the national hospice and palliative care organization navigating the new medicare hospice cops

The National Hospice and Palliative Care Organization

Navigating the New Medicare Hospice CoPs

National Hospice and Palliative Care Organization, 2008

The new CoPs

• Focus of new CoPs– Patient centered– Emphasizes quality improvement and patient

outcomes

• The new CoPs are effective December 2, 2008.

• Hospice providers are responsible to be compliant with the current regulations and its requirements until December 2, 2008.– 1983 CoPs with the updates to Subparts B, F, & G

• Effective January 2006

• Link to current version

– http://www.nhpco.org/i4a/pages/index.cfm?pageid=5494


Sec. 418.3: Definitions

• New in the final rule– Comprehensive assessment– Dietary counseling– Initial assessment– Physician designee


§ 418.52 Patient’s rights

• (a) Standard: Notice of rights and responsibilities.– Verbally and in writing; – In a language and manner that the patient

understands; and– During the initial assessment visit in advance

of furnishing care.– Advance directives

– Must obtain patient’s/ representative’s signature confirming receipt of copy of the notice of rights and responsibilities



• (b) Standard: Exercise of rights and respect for property and person.

– Report violations to hospice administrator– Investigate violations & complaints– Take corrective action if violation is verified– Report verified significant violations to State/

local bodies within 5 days of incident



• (c) Standard: Rights of the patient– Pain management and symptom

control.– Be involved in developing plan of care.– Refuse care or treatment.– Choose attending physician.– Confidential clinical record/ HIPAA.– Be free of abuse.– Receive information about hospice

benefit.– Receive information about scope and

limitations of hospice services.


§ 418.54 Initial and comprehensive assessment of the patient

• (a) Standard: Initial assessment. – Completed by RN– Must occur within 48 hours after election

of hospice care– This is an assessment of the

patient/family immediate needs– The purpose of the initial assessment is not to

determine the patient’s eligibility for the hospice benefit, which is addressed in 418.22 and 418.24, or to orient the patient to the hospice benefit and obtain the election statement.



• 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.

• Comprehensive assessment is about assessing WHAT the patient needs, not all about WHO completes the assessment.



• (b) Standard: Time frame for completion of the comprehensive assessment.– Completed by the hospice IDG in

consultation with the attending physician.

– Completed within 5 calendar days after the patient elects hospice care.

– CMS does not dictate how the comprehensive assessment is completed



• (c) Standard: Content of the comprehensive assessment.– Physical, psychosocial, emotional, and spiritual needs

related to the terminal illness and related conditions– Nature and condition causing admission– Complications and risk factors– Functional status– Imminence of death– Symptom severity– Drug profile

• Identify ineffective drug therapies- §418.54(c)(6)(i).

– Bereavement– Referrals



• (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. – Hospices are free to choose the method that best

suits their needs when documenting the comprehensive assessment and the updates to that assessment.



• (e) Standard: Patient outcome measures.

– Patient level data elements must be included in each patient assessment

– Data elements must be used in patient care planning and evaluation AND in the hospice’s QAPI program

– Data elements must be collected and documented in a consistent, systematic, and retrievable way.


§ 418.56 Interdisciplinary group, care planning, and coordination of services

(a) Standard: Approach to service delivery– Hospice designates an IDG– Hospice designates an IDG RN to provide

program coordination, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation and revision of the plan of care.

– Hospice identifies a specifically designated IDG to establish day-to-day policies and procedures.



• (b) Plan of Care– The plan of care is one of the most

important documents in hospice care.– IDG consults with the following to establish

plan of care• Attending physician (if any);

• Patient or representative; and

• Primary caregiver

– All services must follow a written plan of care.

– Patient and primary caregiver(s) educated & trained related to their care responsibilities identified in the plan of care.



• (c) Standard: Content of the plan of care– Reflects patient and family goals– Includes interventions for problems identified throughout

the assessment process– Includes all services necessary for palliation and

management of terminal illness and related conditions– Detailed statement of the scope and frequency of

services to meet the patient’s and family’s needs– Measurable outcomes – Drugs and treatments– Medical supplies and appliances – Documentation (in the clinical record) of the

patient’s or representative’s level of understanding, involvement and agreement with the plan of care



• (d) Standard: 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 and goals

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

– Completed by the IDG in collaboration with the attending physician (if any)



• (e) Standard: Coordination of services– Develop and maintain a system of

communication and integration– Ensure the IDG maintains responsibility for

directing, coordinating, and supervising the care and services provided

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

– Care and services are based on assessments of the patient and family needs



• (e) Standard: Coordination of services (cont’d)– Sharing information between all disciplines

providing care and services, in all settings, whether provided directly or under arrangement

– Sharing information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions.


