16 Ensuring Compliance With Hospice Regulations Today’s health care arena is highly regulated and ever-changing. Remaining abreast of the rapid changes in regulations and reporting requirements can be daunting. The purpose of this chapter is to provide an overview of hospice regulations for hospices and to offer resources where the most current information can be found. After reading this chapter, you will be able to: ■ Discuss key points of Medicare regulations for hospices ■ Describe quality indicators for hospice and palliative care ■ Identify key requirements for changing the patient’s level of care REGULATIONS The Social Security Act, Section 1861(dd), ensures that hospice care is available and will be covered for Medicare beneficiaries who choose to receive such care from a Medicare-participating hospice (National Hospice and Palliative Care Organization, 2016b). Since most (87.2%) hospice patients are Medicare beneficiaries (National Hospice and Palliative Care Organization, 2014), compliance with Medicare regulations is critical to the success of every hospice organization. The Secretary of the Department of Health and Human Services (HHS) is responsible for the development of the conditions of participation (CoPs) that a hospice must meet in order to be reimbursed by Medicare or Medicaid for the care provided (National Hospice and Palliative Care Organization, 2016b). The CoPs are outlined, with extensive explanations of the associated requirements, in 42 CFR 418 in the Federal Register and contain information regarding the following hospice-related topics: ■ The scope of hospice services ■ Patients’ rights ■ Initial and comprehensive assessment of the patient ■ Quality assessment and performance improvement ■ Infection control ■ Licensed professional services ■ Core services (includes bereavement and counseling services) ■ Nursing service waiver of requirements that substantially all nursing services be routinely provided directly by a hospice ■ Furnishing noncore services ■ Physical therapy, occupational therapy, and speech–language pathology ■ Waiver of requirement—physical therapy, occupational therapy, speech–language pathology, and dietary counseling ■ Hospice aide and homemaker services ■ Volunteers ■ Organization and administration of services ■ Medical director ■ Clinical records ■ Drugs, biologicals, medical supplies, and durable medical equipment ■ Short-term inpatient care ■ Hospices that provide inpatient care directly ■ Hospices that provide care to residents of a skilled nursing facility, or other residential facility ■ Personnel qualifications The CoPs are enforced to ensure that hospice patients are consistently receiving safe, quality care. State survey agencies conduct surveys of hospices to determine compliance with CoPs. In some cases, approved accreditation agencies may serve as a substitute for state survey agencies. If a hospice is found to not be in compliance with all or some of the CoPs, there can be financial penalties. Ultimately, an agency that does not bring practices into compliance can lose Medicare approval and become ineligible for Medicare/Medicaid funds. Because of the potential for severe financial repercussions, each hospice agency develops processes to ensure that the CoPs are met. Still, the requirements can be daunting and charting errors or oversights can result in deficiencies. Deficiencies in some areas are more common than in others. Each year, the National Hospice and Palliative Care Organization (2016a) compiles a list of the most common areas of deficiency. A review of this list (see Table 16.1) can help hospice organizations to focus on problem areas. Fast Facts in a Nutshell Although there is no limit on the number of days or episodes of general inpatient (GIP) care a patient can receive under the Medicare hospice benefit, this type of inpatient care is intended to be short-term, allowing the patient to return to the home setting once symptoms are managed (National Hospice and Palliative Care Organization, 2012b). SPECIAL CONDITIONS FOR CHANGE IN LEVEL OF CARE Hospice was originally intended to allow patients with a terminal illness who choose to forgo curative care to remain at home (routine home care) throughout the trajectory of the disease process with the support of the hospice team members, who manage distressing symptoms and provide support and education for the patient’s family. However, patients cannot always remain at home due to the severity of their symptoms and may need more intense medical treatment in an inpatient facility. Also, some patients experience an improvement in their health status, or plateau, and are discharged from hospice service due to a lack of need. A third group of patients includes those who choose to discontinue hospice care in order to seek curative treatments. All three of these groups of patients require special considerations. Table 16.1 Top Ten Medicare Hospice Recertification Survey Deficiencies
Medicare hospice CoP
Example of the deficiency
1) §418.76: Hospice aide and homemaker services, (h) Standard: Supervision of hospice aides: A registered nurse must make an on-site visit to the patient’s home: No less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. The hospice aide does not have to be present during this visit.
