Presentation on theme: "Introduction to the Medicare Conditions of Participation"— Presentation transcript:
1 Introduction to the Medicare Conditions of Participation Mandatory In-Service2013
2 Medicare Conditions of Participation Written in 1983Few changes since 1983 despite changes in the hospice industryRevised in 2006 by the Center for Medicare and Medicaid Services (CMS)
3 Revisions to the CoPsSubparts, B,F,G were updated effective January 2006Subparts A,C,D were revised and became effective in December 2008The new CoPs arePatient centeredFocused on quality improvement and patient outcomes
4 Conditions of Participation Important to know because if hospices do not comply with the conditions then they could lose Medicare certification.Medicare covers over 80% of our patients
5 Hospice of the Bluegrass Licensed by the State of Kentucky and adheres to Hospice State Regulations: 902 KAR 20:140, KRS 216B.042Medicare Certified and complies with the Medicare Conditions of ParticipationAccredited by Joint CommissionGoverned by a Board of Directors
6 Staff Must Know the CoPs Because we must be in compliance with CMSBecause of fraud and abuse initiativesBecause they assure a certain standard of careBecause they provide a foundation for a strong hospice programBecause all except two conditions apply to all hospice patients regardless of payer source.Those two are 1) continuation of care; 2) the inpatient rule
7 Eligibility for the Medicare Hospice Benefit A prognosis of six months or less if the disease follows its expected courseEntitle to Part A of MedicareElection of the Medicare Hospice Benefit from a Medicare certified hospiceHospice only admits a patient on the recommendation of the hospice’s Medical Director in consultation with the patient’s attending MD
8 Electing the Medicare Hospice Benefit Medicare beneficiaries must have the hospice benefit thoroughly explained to themIn “electing” to receive hospice care, other Medicare benefits related to the terminal illness are waived.
9 Patient RightsHospices must provide the patient and family notice of their rights at the time of the initial assessment in advance of providing care-verbally and in writingThe rights must be in a language and manner that the patient understandsHospice must obtain patient’s/representative’s signature confirming receipt of copy of the notice of rights and responsibilities
10 Patient Rights Hospice providers must Report violations to hospice administratorInvestigate violations and complaintsTake corrective action if violation is verifiedReport verified significant violations to state/local bodies within 5 days.
11 What You Need to Know About Hospice Eligibility and Election How to assess for and document eligibility of patients with non-cancer diagnoses (Local Coverage Determinants, NHPCO Guidelines)How to explain the Medicare Hospice Benefit to patients and caregiversThat the patient’s attending physician and the Hospice Medical Director must certify that the patient is terminally ill
12 Benefit Periods Initial period of 90 days Second benefit period of 90 daysUnlimited number of 60 day periods when continued to be certified as terminally ill by the Hospice Medical Director
13 What You Need to Know About Benefit Periods Number of benefit periodsThe process for assessing continued hospice eligibility & recertificationThe system for tracking recertification dates for each patientRecertification of terminal illness signed by the Medical Director within 2 days of a new benefit periodThe hospice provider should determine if a patient has ever enrolled in hospice care to determine their benefit period
14 Levels of Care Routine Home Care Inpatient Respite Care General Inpatient CareContinuous Care
15 Routine Home Care Care provided in the patient’s place of residence Reimbursement is approximately $137 per day.Most commonly billed level of care
16 Continuous CareProvided during times of crisis in an attempt to keep a patient at homeThe hospice must provide a minimum of 8 hours of care during a 24-hour day beginning/ending at midnightCare need not be continuousNursing services (RN,LPN) must comprise more than half of the care and care must be provided by employees of the hospiceReimbursement at approximate rate of $33/hour
17 Situations that may require Continuous Care Uncontrolled, severe symptoms that require continuous skilled assessment, intervention, evaluation.When a medical intervention that needs monitoring is implemented (ex. IV)Highly unstable vital signs, e.g., diabetic managementSevere anxiety, agitation or confusion that poses a safety threatSuicide ideation or related actionThe patient’s condition is deteriorating rapidly to the extent that death is imminent and the care needs are beyond the physical and emotional resources of the family.
18 Respite Care Designed to provide respite for caregivers Must be provided in a contracted inpatient unit- Do not need a RN in the facility 24 hours a dayHospice retains professional management responsibilities.Reimbursement is approximately $144 per day and is available for a maximum of 5 days at a time
19 Inpatient Care Sometimes needed for pain and symptom management Reimbursement rate is $620 per day in contracted facilityTreatment must conform to the patient’s plan of care and hospice retains professional management responsibilities.
20 What You Need to Know About Inpatient Care How important it is to educate patient/families on calling hospice before 911How to determine if a hospitalization is related or unrelated to the terminal illnessWhat hospitals the hospice contracts withWhat your responsibilities are in managing a patient’s care while hospitalizedThe hospitalization does not mean the same as discharge
21 What You Need to Know About Inpatient Care Staff should educate patients and families about hospitals that have a contractual arrangement with Hospice of the Bluegrass.If a patient is admitted to a hospital where no contractual arrangement exists, the hospice can either discharge the patient using Condition Code 52 or the patient may revoke the hospice benefit.
