrangement. For Medicare services, hospice is responsible for payment For non-Medicare services, hospice is responsible for establishing how payment for those services will occur 172

173 Organization & administration of services (e) Standard: Professional management responsibility Procedures and Probes: Ask how the hospice: Assures that all contracted personnel provide care that is in accordance with POC? Assures that all services are authorized? Monitors and exercises control over services? Assure professional management of pts receiving inpatient care under arrangement? Communicates with contracted individuals, agencies, organizations? Assure that services are furnished by qualified staff? 173

174 Organization & administration of services (f) Standard: Multiple locations Medicare approval before providing services to Medicare patients The multiple location must share administration, supervision, and services with the hospice issued the certification (provider) number Lines of authority and control must be clearly delineated All locations must comply with CoPs Interpretive Guidelines: Several pages of these to review prior to doing this 174

175 Organization & administration of services (g) Standard: Training Must provide orientation to all employees (includes volunteers) and contracted staff who have patient and family contact, addressing specific job duties Must assess skills and competencies of employees Must have written P&P describing methods of assessment of competency Maintain written description of in-service training and education provided during the previous 12 months 175

176 Organization & administration of services (g) Standard: Training Procedures and Probes: Review sample of personnel records to verify initial orientation, assessment of skills/competency, and in-service training was provided to all employees, contracted staff and volunteers furnishing care/services to pts Review written agreements and training programs provided for contracted personnel If concerns are identified, interview the administrator/staff regarding the specific issue. 176

177 Medical Director Must designate a physician to serve as medical director. Must be an MD or DO who is employee or under contract When medical director not available, physician designated by the hospice assumes the same responsibilities Interpretive Guidelines: There is only one medical director, including multiple locations. May be FT/PT, may be volunteer All other hospice physicians functions under the supervision of the medical director 177

178 Medical Director (a) Standard: Medical director contract May contract for medical director with self-employed physician OR a physician employed by a professional entity or physicians group. When contracting with group, must specify the physician who assumes the medical director responsibilities Interpretive Guidelines: May be volunteer, a long as person meets all Federal and State requirements 178

179 Medical Director (b) Standard: Initial certification of terminal illness Reviews clinical information for each patient and provides written certification of terminal illness Factors to examine when making terminal illness determination Primary terminal condition Related diagnoses Current subjective/objective medical findings Current medications and treatment orders Information about medical management of unrelated conditions 179

180 Medical Director (c) Standard: Recertification of the terminal illness Review clinical information before recertifying (d) Standard: Medical director responsibility Responsible for medical component of the hospice’s patient care program Interpretive Guidelines: Single individual assumes overall responsibility for medical component of pt’s care. Extends to all multiple locations Includes overseeing implement of care for entire IDG 180

181 Clinical records Correct past and current clinical information available to attending physician and hospice staff May be maintained electronically 181

182 Clinical records (a) Standard: Content Initial plan of care, updated plans of care, initial/comprehensive/updated assessments, clinical notes Signed notice of patient rights and election statement Responses to medications, symptom management, treatments and services Outcome measure data elements (from assessments) Physician certification and recertification Advance directives Physician orders 182

183 Clinical records (b) Standard: Authentication Entries must be clear, complete, legible, authenticated and dated in accordance with hospice policy and current standards of practice. Interpretive Guidelines: May create its own policy on authentication Must be handwritten or electronic (not stamped) Surveyors must have access to the clinical record. If maintained electronically, hospice must provide all equipment necessary to read record in its entirety Must also produce a paper copy, if requested 183

184 Clinical records (b) Standard: Authentication Procedures and Probes: Ask hospice to explain system of authentication Verify that it includes the following safeguards Method of identify author of each entry, includes verification of author of faxed/electronic entries Electronic authentication must have user ID and password protections in place Every entry must be signed and dated 184

185 Clinical records (c) Standard: Protection of information Must be safeguarded against loss or unauthorized use Must be in compliance with HIPAA regulations Interpretive Guidelines: Must ensure that unauthorized individuals cannot gain access to patient records, and that individuals cannot alter patient records 185