Failure to complete or document supervisory visits by RN
Failure to complete supervisory visit every 14 days
2) §418.56: Interdisciplinary group, care planning, and coordination of services, (b) Standard: Plan of Care: All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient’s needs if any of them so desire. The hospice must ensure that each patient and the primary care giver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care.
Failed to establish, document, or follow plan of care
Failure to document assessments of issues noted in the plan of care. For example, if an intervention is part of the plan of care, then nursing assessments should address the ongoing need for the intervention and patient/family teaching regarding the intervention (i.e., oxygen, medications, life chair, etc.)
3) §418.54: Initial and comprehensive assessment of the patient, (c) Standard: Content of the comprehensive assessment, (6): A review of all of the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following: (i) Effectiveness of drug therapy (ii) Drug side effects (iii) Actual or potential drug interactions (iv) Duplicate drug therapy Drug therapy currently associated with laboratory monitoring.
Failure to add a prescribed medication to the patient’s drug profile
Duplicate medications included on patient’s medication record (e.g., drug listed twice, once with generic name and once with trade name)
Failure to list oxygen in medication orders with route, dose, and frequency
Failure to document that a recommendation was carried out
4) §418.56: Interdisciplinary group, care planning, and coordination of services, (c) Standard: Content of the plan of care: The hospice must develop an individualized written plan of care for each patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions.
Failure to document care specifically required for the individual patient such as wound care, stoma care, ileostomy care, etc.
Failure to remove specific items from the plan of care when discontinued such as an IV, Foley catheter, etc.
Failure to adjust frequency of interventions, such as dressing changes
5) §418.56: Condition of participation: Interdisciplinary group, care planning, and coordination of services, (c) Standard: Content of the plan of care, (2): A detailed statement of the scope and frequency of services necessary to meet specific patient and family needs.
Failure to document the rationale for services provided and the frequency of visits
6) §418.54: Initial and comprehensive assessment of the patient, (b) Standard: Timeframe for completion of the comprehensive assessment: The hospice interdisciplinary group, in consultation with the individual’s attending physician (if any) must complete the comprehensive assessment no later than 5 calendar days after the election of hospice care in accordance with §418.24.
Failure to document comprehensive assessment within 5 days of the election of the hospice benefit
7) §418.78: Volunteers, (e) Standard: Level of activity: Volunteers must provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff. The hospice must maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked.
Failure to provide proper training and supervision for volunteers
Failure to document the work of volunteers
Failure to recruit and assign volunteers for the appropriate number of hours
8) §418.56: Interdisciplinary group, care planning, and coordination of services, (e) Standard: Coordination of services, (2): Ensure that the care and services are provided in accordance with the plan of care.
Failure to ensure that all services included in the interdisciplinary plan of care are provided for the patient in a timely manner
Failure to document that frequency of visits is consistent with the plan of care
9) §418.56: Interdisciplinary group, care planning, and coordination of services, (d) The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any,) must review, revise, and document the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days.
Failure to document that plans of care were reviewed every 14 days by the interdisciplinary team
Failure to update plan of care when the patient’s status or family’s needs changed
Failure to document team collaboration in the development of the plan of care
10) §418.76: Condition of participation: Hospice aide and homemaker services, (g) Standard: Hospice aide assignments and duties: Hospice aides are assigned to a specific patient by a registered nurse who is a member of the interdisciplinary group. Written patient care instructions for a hospice aide must be prepared by a registered nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of this section.
Failure to complete supervisory visit or document that it was completed within the required time frame
Failure to document that the care provided by the hospice aide was in accordance with the plan of care
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