Introduction to the Medicare Conditions of Participation

Mandatory In-Service

2013

Medicare Conditions of Participation

• Written in 1983

• Few changes since 1983 despite changes in the hospice industry

• Revised in 2006 by the Center for Medicare and Medicaid Services (CMS)

Revisions to the CoPs

• Subparts, B,F,G were updated effective January 2006

• Subparts A,C,D were revised and became effective in December 2008

• The new CoPs are– Patient centered– Focused on quality improvement and patient

outcomes

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

Hospice of the Bluegrass

• Licensed by the State of Kentucky and adheres to Hospice State Regulations: 902 KAR 20:140, KRS 216B.042

• Medicare Certified and complies with the Medicare Conditions of Participation

• Accredited by Joint Commission

• Governed by a Board of Directors

Staff Must Know the CoPs

• Because we must be in compliance with CMS• Because of fraud and abuse initiatives• Because they assure a certain standard of care• Because they provide a foundation for a strong

hospice program• Because all except two conditions apply to all

hospice patients regardless of payer source.• Those two are 1) continuation of care; 2) the 80-20

inpatient rule

Eligibility for the Medicare Hospice Benefit

• A prognosis of six months or less if the disease follows its expected course

• Entitle to Part A of Medicare• Election of the Medicare Hospice Benefit from a

Medicare certified hospice• Hospice only admits a patient on the

recommendation of the hospice’s Medical Director in consultation with the patient’s attending MD

Electing the Medicare Hospice Benefit

• Medicare beneficiaries must have the hospice benefit thoroughly explained to them

• In “electing” to receive hospice care, other Medicare benefits related to the terminal illness are waived.

Patient Rights

• Hospices 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 writing

• The rights must be in a language and manner that the patient understands

• Hospice must obtain patient’s/representative’s signature confirming receipt of copy of the notice of rights and responsibilities

Patient Rights

• Hospice providers must– Report violations to hospice administrator– Investigate violations and complaints – Take corrective action if violation is verified– Report verified significant violations to

state/local bodies within 5 days.

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 caregivers

• That the patient’s attending physician and the Hospice Medical Director must certify that the patient is terminally ill

Benefit Periods

• Initial period of 90 days

• Second benefit period of 90 days

• Unlimited number of 60 day periods when continued to be certified as terminally ill by the Hospice Medical Director

What You Need to Know About Benefit Periods

• Number of benefit periods

• The process for assessing continued hospice eligibility & recertification

• The system for tracking recertification dates for each patient

• Recertification of terminal illness signed by the Medical Director within 2 days of a new benefit period

• The hospice provider should determine if a patient has ever enrolled in hospice care to determine their benefit period

Levels of Care

• Routine Home Care

• Inpatient Respite Care

• General Inpatient Care

• Continuous Care

Routine Home Care

• Care provided in the patient’s place of residence

• Reimbursement is approximately $137 per day.

• Most commonly billed level of care

Continuous Care• Provided during times of crisis in an attempt to

keep a patient at home• The hospice must provide a minimum of 8 hours

of care during a 24-hour day beginning/ending at midnight

• Care need not be continuous• Nursing services (RN,LPN) must comprise more

than half of the care and care must be provided by employees of the hospice

• Reimbursement at approximate rate of $33/hour

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 management• Severe anxiety, agitation or confusion that poses a safety

threat• Suicide ideation or related action• The 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.

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 day

• Hospice retains professional management responsibilities.

• Reimbursement is approximately $144 per day and is available for a maximum of 5 days at a time

Inpatient Care

• Sometimes needed for pain and symptom management

• Reimbursement rate is $620 per day in contracted facility

• Treatment must conform to the patient’s plan of care and hospice retains professional management responsibilities.

What You Need to Know About Inpatient Care

• How important it is to educate patient/families on calling hospice before 911

• How to determine if a hospitalization is related or unrelated to the terminal illness

• What hospitals the hospice contracts with• What your responsibilities are in managing a

patient’s care while hospitalized• The hospitalization does not mean the same as

discharge

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.

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.