186 Clinical records (c) Standard: Protection of information Procedures and Probes: How does the hospice protect confidentiality of clinical records? What is the policy on leaving and protecting clinical record info in the patient’s home? For EMR, what security safeguards are in place to protect the EMR against loss, theft, damage, disruption of operations or unauthorized use? Is access controlled? Are there measures in place to protect the patient from identify theft? Observe the security practices for patient records – are they left unsecured or unattended (hard copy or electronic?) Verify that adequate precautions are taken to prevent physical or electronic altering. 186

187 Clinical records (d) Standard: Retention of records 6 years after death or discharge unless State law says longer If the hospice discontinues operation, it must still comply and notify State agency and CMS Regional Office (RO) of where records will be stored 187

188 Clinical records (e) Standard: Discharge or transfer of care Another Medicare/Medicaid facility- Forward the discharge summary (always) and record (if requested) Revoke election or discharge- Copy of discharge summary to attending physician (always) and record (if requested) Discharge summary includes summary of treatments, symptoms, and pain management; current plan of care; recent physician orders; other documentation 188

189 Clinical records (f) Standard: Retrieval of clinical record Whether hard copy or electronic, the clinical record must be readily available on request by appropriate authority Interpretive Guidelines: Appropriate authority includes representatives from the Surveying Authority or other authorized entity who visit the hospice for the purpose of determining whether the hospice is meeting all CoPs. If EMR, the hospice must provide all equipment necessary to read the record in its entirety. Must also produce a paper copy of the entire record, if requested by the surveyor. Ascertain how the hospice ensures that the record is up-to-date including documentation of recent services/visits or handwritten notes held by staff that were not included in the record when the paper copy was produced. 189

190 Drugs/biologicals, medical supplies, and DME Medical Supplies, Appliances, DME, drugs and biologicals related to the palliation and management of the terminal illness and related conditions, as identified in the hospice POC, must be provided by the hospice while the patient is under hospice care. 190

191 Drugs/biologicals, medical supplies, and DME (a) Standard: Managing drugs and biologicals Ensure that IDG confers with individual with education and training in drug management to ensure that drugs and biologicals meet each patient’s needs. Employee or under contract Interpretive Guidelines: Pharmacist, Physicians or Nurses certified in palliative care Or others who complete a specific palliative care drug management. Must demonstrate the individual has the training. May take place in person or through other means 191

192 Drugs/biologicals, medical supplies, and DME (a) Standard: Managing drugs and biologicals Inpatient care directly: Pharmacy services under direction of licensed pharmacist, including evaluation of patient’s response to medication therapy, identification of potential adverse drug reactions, and recommended appropriate corrective actions. (Ensure that no drugs are obtained through Medicare Part D.) 192

193 Drugs/biologicals, medical supplies, and DME (b) Standard: Ordering of drugs Ordered by physician or NP Verbal or electronic orders given only to licensed nurse, pharmacist, or physician and must be recorded and signed in accordance with all regulations 193

194 Drugs/biologicals, medical supplies, and DME (c) Standard: Dispensing of drugs and biologicals Obtain drugs from community or institutional pharmacists or stock itself (no Canadian pharmacies) Inpatient care directly: Written policy to promote dispensing accuracy; accurate records (Ensure no conflict of interest – Access/performance rebates should not drive patient care decisions) Interpretive Guidelines: Biological is any medicinal preparation made from living organisms and their products including, but not limited to serums, vaccines, antigens and antitoxins 194

195 Drugs/biologicals, medical supplies, and DME (d) Standard: Administration of drugs and biologicals IDG must determine, as part of POC, patient/family ability to safely administer drugs Inpatient care directly-Administered by licensed nurse, physician, other health care professionals in accordance with State requirements(family intentionally left out) Patient may self administer upon approval by IDG Interpretive Guidelines: Individualized written POC should identify if pt and/or family are self-administering. If not capable, IDG must address this in POC 195