§ 418.58 Quality assessment and performance improvement

• (a) Standard: Program scope– Show measurable improvement in indicators

for which there is evidence that improvement in those indicators will improve palliative outcomes and end of life support services

– Replaces the existing § 418.66, ‘‘Condition of participation-Quality assurance”.



• (b) Standard: Program data– Must utilize quality indicator data, including

patient care, and other relevant data, in the design of its program

– Must use data collected to monitor effectiveness and safety of services and quality of care and identify opportunities and priorities for improvement

– Frequency and detail of the data collection must be specified by the hospice’s governing body



• (c) Standard: Program activities– The hospice’s performance improvement

activities must:• Focus on high risk, high volume, problem

prone areas

• Consider evidence, prevalence, and severity of problems in those areas

• Affect palliative outcomes, patient safety and quality of care


§ 418.58 Quality assessment and performance improvement• (c) Standard: Program activities

– The hospice’s performance improvement activities must:

• Performance activities must track adverse patient events, analyze their causes and implement preventive actions and mechanisms that include feedback and learning throughout the hospice

• Take action aimed at performance improvement

• Measure success of action• Track performance of action to ensure

that improvements are sustained


§ 418.58 Quality assessment and performance improvement• (d) Standard: Performance

improvement projects– Hospice providers have until February 2,

2009 to demonstrate active performance improvement projects.

– The number and scope of projects conducted annually must reflect the scope, complexity and past performance of the hospice’s services and operations.

– Be prepared to show an operational QAPI program by December 2, 2008.


Quality Partner Self-Assessments

• The self-assessments can help you decide where to start your Performance Improvement Projects.

• Provide a 3600 assessment of your hospice operations.

• Based on NHPCO’s “Standards of Practice for Hospice Programs” (2006)

• Can be used by any provider member.



• (e) Standard: Executive responsibilities– Governing body ensures:

• That an ongoing program for QI and patient safety is defined, implemented and maintained.

• The QAPI efforts address quality of care and patient safety, and all improvement actions are evaluated for effectiveness.

• That an individual(s) is designated to lead QAPI efforts.


§ 418.60 Infection control

• (a) Standard: Prevention– Follow accepted standards of practice, including

standard precautions

• (b) Standard: Control– Maintain a coordinated, agency-wide program for

surveillance, identification, prevention, control, and investigation of infectious and communicable diseases

• (c) Standard: Education– Infection control education provided to staff,

patients, families, and other caregivers


§ 418.62 Licensed professional services

• (a) Services, whether provided directly or under arrangement, must be authorized, delivered, and supervised by qualified personnel

• (b) Professionals must actively participate in coordinating patient care (includes: patient assessment; care planning and evaluation; and patient and family counseling and education)

• (c) Professionals must participate in the hospice’s QAPI and in-service training programs


§ 418.64 Core services

• Hospice must routinely provide substantially all core services directly by hospice employees.– Nursing– Medical Social Services– Counseling

• May use contracted staff, if necessary, to supplement hospice employees in order to meet the needs of patients under extraordinary or other non-routine circumstances.


§ 418.64 Core services• May also enter into a written arrangement with another

Medicare certified hospice program for the provision of core services to supplement hospice employee/staff to meet the needs of patients.

• Circumstances under which a hospice may enter into a written arrangement for the provision of core services include: – Unanticipated periods of high patient loads– Staffing shortages due to illness – Other short-term temporary situations that interrupt patient care– Temporary travel of a patient outside of the hospice’s service

area.



• (a) Standard: Physician services– Employee or contracted– Responsible for the palliation and

management of the terminal illness and related conditions

– Supervised by the hospice medical director– Meets the medical needs of the patient when

the attending physician is not available


§ 418.64 Core services• (b) Standard: Nursing services

– Role of the registered nurse– Highly specialized nursing services maybe

provided under contract

• (c) Standard: Medical social services– Provided by a qualified social worker under the

direction of a physician– Services to patient and family based on

psychosocial assessment



• (d) Standard: Counseling services– Bereavement counseling: under the

supervision of a qualified professional with experience or education in grief or loss counseling

– Available to family and other individuals, including residents of a SNF/NF or ICF/MR, when appropriate and identified in the bereavement plan of care

– Development of the bereavement plan of care starts before the patient’s death.



