new survey requirements: is your hospice ready? anne koepsell, rn, bsn, mha koepsell consulting. 1

NEW SURVEY REQUIREMENTS: NEW SURVEY REQUIREMENTS: Is Your Hospice Ready?Is Your Hospice Ready?

Anne Koepsell, RN, BSN, MHAKoepsell Consulting.

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Course ObjectivesCourse Objectives

Learner will be able to:Define the process to become

survey ready.Identify resources and tools to help

you be ready for a surveyList the CMS Top Ten Survey

Deficiencies and determine how to ensure your agency isn’t on the list.

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IMPACT Act DetailsIMPACT Act Details

Improving Medicare Post-Acute Care Transformation Act of 2014

Hospice Medicare surveys no less than every 36 months for the next 10 years starts April 6, 2015

Sets threshold that triggers 100% medical prepayment review on long-stay patients over 180 days.

Aligns economic inflation index to calculate cap and reimbursement.

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How to become survey How to become survey readyreadyDedicated staff whose primary

priority is complianceReview the Medicare State

Operations ManualReview NHPCO Survey Readiness

toolsComplete regular self-auditsInvolve all staff – IDT and admin

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DiscussionDiscussion

How is your agency

structured for compliance oversight?

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Resources

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Regulatory Requirements

Are you compliant?

Actions required for compliance Responsible party

Added to QAPI program?

Target compliance

date Complete date

Yes No

Yes No

Ensure that organizational policies include procedures about the function of the IDG, care planning, and coordination of services per regulations and are reviewed and revised as needed at least annually.

IDG who establishes policies governing day to day provision of hospice care and services is designated in writing.

RN member of IDG responsible provide coordination of care and ensure continuous assessment is designated.

Care is initiated based on initial assessment and plan of care developed by IDG in collaboration with attending physician.

Survey Readiness Compliance Audit Tool §418.56 - Interdisciplinary group, care planning, andcoordination of services

State Operations ManualState Operations ManualPart 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 B. Applies to Medicare only◦Subpart C. Patient Care – all patients◦Subpart D. Organizational Environment -

all

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Top 10 Deficiencies – 2013 Top 10 Deficiencies – 2013 rankedranked1. 418.56(b) – Standard: Plan of Care

◦L543 – #1 past 3 years

2. 418.56(c) – Standard: Content of POC

◦L545 –top 3 past 3 years

3. 418.54(c)(6) – Drug Profile◦L530 –top 10 past 3 years

4. 418.56 (e)(2) – Standard: Coordination of services

◦L555 – 2 out of past 3 years

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Top 10 Deficiencies – 2013 Top 10 Deficiencies – 2013 rankedranked5. 418.56(c)(2) – Standard: Scope

and frequency of services◦ L547 – New – first year in top 10

6. 418.64(b) – Standard: Nursing services

◦ L591 - top 10 past 3 years

7. 418.76(h) – Standard: Supervision of hospice aides

◦ L629 – top 10 past 3 and 30 years

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Top 10 Deficiencies – 2013 Top 10 Deficiencies – 2013 rankedranked8. 418.56 (e)(4) – Standard:

Coordination of Services◦ L557 - 2 out of past 3 years

9. 418.54(d) Standard: Update of the comprehensive assessment

◦ L533 - New – first year in top 10

10.418.104 – Condition of Participation: Clinical Records

◦ L671 - 2 out of past 3 years

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DiscussionDiscussion

Which deficiencies

keep you up at night?

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418.54 418.54 Initial/Comprehensive Initial/Comprehensive assessmentassessmentConduct 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

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418.54 418.54 Initial/Comprehensive Initial/Comprehensive assessmentassessmentc) 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

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418.54 418.54 Initial/Comprehensive Initial/Comprehensive assessmentassessment(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.

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418.54 418.54 Initial/Comprehensive Initial/Comprehensive assessmentassessment(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

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418.54 Initial/comprehensive 418.54 Initial/comprehensive assessmentassessment

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418.56 IDG, care planning, 418.56 IDG, care planning, and coordination of servicesand 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.

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418.56 IDG, care planning, 418.56 IDG, care planning, and coordination of servicesand coordination of services(c) Standard: Content of the plan of

careReflects individualized patient and

family goalsIncludes 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

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careProcedures 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?

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care2. 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

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Interpretive Guidelines◦ If requires frequent use of PRN, POC

should update frequency to meet current need

◦Standing orders must be individualized

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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

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Procedures and Probes◦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

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418.56 IDG, care planning, 418.56 IDG, care planning, and coordination of servicesand coordination of services(e) Standard: Coordination of

services2. Care and services are provided in accordance with the plan of care

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services – cont.4. Sharing information between all disciplines providing care and services, in all settings, whether provided directly or under arrangement

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services – cont.Probes

◦What systems are in place to facilitate exchange of information among staff and with non-hospice providers?

◦Is there documentation of the sharing of information between all disciplines and other providers?

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418.56 IDG, care planning, 418.56 IDG, care planning, and coordination of servicesand coordination of servicesHow to Prepare – Team, Tools, TechniquesTeam

◦Provide education to RNs to ensure competence in, and compliance with, care coordination responsibilities

◦Ensure that the IDG maintains responsibility for directing, coordinating and supervising all care.

Tools◦Develop scheduling/tickler systems to

reflect 15 day (or sooner) update requirements

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418.56 IDG, care planning, 418.56 IDG, care planning, and coordination of servicesand coordination of servicesTechniques

◦Establish methods of communication to ensure that modalities are adequate, efficient and reliable.

◦Define term ‘change in condition’

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418.56 IDG, care planning, 418.56 IDG, care planning, and coordination of servicesand coordination of servicesTechniques

◦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)

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418.64 Core services418.64 Core services(b) Standard: Nursing services

◦Role of the 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)

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418.76 Hospice aide & 418.76 Hospice aide & homemaker serviceshomemaker services(h) Standard: Supervision of hospice

aidesRN 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 418.76 (g))

Hospice aide does not have to be present during this visit

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418.104 Clinical records418.104 Clinical recordsCondition of ParticipationCorrect past and current clinical

informationAvailable to attending physician

and hospice staffMay be maintained electronicallyFocus on (a) content, (b)

authentication, and (c)protection

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418.104 Clinical records418.104 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

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418.104 Clinical records418.104 Clinical records(b) Standard: AuthenticationEntries 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

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418.104 Clinical records418.104 Clinical records

(b) Standard: AuthenticationProcedures 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 dated41

418.104 Clinical records418.104 Clinical records

(c) Standard: Protection of informationMust 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

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418.104 Clinical records418.104 Clinical records(c) Standard: Protection of informationProcedures 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?

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418.104 Clinical records418.104 Clinical records(c) Standard: Protection of informationProcedures and Probes:

◦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.

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418.104 Clinical records418.104 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

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How to become survey How to become survey readyreadyDedicated staff whose first

priority is complianceReview the Medicare State

Operations ManualReview NHPCO Survey Readiness

toolsComplete regular self-auditsInvolve all staff – IDT and admin

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?Any Final Questions?

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Resource LinksResource LinksMedicare State Operations Manualhttp://www.cms.gov/Regulations-and-Gui

dance/Guidance/Manuals/downloads/som107ap_m_hospice.pdf

Survey Readiness tools www.nhpco.org/surveyreadinessAgency for Healthcare Research and

Qualitywww.ahrq.govNational Quality Forumwww.qualityforum.org

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new survey requirements: is your hospice ready? anne koepsell, rn, bsn, mha koepsell consulting. 1

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