196 Drugs/biologicals, medical supplies, and DME (e) Standard: Labeling, disposing, and storing of drugs and biologicals Labeled in accordance with accepted standards, including appropriate instructions and expiration date Interpretive Guidelines: Must have system to ensure that outdated, mislabeled, or otherwise unusable drugs are not provided 196

197 Drugs/biologicals, medical supplies, and DME (e) Standard: Labeling, disposing, and storing of drugs and biologicals (cont’d) Written policies and procedures for managing and disposing of drugs in patient’s home At the time when controlled drugs are first ordered, must provide these P&P to family in a language and manner the patient and family can understand, document discussion in clinical record Interpretive Guidelines: Must also address safe use and disposal of controlled drugs at other times, such as when discontinued, new drug ordered, or patient dies 197

198 Drugs/biologicals, medical supplies, and DME (e) Standard: Labeling, disposing, and storing of drugs and biologicals (cont’d) Inpatient care directly- Dispose in compliance with hospice policy and Federal and State requirements, maintain current and accurate records Inpatient care directly- Stored in secured areas in locked compartments, only authorized personnel may have access (double locked) Inpatient care directly: Investigate discrepancies and report to appropriate State authority, document investigation and make available to appropriate authorities as required 198

199 Drugs/biologicals, medical supplies, and DME (f) Standard: Use and maintenance of equipment and supplies Follow manufacturer recommendations for DME maintenance Ensure policies developed in absence of manufacturer recommendations DME must be safe and must work as intended Instruct patient and family in proper use of DME and supplies, must be able to demonstrate May contract for all DME services; must only contract with supplier meeting Medicare DMEPOS Standards 199

200 Drugs/biologicals, medical supplies, and DME (f) Standard: Use and maintenance of equipment and supplies Interpretive Guidelines: Instruction on use of DME and supplies must be documented in the clinical record as well as the pt/family’s understanding of the safe use of Procedures and Probes: During home visit ask the pt/family to describe any instructions received regarding use of DME/supplies. Has the pt/family had any problems? Does the DME function as required and intended Clinical record should support their responses 200

201 Short Term In-Patient Care Inpatient care must be available for pain control, symptom management and respite purposes (a) Standard: Inpatient care for symptom management and pain control Provided in a Medicare-certified facility Hospice that meets CoPs of Hospital that meets CoPs of 418. (b) and (e) LTC with 24 hour nursing (RN) services 201

202 Short Term In-Patient Care (b) Standard: Inpatient care for respite purposes Same 3 locations as (a) Nursing services must meet patient needs (does not require 24 hour RN) Typo in CoPs- Reference SHOULD be to (e) NOT (f) Interpretive Guidelines: Must assure that the facility has enough nursing personnel present on all shifts to guarantee adequate safety measures and routine, special and emergency needs of all patient are met at all times. 202

203 Short Term In-Patient Care (c) Standard: Inpatient care provided under arrangements with written agreement Hospice must: provide copy of the plan of care, specify services, retain responsibility for ensuring training of facility personnel, and have a method for verifying that the requirements of this section are met. Facility must: have copy of plan of care, have patient care policies consistent with the hospice, and have an identified individual responsible for implementation of the written agreement. Inpatient clinical record must document all inpatient services and events; a copy of the inpatient clinical record must be available to the hospice at discharge; and a copy of the discharge summary is provided to the hospice at discharge 203

204 Short Term In-Patient Care (c) Standard: Inpatient care provided under arrangements with written agreement Interpretive Guidelines: May have arrangements with more than one facility Procedures and Probes Ask the clinical manager what facility they use and how they monitor care. If concerns, ask to review the written agreement. Ask how the hospice assures that all staff caring for hospice patients have been trained in hospice philosophy and are able to provide care according to POC. If necessary, contact or visit the facilities to verify compliance. 204

