Section 418.3 Definitions
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Transcript Section 418.3 Definitions
Anne Koepsell, RN, BSN, MHA, CLNC
Executive Director
WA State Hospice & Palliative Care Org.
1
Course Objectives
Learner will be able to:
Identify the components of certification/recertification.
Identify the elements of the Comprehensive Assessment.
Describe how the IDT care planning process improves
patient care.
Describe the cycle of care process.
Restate the role of the Medical Director.
2
Focus of CoPs
Patient centered
Emphasizes quality improvement
Emphasizes patient outcomes
Non-prescriptive, organization policy determines process
3
Components of Rule
List of Subjects/Authority
Subpart A. General Provision and Definitions
Subpart B. Eligibility, Election and Duration of Benefits
Applies to Medicare patients only
Subpart C. Patient Care
Applies to all patients served
Subpart D. Organizational Environment
Applies to all patients served
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State Operations Manual
Part 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 C. Patient Care
Subpart D. Organizational Environment
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107ap_m_hospice.pdf
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SUBPART A: General Provisions
Section 418.3 Definitions
Always review definitions and refer back to them when
reading a condition or standard
Bereavement counseling
means emotional, psychosocial, and spiritual support and services
provided before and after the death of the patient to assist with
issues related to grief, loss, and adjustment.
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Section 418.3 Definitions – cont
Clinical note:
Clinical note means a notation of a contact with the patient and/or
the family that is written and dated by any person providing
services and that describes signs and symptoms, treatments and
medications administered, including the patient's reaction and/or
response, and any changes in physical, emotional, psychosocial or
spiritual condition during a given period of time.
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Section 418.3 Definitions – cont
Employee:
Employee means a person who works for the hospice and for whom
the hospice is required to issue a W–2 form on his or her behalf, or if
the hospice is a subdivision of an agency or organization, an
employee of the agency or organization who is appropriately trained
and assigned to the hospice or is a volunteer under the jurisdiction
of the hospice.
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Section 418.3 Definitions – cont
Hospice care:
Hospice care means a comprehensive set of services described in
1861(dd)(1) of the Act, identified and coordinated by an
interdisciplinary team to provide for the physical, psychosocial,
spiritual, and emotional needs of a terminally ill patient and/or
family members, as delineated in a specific patient plan of care.
9
Section 418.3 Definitions – cont
Licensed professional:
Licensed professional means a person licensed to provide patient
care services by the State in which services are delivered.
No list of examples because CMS felt it was unnecessary and may be
confusing.
States vary in titles and licensure requirements
Must be familiar with state requirements
10
Section 418.3 Definitions – cont
Multiple location
means a Medicare-approved location from which the hospice
provides the same full range of hospice care and services that is
required of the hospice issued the certification number. A multiple
location must meet all of the conditions of participation applicable
to hospices.
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Section 418.3 Definitions – cont
Restraint
(1) Any manual method, physical or mechanical device, material, or
equipment that immobilizes or reduces the ability of a patient to
move his or her arms, legs, body, or head freely, not including
devices, such as orthopedically prescribed devices, surgical
dressings or bandages, protective helmets, or other methods that
involve the physical holding of a patient for the purpose of
conducting routine physical examinations or tests, or to protect the
patient from falling out of bed, or to permit the patient to participate
in activities without the risk of physical harm (this does not include
a physical escort); or
(2) A drug or medication when it is used as a restriction to manage
the patient’s behavior or restrict the patient’s freedom of movement
and is not a standard treatment or dosage for the patient’s
condition.
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Section 418.3 Definitions – cont
Seclusion:
Seclusion means the involuntary confinement of a patient alone in a
room or an area from which the patient is physically prevented from
leaving.
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Section 418.3 Definitions
Comprehensive assessment:
Comprehensive assessment means a thorough evaluation of the
patient’s physical, psychosocial, emotional and spiritual status
related to the terminal illness and related conditions. This includes a
thorough evaluation of the caregiver’s and family’s willingness and
capability to care for the patient.
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Section 418.3 Definitions
Dietary counseling:
Dietary counseling means education and interventions provided to
the patient and family regarding appropriate nutritional intake as
the patient’s condition progresses. Dietary counseling is provided by
qualified individuals, which may include a registered nurse, dietitian
or nutritionist, when identified in the patient’s plan of care.