22 Payment for Hospice Care Based on a per diem or daily rate according to a patient’s level of care.All services related to the terminal illness are included in the per diem rate.
23 What The Per Diem Rate Covers RN visitsSocial Worker visitsSpiritual CareCertified Nursing AssistantsPT, OT, Speech Therapy, DieticianVolunteersBereavement CareAll medications related to the terminal diagnosisDME servicesMedical Supplies24-hour on-call servicesInpatient careLabsAmbulance
24 Discharge & Revocation Other than death, there are two ways a hospice can end hospice servicesThe hospice can discharge the patientThe patient can revoke the Medicare Hospice BenefitTo revoke the benefit, a patient must sign the revocationThe patient may revoke for any reason
25 Discharge & Revocation Continued Reasons for discharge may include:The patient no longer has a prognosis of 6 months or lessThe patient moves out of the service area or transfers to another hospiceDischarge for cause- the patient’s behavior or situation is such that care cannot be provided to the patient even though all efforts have been made to resolve the situationWhen a hospice discharges a patient, there must be documentation in the patient’s documentation in the patient’s clinical record of the reason for the discharge, a physician’s order for the discharge and evidence of discharge planning.
26 General ProvisionsCompliance- a hospice must comply with the CoPs in order to be or remain certified.Required Services- a hospice must provide required hospice services including bereavement counseling- Bereavement must begin before the patient diesSome of the services, like nursing, MD and pharmacy, must be available 24 hours/dayServices must conform to accepted standards of practice
27 Governing BodyAssumes legal responsibility for the hospice’s operationsDesignates administratorEnsures quality of careApproves policies and procedures
28 Medical Director A hospice must have one Medical Director The hospice may contract with a self-employed physician or a physician employed by a professional entity or a physician groupThe Medical Director may also be a volunteerThe Medical Director is responsible for the initial certification and recertificationsThey are responsible for the medical component of the hospice’s patient care program
29 Professional Management Continuity of care in all settingsWritten contracts for arranged services that include:How services are to be provided, coordinated, supervised and evaluatedDelineation of roles and documentation requirementsProfessional management and financial responsibilities for hospiceContracts for care
30 What You Need to KnowThe four levels of hospice care available to hospice patientsHow to communicate with staff at contracted facilitiesHow to ensure that the patient’s plan of care is followedHow to maintain continuity of care in all treatment settings
31 Initial & Comprehensive Assessment of the Patient The comprehensive assessment is not a single static document, a symptom & severity checklist, or a set of generic questions that all patients are askedIt is a dynamic process that needs to be documented in an accurate and consistent manner for all patientsComprehensive assessment is about assessing what the patient needs, not all about who completes the assessment
32 Initial Assessment Completed by RN Must occur within 48 hours after election of hospice careThis is an initial overall assessment of the patient and family needsSignificant issue in one area, recommend that the specialty IDG member complete the comprehensive assessment
33 Comprehensive Assessment Time frame for completion of the comprehensive assessment:Competed by the hospice IDG in consultation with the attending MDCompleted within 5 calendar days after the patient elects hospice careMust be updated at least every 15 days
34 Plan of CareThe plan of care is one of the most important documents in hospice careAll services must follow a written plan of carePatient and primary caregiver are educated and trained related to their care responsibilities identified in the plan of careIDG consults with the following to establish plan of careAttending physicianPatient and/or representative/primary caregiver
35 Review of the Plan of Care Revised plan of care includes information from the updated comprehensive assessmentInformation regarding the progress toward achieving specified outcomes & goalsPlan of care must be reviewed as frequently as the patient’s condition requires but no less frequently than every 15 daysCompleted by IDG in collaboration with the attending MD
36 More You Need To KnowThe plan of care tells the story of how and how well the patient was cared for. That the plan of care follows the patient from admission through discharge regardless of the treatment setting.
37 In-Service TrainingOngoing educational/training programs must be provided for hospice employees- whether directly employed or under contract.
38 Quality Assessment and PI Mechanisms for the ongoing assessment of the quality and appropriateness of care provided.Use of defined quality improvement programs that identifies and resolves problems and improves the care provided.
39 Interdisciplinary Group Must include MD, RN, SW and pastoral or other counselorEstablishes and updates the plan of careThe RN coordinates the plan of care
40 VolunteersHospice providers must utilize volunteers and volunteer services must, at a minimum, equal 5% of total patient care hours of all paid hospice staff and contracted employeesMust document recruitment, retention, orientation and training of volunteersMust document cost-savings
41 LicensureThe hospice must be licensed if it is a requirement of the state in which it is locatedEmployees must be licensed, certified or registered in accordance with applicable Federal or State law
42 Central Clinical Records One for each patientEntries for All services providedDocument, Document, DocumentInitial and comprehensive assessmentsPlan of CareIdentification dataConsents, election formsMedical history
43 Hospice Care for Nursing Facility Residents Hospice assumes responsibility for professional management of the resident’s hospice careMust have a written agreement with the facilityHospice designates IDG member to coordinate implementation of plan of care with facility representativesMust orient facility staff to hospice careHospice provides all services to nursing facility patients that is provided in the home setting
44 Two Final RegulationsPatients must be informed of their right to formulate advance directivesThe Medicare Secondary Payer questionnaire must be completed