205 Short Term In-Patient Care (d) Standard: Inpatient care limitation Total number of inpt days used by Medicare beneficiaries over 12 month period may not exceed 20% of total number of hospice days in the aggregate. Interpretive Guidelines: Applies to Medicare beneficiaries only (e) Standard: Exemption from limitation Exemption applied between 1975 and

206 Hospices that provide in-pt care directly (a) Standard: Staffing Reflects volume, acuity, and intensity of services needed by patients to achieve patient care outcomes and avoid negative outcomes Interpretive Guidelines Adequate staffing means that the numbers and types of qualified, trained and experienced staff on the inpt unit meet the care needs of every patient. 206

207 Hospices that provide in-pt care directly (a) Standard: Staffing Procedures and Probes: How does the hospice assure there is adequate staff, especially during evenings, nights, weekends and holidays? Interview pt/family to determine if they were satisfied with the care and services Observe if staff is responsive to needs and if call bells are answered promptly Do pts frequently call for assistance? Are pts checked frequently? 207

208 Hospices that provide in-pt care directly (a) Standard: Staffing Procedures and Probes: Ask hospice management for inpt staffing schedules and pt census for the past month to determine if staffing was adequate to meet needs How does the hospice determine the staff-to-patient ratios on each shift? Review at least one clinical record to evaluate if staff provided treatments, medications, personal care and diet in compliance with POC If questions arise concerning staffing patterns (illness, tardiness), review staffing schedule and/or timecards 208

209 Hospices that provide in-pt care directly (b) Twenty-four hour nursing services 24 hour nursing services to meet patient needs Each pt must received nursing services prescribed and must be kept comfortable, clean, well-groomed and protected from accident, injury and infection If at least one patient is receiving GIP, then each shift must include a RN who provides direct patient care Interpretive Guidelines: General Inpatient Care for pain control, symptom management, which cannot be managed in other settings, is a different level of care than respite care. Procedures and Probes: Ask for schedule of RN personnel for past month, inquire about mechanism to ensure RN provides direct pt care. 209

210 Hospices that provide in-pt care directly (c) Standard: Physical environment Maintain a safe environment free of hazards Procedures and Probes: Ask what security mechanism are in place and being followed Review and analyze incident and accident reports, expand review if suspect a problem. If hospice has identified problems, did it evaluate and take steps to ensure a safe patient environment? How does hospice assure staff follows current standards of practice for environmental safety, infection control and security? 210

211 Hospices that provide in-pt care directly (c) Standard: Physical environment Written disaster preparedness plan for emergencies that affect ability to provide care. Plan must be periodically reviewed and rehearsed with staff Interpretive Guidelines: There should be documentation of LSC fire drills at varied times on all shifts 211

212 Hospices that provide in-pt care directly (c) Standard: Physical environment Procedures and Probes: Request a copy of the disaster plan and determine if content addresses power failures, natural disasters and other potential emergencies Request a copy of staff orientation/training on components of the disaster plan What is the procedure for notification of staff, pts, physicians and others in the case of an emergency? Interview random staff to assess their knowledge of specific responsibilities during a disaster or drill Are evacuation diagrams posted and visible? Review evidence of planning 212

213 Hospices that provide in-pt care directly (c) Standard: Physical environment Procedures to control trash, light, temperature, ventilation, gas, water, and equipment Interpretive Guidelines: Trash refers to garbage and biohazardous waste Disposal should be in accordance with laws and regs Must have system to provide emergency gas and water as needed Procedures and Probes: Ask for explanation of system for providing emergency water and gas and routine maintenance. Determine that maintenance inspections are performed How does hospice assure reliability and quality of light, temperature, ventilation/air? 213

214 Hospices that provide in-pt care directly (d) Standard: Fire protection- compliance with 2000 edition of the Life Safety Code Procedures and Probes: Is there documentation of compliance with LSC or state requirements? Request to see evidence that drills have been held on all shifts at varied times Where does the hospice document and store its dated, written report and evaluation of each drill? Request evidence of latest checks of fire extinguishers, sprinkler systems, smoke alarms and observe location of each Are there functional smoke alarms in each patient room? Does a preventive maintenance program exist? 214