(d) Standard: Counseling services (cont’d)

– Dietary counseling: preformed by a qualified individual such as dieticians and nurses

– Spiritual counseling: Make all reasonable efforts to facilitate visits from local clergy, pastoral counselors, or other individuals who support the patient’s spiritual needs.


§ 418.66 Nursing services – Waiver

• Requirements to qualify for a waiverThe location of the hospice’s central office is in a non-

urbanized area as determined by the Bureau of the Census.There is evidence that a hospice was operational on

or before January 1, 1983.Hospice made a good faith effort to hire nurses.Waiver request is deemed to be granted unless it is denied within 60 days after it is received.Waivers will remain effective for 1 year at a time from the date of the request.


Nursing Shortage Exemption

•Allows hospices to contract for nursing staff in a chronic nurse shortage situation

•“Extraordinary Circumstance” Exemption•Hospice must notify the State Survey Agency (SSA) responsible for licensing and certification that it intends to elect an exception under the "extraordinary circumstance" authority. (written notice)•Must follow instructions in the letter; include specified detail.

•Policy ends September 30, 2008.•CMS S&C-06-28 letter


§ 418.76 Hospice aide and homemaker services• (a) Standard: Hospice aide

qualifications – Completed hospice aide training and

competency evaluation OR Competency evaluation, OR nurse aide training and competency evaluation, OR State licensure program

• (e) Standards: Qualifications for instructors conducting classroom and supervised practical training– Training performed by RN, at least 2 years

experience, with at least 1 year in homecare (home health or hospice)


§ 418.76 Hospice aide and homemaker services(h) Standard: Supervision of hospice aides

– RN onsite visit to assess the quality of care and services provided by the hospice aide (hospice aide does not have to be present during this visit)

• Every 14 days– If concerns related to care and services provided by

the hospice aide are noted by the supervising RN, the hospice must make an on-site visit to the location where the patient receives care

– If concerns are verified the aide must complete a competency evaluation

– The RN must make an annual onsite visit to observe and assess each aide while performing care

– Aide must be supervised one time annually


§ 418.76 Hospice aide and homemaker services• (i) Standard: Individuals furnishing

Medicaid personal care aide-only services under a Medicaid personal care benefit– Medicaid personal care benefit services are used to

the extent that the hospice would use the patient’s family in delivering care

– Coordinate hospice aide services with Medicaid personal care benefit

• (j) Standard: Homemaker qualifications (Reformatted)

• (k) Standard: Homemaker supervision and duties– Homemaker services must be coordinated and

supervised by a member of the IDG


§ 418.78 Volunteers

• (a) Standard: Training

• (b) Standard: Role

• (c) Standard: Recruiting and retaining

• (d) Standard: Cost savings

• (e) Standard: Level of activity– Hospices may count volunteer driving hours in

the 5% calculation as long as they count staff driving hours


§ 418.100 Organization and administration of services

• (a) Standard: Serving the patient and family

• (b) Standard: Governing body and administrator– Administrator appointed by the governing

body• (e) Standard: Professional

management responsibility


§ 418.100 Organization and administration of services

• (f) Standard: Multiple locations– Medicare approval before providing services

to Medicare patients– The multiple location must share

administration, supervision, and services with the hospice issued the certification number

– Lines or authority and control must be clearly delineated

– Initial determination (appeals)


§ 418.102 Medical Director• (a) Standard: Medical director contract

– A hospice may contract with a self-employed physician OR a physician employed by a professional entity or physicians group.

• (b) Standard: Initial certification of terminal illness

• (c) Standard: Recertification of the terminal illness- Review clinical information before recertifying

• (d) Standard: Medical director responsibility- Responsible for medical component of the hospice’s patient care program

• Removed: oversight for QAPI program


§ 418.104 Clinical records

• May be maintained electronically• (a) Standard: Content• (b) Standard: Authentication• (c) Standard: Protection of information• (d) Standard: Retention of records

– 6 years after death or discharge unless State law says longer

• (e) Standard: Discharge or transfer of care– Another Medicare/Medicaid facility- Forward

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


§ 418.106 Drugs and biologicals, medical supplies, and durable medical equipment

– (a) Standard: Managing drugs and biologicals– Ensure that IDG confers with individual with education

and training in drug management to ensure that drugs and biologicals meet each patient’s needs.

