Oregon Hospice Association Professional Practices Exchange September 24, 2018 Teri-Ann Stofiel, RN Hospice Surveyor

Agenda Agency Overview Survey Process Hospice Impact Act 2014 Emergency Preparedness Rules Discharge for Cause Questions & Contact Information

Part 1: Oregon Health Authority OHA Divisions: External Relations Fiscal Agency Operations Health Policy & Analytics Health Systems Office of Equity & Inclusion Oregon State Hospital Public Health Center for Public Health Practice (6 sections) Center for Prevention & Health Promotion (5 sections) Center for Health Protection (6 sections) Fiscal & Business Operations; Program Operations; Policy & Partnerships; Science & Evaluation

Overview of OHA Oregon Health Authority 4 Public Health Division Health Care Regulation & Quality Improvement Section Health Facility Licensing & Certification Program Center for Health Protection Survey and Certification Facilities Planning and Safety 4

Health Facility Licensing & Certification Recent Changes – Facilities Planning & Safety and Survey & Certification now have separate managers Survey & Certification welcomes Anna L. Davis, JD as our new manager

Survey & Certification Regulated Entities Hospitals (CAH, ACU, PSY) including Satellites Caregiver Registries Non-Transplanted Anatomical Research Recovery Organizations Ambulatory Surgical Centers Outpatient Renal Dialysis Facilities Freestanding Birth Centers Hospice Agencies Hemodialysis Techs Home Health Agencies Tissue Bank/Organ Procurement Registry Rural Health Clinics Out-Patient Therapy Special Inpatient Care Facilities Portable X-ray Federal Qualified Health Centers NEW! Extended Stay Centers In-Home Care Agencies

Health Facility Licensing & Certification Team of: 14 surveyors specializing in one facility type & cross- trained. CMS surveyors are RNs. Surveyors sometimes work in teams. FPS Administrative assistants also assist Survey & Certification 1 manager Program Workload: Fixed: Standard surveys required to satisfy state licensure &/or federal certification requirements Variable: Federal and state complaint investigations, federal EMTALA reports & immediate jeopardy situations.

Part 2: Survey Process Pre-Survey Preparation waivers Develop survey plan and review facility information including: waivers prior surveys & complaints services provided on-campus & off-campus satellite locations licensure & ownership Survey Day 1 Entrance Activities – Meet with administration to: Explain purpose & scope of survey Explain survey process Discuss logistics (e.g., survey team work space, photocopies, etc.) Provide “needs list” detailing documents to be provided to surveyor

Survey Process Survey Days 1 to ≤ 5 Final Day of Survey Information Gathering Includes: On-site observations Interviews with staff & patients Administrative document review of policies & procedures, contracts, & personnel records, etc. Medical record review using representative patient samples Preliminary Findings Surveyors use survey tools to quantify information gathered Final Day of Survey Exit Conference with Facility Administration Survey team shares preliminary findings & next steps Note: Survey closure date will be later if survey team asks provider to submit additional information to clarify outstanding questions

Survey Process 10 Business Days Post Survey Agency Issues Survey Report Statement of Deficiencies (SOD) documents any deficiencies identified during onsite audit or complaint investigation Issued to facility leadership 10 Calendar Days After Facility Receives Report Facility Submits Plan of Corrections (POC) Written response to each deficiency identified during onsite audit or complaint investigation POC documents facility’s plan to return to compliance Revisits Conditions Out Required; Standard Tags Agency’s Option Surveyors conduct second survey to assess implementation of provider’s POC & abatement of cited deficiencies

Part 3: IMPACT Act of 2014 Hospice Integrity Provisions to Improve & Support Patient Care New Medicare Survey Intervals: Once every three (3) years (aligns with state licensing standards) CMS Medical Reviews for “long-stay” hospice patients (care > 180 days) Standardized Patient Assessment Data Provisions Inflationary Indexing for Hospice Reimbursements State Agency Performance Standards Ensure all Oregon Hospice facilities are surveyed by April 2018 – This was achieved with the help of Federal contracted surveyors Adhere to new survey intervals going forward Improving Medicare Post-Acute Care Transformation (IMPACT) Act 11

Oregon Hospice Facilities Hospice Facilities (as of August 2018) Total: 62 Deemed: 13 Non-Deemed: 38 License Only: 11 New/Vol. Termination: 4/1 Annual Workload Hospice Recertification / Relicensure Surveys: 20-21 per year Hospice Complaint Investigations: varies (8 from Aug 2017 - Aug 2018) Hospice initial licensure surveys: varies (3 from Aug 2017 - Aug 2018) 12