215 Hospices that provide in-pt care directly (e) Standard: Patient areas Home-like, family accommodations, visitors at any hour Privacy during stay and after death Interpretive Guidelines: Homelike de-emphasizes the institutional character of the setting to the extent possible. Procedures: Interview pt/family to validate visiting hours not restricted and accommodations during the night are provided Observe pt areas for above requirements Are window treatments and floor coverings homelike? 215

216 Hospices that provide in-pt care directly (f) Standard: Patient rooms Rooms designed for nursing care, dignity, comfort and privacy Accommodate request for private room whenever possible Details rooms specifics in standard and IG No more than 2 patients per room with a waiver available if there is an unreasonable hardship for facilities in existence prior to Dec. 2, Procedures: Does each bed have flame retardant cubicle curtains, movable screen or other means of providing full visual privacy? 216

217 Hospices that provide in-pt care directly (g) Standard: Toilet / bathing facilities- In the patient room or nearby. (h) Standard: Plumbing facilities- Adequate hot water supply with temperature control valves (i) Standard: Infection control- Program that meets § (j) Standard: Sanitary environment– Current standards of practice Interpretive Guidelines/Procedures and Probes: Review full IG/PP for above standards 217

218 Hospices that provide in-pt care directly (k) Standard: Linen- Adequate supply of clean linens available; handled in a manner to prevent spread of infection (l) Standard: Meal service and menu planning Consistent with patient plan of care Palatable and attractive Prepared under sanitary conditions Interpretive Guidelines/Procedures and Probes: Review full IG and PPs for above standards 218

219 Hospices that provide in-pt care directly (m) Standard: Restraint or seclusion All patients have the right to be free from restraint or seclusion imposed as a means of coercion, discipline, convenience, or retaliation Only imposed to ensure safety of patient, staff, or others when less restrictive interventions have not succeeded Discontinued at the earliest possible time In accordance with a modification to the patient’s plan of care AND a physician’s order Interpretive Guidelines: No standing orders or PRN 219

220 Hospices that provide in-pt care directly (m) Standard: Restraint or seclusion Medical Director notified ASAP if attending did not order Implemented with safe techniques No more than 24 hours total; orders renewed every 4 hours for adults (shorter time for pediatrics) Face to face assessment after 24 hours before writing a new order Monitored by trained staff Face-to-face evaluation every hour for violent or self- destructive behavior 220

221 Hospices that provide in-pt care directly (n) Standard: Restraint or seclusion staff training requirements Staff trained before implementing seclusion or restraint techniques, at orientation, and on a periodic basis thereafter Training addresses all relevant areas Training documentation in personnel records Interpretive Guidelines: Review IGs and Standards for details on training and documentation 221

222 Hospices that provide in-pt care directly (o) Standard: Death reporting requirements Report deaths associated with use of or within 24 hours after removed from seclusion or restraint Report deaths within 1 week of seclusion or restraint use when reasonable to assume a relationship. Report by phone to CMS no later than the close of the next business day after death; document reporting in patient’s clinical record Interpretive Guidelines: Review IGs for details regarding this standard 222

223 Hospices that provide care in SNF/NF There will eventually be companion regulations in the SNF/NF rules. These rules apply to SNF residents on Routine Home Care (a) Standard: Resident eligibility, election, and duration of benefits Same as for other hospice patients 223

224 Hospices that provide care in SNF/NF (b) Standard: Professional management Hospice assumes responsibility for professional management of resident’s hospice care Hospice arranges for hospice-related inpatient care Interpretive Guidelines: Professional management for a pt who resides in a SNF has the same meaning as the pt living in his/her own home – all services are provided Involves assessing, planning, monitoring, directing, and evaluating hospice care across all settings Core services cannot be delegated to the facility Facility staff should immediately notify hospice of unplanned interventions 224