– Inpatient care directly: Pharmacy services under direction of licensed pharmacist

– (b) Standard: Ordering of drugs– Ordered by physician or NP– Verbal or electronic orders given only to licensed

nurse, pharmacist, or physician and must be recorded and signed in accordance with all regulations

– (c) Standard: Dispensing of drugs and biologicals



– (c) Standard: Dispensing of drugs and biologicals

– Obtain drugs from community or institutional pharmacists or stock itself

– Inpatient care directly: Written policy to promote dispensing accuracy; accurate records

– (d) Standard: Administration of drugs and biologicals

• IDG must determine patient/family ability to safely administer drugs

– (e) Standard: Labeling, disposing, and storing of drugs and biologicals

• Labeled in accordance with accepted standards, including appropriate instructions and expiration date



– (e) Standard: Labeling, disposing, and storing of drugs and biologicals– Written policies and procedures for managing

and disposing of drugs in patient’s home, discussed with patient and family at the time when controlled drugs are first ordered, document discussion in clinical record

– Inpatient care directly- Dispose in compliance with hospice policy and Federal and State requirements, maintain current and accurate records

– Inpatient care directly: Investigate discrepancies and report to appropriate State authority, document investigation and make available to appropriate authorities as required



• (f) Standard: Use and maintenance of equipment and supplies– Follow manufacturer recommendations for DME maintenance– Ensure policies developed in absence of manufacturer

recommendations– DME must be safe and must work as intended– Instruct patient and family in proper use of DME and supplies– Family should be able to demonstrate the proper use of the

equipment back to hospice staff– May only contract for DME services with a supplier that meets the

Medicare DMEPOS Supplier Quality and Accreditation Standards at 42 CFR § 424.57.

• CMS link to DMEPOS accreditation information: http://www.cms.hhs.gov/MedicareProviderSupEnroll/03_DeemedAccreditationOrganizations.asp


DME Accreditation

• DME providers must be accredited per CMS by September 30, 2009

• Hospice CoPs require contract with accredited DME providers by December 2, 2008

• Disconnect in dates!– Hospice contracted with a DME (that has a Medicare supplier

number), must obtain a letter from the DME stating the DME has applied and is waiting for accreditation by the 9/09 date.

– Hospice contracted with a DME that only serves hospice, (no Medicare supplier number), the hospice will need to make sure the same type of letter from the DME is in place in their files.

– If the hospice owns its own DME, then no accreditation is needed.


§ 418.108 Short-term inpatient care

• (a) Standard: Inpatient care for symptom management and pain control– Provided in a Medicare-certified facility.

• (b) Standard: Inpatient care for respite purposes

• Removed 24 hour RN requirement; not effective until December 2, 2008

• (c) Standard: Inpatient care provided under arrangements– Plan of care to facility– Assure facility staff are trained in hospice care– Inpatient clinical record must document all inpatient

services and events; – a copy of the inpatient clinical record must be available

to the hospice at discharge; and a copy of the discharge summary is provided to the hospice at discharge


§ 418.110 Hospices that provide inpatient care directly

• (a) Standard: Staffing• (b) Twenty-four hour nursing

– 24 hour nursing services to meet patient needs– Each shift must include a RN who provides direct

patient care for GIP• (c) Standard: Physical environment

– Maintain a safe environment– Written disaster preparedness plan

• (f) Standard: Patient rooms- No more than 2 patients per room with a waiver available if there is an unreasonable hardship.

• (l) Standard: Meal service and menu planning– Less prescriptive


§ 418.110 Hospices that provide inpatient care directly

• (m) Standard: Restraint or seclusion– Patient right to be free of restraint– Restraints are the last resort– Discontinued at the earliest possible time– Implemented by specific physician order; no standing

orders– No more than 24 hours total; renewed every 4– Monitored by trained staff

• Staff trained/ competent• Training addresses all relevant areas• Training documentation in personnel records

