Hospice Conditions of Participation

Presented byKim Roche, RN, BSN, RNC, CCS-P

CMSO/SCGThe Centers for Medicare & Medicare Services

January 22, 2009

Medicare Hospice Conditions of Participation

Published May 27, 2008

Effective December 2, 2008 Performance Improvement

Projects begin 02/02/09

www.cms.hhs.gov/center/hospice.asp

Secretary’s Advisory Committee on Regulatory

Reform

Clarified relationship between NHs, ICF/MRs and hospices

Changed respite care nursing requirements

Allowed qualified nurses to provide dietary counseling

BBA ’97 changes

Medical director/physicians may be under contract (§418.64 and §418.102)

Waiver available to provide PT, OT, SLP, and dietary counseling on 24-hour basis (§418.74 )

BBA ’97 changes (Con’t)

Waiver available for providing dietary counseling directly (§418.74)

MMA ‘2003

Hospices may contract with another hospice to provide core hospice services

Hospices may contract with RN for highly specialized services

Report Violations to Administrator & State

Inform Patients of Rights in Language they understand

Investigate Violations

Comply with Advance Directives

Obtain Patient’s Signature

Hospice’s Responsibility

Effective Pain Medication

Respect forProperty & Person

Choose Attending

Confidential Clinical RecordsSymptom Management

Voice Grievances without reprisal

Patient’s Rights

Freedom from Mistreatment, Neglect/ abuse

Involvement with Care

Exercise Rights

Refuse Care or Treatment

Receive information about hospice

Patient’s Rights (Con’t)

Initial Assessment

Registered Nurse

Completes within 48 hours of effective date of election

Patient or Physician may request earlier assessment.

Gathers key information to treat patient

Comprehensive Assessment

IDG completes within 5 days from effective date of election

Assesses need for physical, psychosocial, emotional, and spiritual care

IDG updates every 15 days and as needed

Considers complications and risk factors, bereavement and referrals

Comprehensive Assessment (Con’t)

Functional status and symptom severity reviewed

Patient understanding and imminence of death assessed

Detailed drug profile completed

Data elements to measure outcomes used in QAPI

Assessment Timeframes (example)

Sun Mon Tue Wed Thu Fri Sat

1 2

Effective Date of election

3

Day

1

4

Day

2

Initial assessment due

5

Day

3

6

Day

4

7

Day

5

CA compl-eted

IDG

Includes MD or DO, SW, RN Counselor

Provides Education/ Training to Pt/Family

Consults with Attending Physician

Meets Physical, Medical, Psychosocial, Emotional, and Spiritual Needs of Pt/family

Plan of Care

Written by IDG with input from attending and Pt

Includes measurable outcomes

Includes all necessary services, drugs and treatments

IDG reviews every 15 days and PRN

Reflects pt/family goals/interventions

Includes medical supplies/ appliances

Plan of Care (Con’t)

Includes information from assess-ments

Includes progress toward meeting outcomes

Includes scope and frequency of services

Performance improvement activities

Focus on high risk, high volume, or problem-prone areas

Affect palliative outcomes, patient safety, and quality of care

Track adverse patient events & analyze causes

Performance Improvement Activities (Con’t)

Consider incidence, prevalence, and severity of problems

Take actions aimed at PI & measure success

Track PI actions to assure improvements are sustained

Performance Improvement Projects

Starts February 2, 2009

Reflect scope, complexity & past performance of hospice’s services & operations.

Performance Improvement Projects (Con’t)

Document the quality improvement projects conducted

Document reasons for conducting the projects and measurable

progress achieved

Infection Control

Accepted standards of practice Prevents and Controls Infections & Diseases Part of QAPI Educates/Protects, Patients, Staff

and others

Infection Control

Identifies Infectious and Communicable Diseases and Implements Appropriate Actions

Agency wide program for surveillance, identification, prevention, control and investigation

Licensed Professional Services

Services must be authorized, delivered, and supervised by qualified personnel

Professionals participate in coordinating all patient care

Professionals participate in the hospice’s QAPI and in-service training programs

Hospice Core Services

Physician Services (direct or under contract)

Nursing Services

Medical Social Services

Hospice Core Services (Con’t)

Counseling Services

Bereavement Dietary Spiritual

Hospice Aide Qualifications

Training & competency evaluation OR Competency evaluation OR Nurse aide training and competency

evaluation OR State licensure program

Hospice Aide Supervision

RN supervises aide onsite once annually if no problems noted.

RN visits patient q. 14 days to assess aide services (aide does not have to be present)

If concerns, RN revisits to observe aide If concerns remain, aide completes

competency evaluation

Volunteer Hours Level of ActivityExample

Total # of Volunteer Hours in Administrative and Patient Care

50

Total # of Patient Care Hours worked by Paid Staff

1,000

Percent of Patient Care Hours Provided by the Volunteers

5%

Recruit, Train, & Supervise

Hospice must: Document active volunteer recruitment Document retention plans Provide orientation & training for its

volunteers—consistent with hospice industry standards

Volunteer program must be supervised by a designated hospice employee