225 Hospices that provide care in SNF/NF (c) Standard: Written agreement Signed written agreement specifying the provision of hospice services in the facility before services begin Agreement includes: Communication and documentation strategy to meet patient needs 24 hours/day Interpretive Guidelines: Should be evidence of agreement on how to communicate concerns and responses 24 hours/day to meet needs of pt identified in POC 225

226 Hospices that provide care in SNF/NF (c) Standard: Written agreement Procedures and Probes: What system is in place to assure that the facility knows how to notify the hospice 24/7? Is there evidence that communication is not occurring during various times of week or specific shifts How does hospice ensure that facility staff are able to recognize the individual who are receiving hospice services and know that services should be in accordance with coordinated POC? What evidence is there of communication during and between visits? Does the hospice staff have access to and ability to communicate with facility staff as often as needed? 226

227 Hospices that provide care in SNF/NF (c) Standard: Written agreement Agreement includes: Provision for notifying hospice if: Significant change in patient condition, Clinical complications, Need to transfer and hospice makes arrangements and remains responsible for, Patient dies Procedures and Probes: Have there been instances when facility transferred pt to hospital without notifying the hospice? Have there been instances when the hospice was unaware of significant change in pt status or pt death? How does the hospice ensure that facility staff will contact the hospice immediately with any change in pt condition? 227

228 Hospices that provide care in SNF/NF (c) Standard: Written agreement Agreement includes: Hospice responsibility for determining hospice level of care Facility responsibility for 24 hour room and board, meeting patient needs as the primary caregiver (same level of services) Interpretive Guidelines: Both providers must comply with their application CoPs Facility must offer same services to residents who have elected MHB as those who have not elected MHB If facility failed to address concerns as advised by hospice, surveyor is to report concerns to state agency responsible for oversight of facility. 228

229 Hospices that provide care in SNF/NF (c) Standard: Written agreement (cont’d) Agreement includes: Hospice responsibility to provide services to same extent as serving a patient in a private home (IG - may not delegate services to facility staff) Delineation of hospice responsibilities (same as in home care) Probe: Is there evidence that the hospice provides the services as needed, as well as medications, equipment and supplies 24/7? 229

230 Hospices that provide care in SNF/NF (c) Standard: Written agreement (cont’d) Agreement includes: Provision to use facility personnel to assist in implementing the plan of care only to the extent that a hospice would routinely use a patient’s family, (include how specific crisis situations will be handled in the plan of care.) Hospice reports to facility administrator all patient rights violations by anyone unrelated to the hospice Bereavement services to SNF/NF staff Interpretive Guidelines: Hospice may offer bereavement services to facility staff or residents that fulfill the role of a pt’s family as identified in the POC 230

231 Hospices that provide care in SNF/NF (d) Standard: Hospice plan of care Established and maintained for each patient in accordance with Established and maintained in consultation with facility representatives and patients/families Interpretive Guidelines: POC must identify which provider is responsible for performing a specific service Procedures and Probes: Interview pt/family to determine their involvement in development of POC Determine whether all interventions have been provided by hospice and have there been any delays? 231

232 Hospices that provide care in SNF/NF (d) Standard: Hospice plan of care Changes discussed with patient/ representative and facility representative, and approved by hospice before implementation Interpretive Guidelines: Must have a process by which information will be exchanged when updating the POC. Hospice must authorize all changes to hospice portion Procedures and Probes: Based on observations, if concerns are identified or pt/family indicates that interventions are not meeting needs, interview hospice and facility staff 232

233 Hospices that provide care in SNF/NF (e) Standard: Coordination of services Hospice designates IDG member to coordinate implementation of plan of care with facility representatives Designated individual provides overall coordination of care with facility, communicates with facility to implement hospice plan of care Interpretive Guidelines: May or may not be RN, can be any other member of IDG Coordinate how hospice staff access/communicate with facility staff over elements of providing services 233