What The Per Diem Rate Covers

• RN visits

• Social Worker visits

• Spiritual Care

• Certified Nursing Assistants

• PT, OT, Speech Therapy, Dietician

• Volunteers

• Bereavement Care

• All medications related to the terminal diagnosis

• DME services

• Medical Supplies

• 24-hour on-call services

• Inpatient care

• Labs

• Ambulance

Discharge & Revocation

• Other than death, there are two ways a hospice can end hospice services– The hospice can discharge the patient– The patient can revoke the Medicare Hospice

Benefit– To revoke the benefit, a patient must sign the

revocation– The patient may revoke for any reason

Discharge & Revocation Continued

• Reasons for discharge may include:

– The patient no longer has a prognosis of 6 months or less

– The patient moves out of the service area or transfers to another hospice

– Discharge 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 situation

– When 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.

General Provisions

• Compliance- 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 dies– Some of the services, like nursing, MD and pharmacy,

must be available 24 hours/day– Services must conform to accepted standards of

practice

Governing Body

• Assumes legal responsibility for the hospice’s operations

• Designates administrator

• Ensures quality of care

• Approves policies and procedures

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 group

• The Medical Director may also be a volunteer• The Medical Director is responsible for the initial

certification and recertifications• They are responsible for the medical component of the

hospice’s patient care program

Professional Management

• Continuity of care in all settings• Written contracts for arranged services that include:

– How services are to be provided, coordinated, supervised and evaluated

– Delineation of roles and documentation requirements– Professional management and financial

responsibilities for hospice– Contracts for care

What You Need to Know

• The four levels of hospice care available to hospice patients

• How to communicate with staff at contracted facilities

• How to ensure that the patient’s plan of care is followed

• How to maintain continuity of care in all treatment settings

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 asked

• It is a dynamic process that needs to be documented in an accurate and consistent manner for all patients

• Comprehensive assessment is about assessing what the patient needs, not all about who completes the assessment

Initial Assessment

• Completed by RN

• Must occur within 48 hours after election of hospice care

• This is an initial overall assessment of the patient and family needs– Significant issue in one area, recommend that

the specialty IDG member complete the comprehensive assessment

Comprehensive Assessment

• Time frame for completion of the comprehensive assessment:– Competed by the hospice IDG in consultation

with the attending MD– Completed within 5 calendar days after the

patient elects hospice care– Must be updated at least every 15 days

Plan of Care

• The plan of care is one of the most important documents in hospice care

• All services must follow a written plan of care• Patient and primary caregiver are educated and trained

related to their care responsibilities identified in the plan of care

• IDG consults with the following to establish plan of care– Attending physician – Patient and/or representative/primary caregiver

Review of the Plan of Care

• Revised plan of care includes information from the updated comprehensive assessment

• Information regarding the progress toward achieving specified outcomes & goals

• Plan of care must be reviewed as frequently as the patient’s condition requires but no less frequently than every 15 days

• Completed by IDG in collaboration with the attending MD

More You Need To Know

• The 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.

In-Service Training

• Ongoing educational/training programs must be provided for hospice employees- whether directly employed or under contract.

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.

Interdisciplinary Group

• Must include MD, RN, SW and pastoral or other counselor

• Establishes and updates the plan of care

• The RN coordinates the plan of care

Volunteers

• Hospice 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 employees

• Must document recruitment, retention, orientation and training of volunteers

• Must document cost-savings

Licensure

• The hospice must be licensed if it is a requirement of the state in which it is located

• Employees must be licensed, certified or registered in accordance with applicable Federal or State law

Central Clinical Records

• One for each patient

• Entries for All services provided– Document, Document, Document

• Initial and comprehensive assessments

• Plan of Care

• Identification data

• Consents, election forms

• Medical history

Hospice Care for Nursing Facility Residents

• Hospice assumes responsibility for professional management of the resident’s hospice care

• Must have a written agreement with the facility• Hospice designates IDG member to coordinate

implementation of plan of care with facility representatives

• Must orient facility staff to hospice care• Hospice provides all services to nursing facility patients

that is provided in the home setting

Two Final Regulations

• Patients must be informed of their right to formulate advance directives

• The Medicare Secondary Payer questionnaire must be completed