Most Common Tags 8/2015 to 8/2018 State OARs (Chapter 333 Division 35) 0100 - Criminal Background Checks: Required prior to employment and every 3 years (includes volunteers) 0104 - Criminal Background Checks Written Policies: Policies must include description of convictions that disqualify an individual Federal (42 CFR CoP for Hospice Part 418) L565 - Program Data: QAPI data collection must be approved by governing body L548 - Content of Plan of Care: Must have measurable outcomes anticipated from implementing and coordinating the plan of care 13

Most Common Tags 8/2015 to 8/2018 Federal 14 L547 - Content of Plan of Care: Must include detailed statement of the scope and frequency of services L573 - Performance Improvement Projects: Must document what PIPs are being conducted, the reason, and measurable progress L580 - Control: Infection control program must be integral part of QAPI L663 - Training: Must assess competency and provide in-service training for those giving care (including volunteers) and must have P & Ps and maintain documentation of both 14

Most Common Tags 8/2015 to 8/2018 Federal 15 L531 - Content of Comprehensive Assessment: Must include initial bereavement assessment L629 - Supervision of Hospice Aides: Must provide supervisory visit every 14 days L643 - Training: Must maintain, document and provide volunteer orientation and training consistent with hospice industry standard L545 - Content of Plan of Care: Must reflect patient and family goals and interventions and must include all services necessary for the palliation and management of terminal illness and related conditions 15

Part 4: Emergency Preparedness New Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Overview: One additional Condition of Participation (CoP) / Condition for Coverage (CfC) that is required to participate in Medicare. Purpose: To establish national emergency preparedness requirements that ensure adequate planning for natural and manmade disasters, and coordination with federal, state, tribal, regional and local emergency preparedness systems. Application: All 17 provider and supplier types: Hospitals; Comprehensive Outpatient Rehabilitation Facilities (CORFs) Religious Nonmedical Health Care Institutions (RNHCIs); Critical Access Hospitals (CAHs) Ambulatory Surgical Centers (ASCs); Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services Hospices; Psychiatric Residential Treatment Facilities (PRTFs); All-Inclusive Care for the Elderly (PACE); Community Mental Health Centers (CMHCs) Transplant Centers; Organ Procurement Organizations (OPOs) Long-Term Care (LTC) Facilities; Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID); End-Stage Renal Disease (ESRD) Facilities Home Health Agencies (HHAs) Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers 16

Emergency Preparedness (4) Enforcement Date: started on November 15, 2017 (5) Substantive Requirements: Each provider/supplier has dedicated EP regulations incorporated into its CoPs / CfC requirements. Some vary by provider/supplier (e.g. Hospice required to track and inform officials of patients in need of evacuation, address power outages) (6) Emergency Preparedness Program Shared Elements: Risk Assessment and Planning – Develop emergency plan based on risk assessment, use “all hazards” approach, focus on capacities and capabilities, update annually Policies and Procedures – Develop P&Ps based on emergency plan, ensure that P&Ps address range of issues, update annually Communication Plan – Develop communications plan that meets state and federal standards and coordinates care within facility, across providers, with state/local public health departments and emergency management systems, update annually Training and Testing – Develop training & testing programs, P&Ps, conduct drills & exercises, document analysis of drills and exercises (7) Resources: CMS website downloads; SOM Appendix Z (8) Note: EP requirements do apply to license only facilities (9) Note: EP citations result in 3 SODs Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers 17

Most Common Tags Emergency Preparedness E016 - Hospice Follow up for Staff: P & Ps must include procedures to follow up with on duty staff and patients and must notify local officials of those they are unable to contact E019 - Homebound HHA/Hospice Inform EP Officials: P & Ps must include procedure for notifying officials of patients needing assistance with evacuation from their residences E032 - Primary/Alternate Means for Communication: Must include staff and Federal, State, tribal, regional, and local emergency management officials E039 - EP Testing Requirements: Must have one full-scale and additional full-scale or tabletop exercise and must include analysis of response to exercises and whether changes to emergency plan were made or needed

Part 5: Discharge for Cause Required before discharge: Advise patient discharge for cause is being considered Make a serious effort to resolve the problem Document the problem and efforts to resolve in the clinical record Obtain a physician’s order; consult attending physician if there is one involved Consider notification of other agencies Notification of State Agency: Written notification that includes: patient name, date patient was notified discharge was being considered, summary of problem and efforts to resolve, date of discharge Fax: 971-673-0556 or e-mail: mailbox.hclc@state.or.us 19

Part 6: Questions & Contact Information Program Information: General Inquiries mailbox.hclc@state.or.us (971) 673-0540 www.healthoregon.org/hflc Additional Resources: Teri-Ann Stofiel, RN Hospice Surveyor teri-ann.stofiel@state.or.us (971) 673-3760 John Pilmer, RN Lead Surveyor john.g.pilmer@state.or.us (971) 673-0545 Anna L. Davis, JD Survey & Certification Manager anna.l.davis@state.or.us (971) 673-2950 New slide