234 Hospices that provide care in SNF/NF (e) Standard: Coordination of services Procedures and Probes: Does the hospice’s system for ordering, renewal, delivery and administration of medications work effectively in the facility? What procedures are in place to ensure that the pt receives timely medication and treatments? Is the evidence that the hospice provides education to the facility on hospice resident’s pain and symptom management plan? Does the hospice work with the facility to monitor effectiveness of treatments related to pain and symptom control? 234

235 Hospices that provide care in SNF/NF (e) Standard: Coordination of services Hospice ensures IDG communication with outside physicians, beyond terminal illness Procedures and Probes: If problems identified regarding failure to communicate, interview hospice designated IDG member and facility care plan coordinator in order to determine system of communication If concerns related to coordination and implementation of POC, interview facility nurse aides who provide direct care to patient Review POC to determine if plan was coordinated Interview facility staff person who is knowledgeable about needs and care of pt to determine if needs met 235

236 Hospices that provide care in SNF/NF (e) Standard: Coordination of services Hospice provides facility with: Plan of care Hospice election form and advance directives Certification and re-certification forms Contact information for hospice personnel Instructions for accessing hospice’s 24-hour on-call system Patient-specific medication information Physician orders – hospice and attending Interpretive Guidelines: Must have process by which information will be exchanged Probes: Interview facility staff involved in care of pt on their knowledge of how to contact hospice 24/7 236

237 Hospices that provide care in SNF/NF (f) Standard: Orientation and training of staff Hospice assures orientation of facility staff in hospice philosophy, policies and procedures, pain control and symptom management methods, patient rights, forms, and record keeping. Include rules and processes for hospice/SNF care coordination Interpretive Guidelines: Hospice’s responsibility to assess need and frequency for training Procedures and Probes: During observations, if concerns noted, interview hospice staff on how they provide education to facility staff 237

238 Personnel Qualifications (a) Standard: General qualification requirements All professionals (direct employees, individual contractors, and those under arrangements) must be legally authorized to practice in the State in which they work All professionals must only act within their scope All professionals must keep their qualifications current at all times 238

239 Personnel Qualifications (b) Standard: Personnel qualifications for certain disciplines Physicians- 1861(r) of the Act and § Hospice aide- Meet requirements of § Social worker- MSW with 1 year experience; or Bachelors in social work, psychology, sociology, or other related field AND 1 year experience AND supervised by MSW; or Bachelor’s in social work AND employed by hospice before the effective date of the final rule (December 2, 2008) Interpretive Guidelines: Must employ or contract with at least one MSW to serve in supervisor role, may occur in person, over phone or electronic 239

240 Personnel Qualifications (b) Standard: Personnel qualifications for certain disciplines Speech-language pathologists Occupational therapist Occupational therapy assistant Physical therapist Physical therapist assistant (c) Personnel qualifications when no State licensing, certification or registration requirements exist Registered nurse Licensed practical nurse 240

241 Personnel Qualifications (d) Standard: Criminal background checks All employees with direct patient contact or access to patient records (hospice staff & contracted staff) Hospice contracts must require contracted entities to obtain employee background checks Obtained in accordance with State requirements If no State requirements, must be obtained within 3 months of date of employment for all states where the individual has lived or worked in the past 3 years WA has less restrictive requirements that meet this standard 241

242 Compliance with Federal, State, and local laws and regulations related to health and safety of patients In compliance with all laws and regulations. (Catch all condition) Hospice licensed if required by State (a) Standard: Multiple locations Disclosure of ownership Approved by Medicare and licensed by the State (b) Standard: Laboratory services Lab testing (self or contracted) in accordance with CLIA requirements Interpretive Guidelines: Review in detail as they apply to this standard 242

243 Any Final Questions? Anne Koepsell WSHPCO

244 Resources CMS – Center.html NHPCO - Weatherbee Resources, Inc. Deyta OCS Systems 244

245 Resources Agency for Healthcare Research and Quality National Quality Forum excelleRx – (Hospice Pharmacia) MultiView 245


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