• (o) Standard: Death reporting requirements– Report deaths within 1 week of use– Report by phone to CMS no later than the close of the next

business day after death; document reporting in patient’s clinical record


§ 418.112 Hospices that provide hospice care to residents of a SNF/NF or ICF/MR

• (a) Standard: Resident eligibility, election, and duration of benefits

• (b) Standard: Professional management– Hospice assumes responsibility for professional

management of resident’s hospice care

• (c) Standard: Written agreement • (d) Standard: Hospice plan of care• (e) Standard: Coordination of services

– Hospice designates IDG member to coordinate implementation of plan of care with facility representatives

– Provide specific documentation to facility

• (f) Standard: Orientation and training of staff– Hospice assures orientation facility staff in hospice


§ 418.114 Personnel qualifications

• (a) Standard: General qualification requirements

• (b) Standard: Personnel qualifications for certain disciplines– Social worker-

• MSW with 1 year experience; or• Bachelors in social work, psychology,

sociology, or other related field AND 1 year experience AND supervised by MSW; or

• Bachelor’s in social work AND employed by hospice before the effective date of the final rule (December 2, 2008)


§ 418.114 Personnel qualifications

• (b) Standard: Personnel qualifications for certain disciplines

• (c) Personnel qualifications when no State licensing, certification or registration requirements exist

• (d) Standard: Criminal background checks• All employees with direct patient contact or access to

patient records (hospice staff & contracted staff)• Hospice contracts must require contracted entities to

obtain employee background checks• Obtained in accordance with State requirements• If no State requirements, must be obtained within 3

months of date of employment for all states where the individual has lived or worked in the past 3 years


418.114 – Criminal Background Checks Hospice Employees

(d) Standard: Criminal background checks

• Hospice employees:– All hospice employees who have direct patient contact

– All hospice employees who have access to patient records.

• New hires:– Obtain a criminal background check within three months

of the date of employment

– From all states that the individual has lived or worked in for the past three years.

– If no State requirements, obtain criminal background checks within three months of the date of employment


Criminal Background Checks

• Licensed Health Care Practitioners – If the state has a requirement for background checks as a part of

licensing for a specific discipline and the hospice complies with the State requirement for that discipline, then the hospice is in compliance with this Federal requirement.

– This means that an individual does not need a criminal background check if his or her license is current and the State licensure requires a background check and it is updated when the license is renewed.

• Contract Entities:– All contracted entities on contracted employees who have direct

patient contact– All contracted entities on contracted employees who have

access to patient records.


§ 418.116 Compliance with Federal, State, and local laws and regulations related to the health and safety of patients

– In compliance with all laws and regulations.

– Hospice licensed if required by State– (a) Standard: Multiple locations

• Disclosure of ownership• Approved by Medicare and licensed by

the State– (b) Standard: Laboratory services

• Lab testing (self or contracted) in accordance with CLIA requirements


“CoPs-Planning for Success”!

• NHPCO campaign to assist hospices to implement the new regulations.

• Education:– Audio web seminars in June 2008– Online education modules– Downloadable tools, tips, and information– Resources in the NHPCO “Regulatory &

Compliance Center”– Audio web seminars & online education module

about the upcoming interpretive guidelines


“CoPs-Planning for Success”!

• NHPCO campaign to assist hospices to implement the new regulations.

• Education:– Audio web seminars – June 2008– Online education modules– Downloadable tools, tips, and information– Resources in the NHPCO “Regulatory &

Compliance Center”– Audio web seminars and online education

modules when interpretive guidelines released


More Resources

• NHPCO Regulatory & Compliance Center– Redesigned to be user friendly for members– Topic area buttons give user information in 1-2 clicks

• Quality Partners – Self Assessments– Self-assessments are a foundation for building or refining your

quality improvement program to meet the new demands for quality (i.e., QAPI requirements).

• “We can Do This”– An easy how-to guide to implement a hospice QAPI program


Connecting to Quality Partners

• Quality Partners is your resource for complying with QAPI

• Don’t know where to start? Try the Self Assessment process:– Will help you identify areas to work on– Will address both clinical and non-clinical

projects

• Go to www.nhpco.org/quality to get started


NHPCO Regulatory

Judi Lund Person, MPHVice President

Regulatory & State Leadership

Jennifer Kennedy, MA,BSN, RN, CLNCRegulatory & Compliance Specialist

NHPCO Regulatory [email protected]

703-647-8516

Questions?

the national hospice and palliative care organization navigating the new medicare hospice cops

Documents

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palliative care organization

hospice benefit

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new medicare hospice

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