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Section 418.3 Definitions
Initial assessment:
means an evaluation of the patient’s physical, psychosocial and
emotional status related to the terminal illness and related
conditions to determine the patient’s immediate care and support
needs.
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Section 418.3 Definitions
Physician designee:
means a doctor of medicine or osteopathy designated by the hospice
who assumes the same responsibilities and obligations as the
medical director when the medical director is not available.
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SUBPART B: Eligibility, election and
duration of benefits
Eligibility requirements
Duration of hospice care coverage – Election periods
Certification of terminal illness
Election of hospice care
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Section 418.20 & 418.21
418.20 – Eligibility requirements
Entitled to Medicare Part A
Certified as Terminally Ill in accordance with 418.22
418.21 – Election periods
Initial 90-day period
Subsequent 90-day period
Unlimited number of subsequent 60-day periods
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Section 418.22
Certification of Terminal Illness
(a) Timing
Written certification for each of the periods in 418.21
Must be obtained before submitting claim
Exceptions:
If not obtained within 2 calendar days after period begins, must
obtain oral certification within 2 days and written prior to
submitting claim
Certs/Recerts may be completed no more than 15 days prior to
effective date of election or start of subsequent period
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Section 418.22
Certification of Terminal Illness – cont.
(a) Timing – cont.
Face-to-Face encounter
Hospice Physician or NP must have F2F with each hospice patient
whose total stay across all hospice is anticipated to reach the 3rd
benefit period.
No more than 30 calendar days prior to recertification thereafter
To gather clinical findings to determine continued eligibility for
hospice care (my emphasis)
Can occur on the first day of the 3rd benefit period (clarified in 2012)
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Section 418.22
Certification of Terminal Illness – cont.
(b) Content
Based on the physician/medical director’s clinical judgment
regarding the normal course of illness.
Cert must conform to the following:
Specify that the individual’s prognosis is for a life expectancy of 6
months or less if the terminal illness runs its normal course
Clinical information that supports the medical prognosis must
accompany certification
Initial certification requires two signatures – hospice medical
director/physician AND attending.
Recertifications only require one signature
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Section 418.22
Certification of Terminal Illness – cont.
(b) Content – cont.
Brief Narrative explanation of clinical findings that
supports a life expectancy of 6 months or less
Can be on form or as an addendum
If part of form, narrative must be immediately prior to the
physician’s signature
If addendum, physician must also sign immediately following the
narrative.
Addendum creates need for two signatures – one with certification
statement and one with brief narrative addendum
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Section 418.22
Certification of Terminal Illness – cont.
(b) Content – cont.
Brief Narrative explanation of clinical findings that
supports a life expectancy of 6 months or less
Narrative shall have statement directly above the signature attesting
that physician composed narrative based upon his/her review of
medical record or examination of patient.
Narrative must reflect the patient’s individual clinical circumstances
and cannot contain check boxes or standard language used for all
patients
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Section 418.22
Certification of Terminal Illness – cont.
(b) Content – cont.
Face-to-Face Encounter if entering third benefit period
More than one physician can be involved.
MD or NP must attest in writing that he/she had a face to face
encounter with the patient, including the date of that visit.
If different NP or MD performs F2F, they shall state the clinical
findings were provided to MD for use in determining prognosis.
Attestation, signature, and date must be a separate and distinct
section of addendum or form and must be clearly titled.
CMS change in position memo dated 25 Mar 2011
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SUBPART C: PATIENT CARE
Conditions:
Patient Rights
Initial and Comprehensive Assessment
Interdisciplinary Group, Care Planning, and Coordination of
Services
Quality Assessment and Performance
Infection Control
Licensed Professional Services
Core Services
Nursing Services Waiver
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SUBPART C: PATIENT CARE – Cont.
Conditions, cont.
Furnishing of non-core services
PT, OT, Speech
Waiver of requirement – PT, OT, Speech, Dietary
Hospice Aide and Homemaker services
Volunteers
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Subpart C – Patient Rights
SEC. 418.52: PATIENT RIGHTS
While not a new rule, it is new to Hospice rules
Determine how you will demonstrate compliance during a
survey
Train staff on reviewing as part of assessment
Obtain a signature that acknowledged receipt of Notice
Look at P&P on communication barriers with persons of
limited English proficiency
Family members should not be first choice
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418.52 Patient’s rights
(a) Standard: Notice of rights and responsibilities.
Verbally and in writing;
make all reasonable efforts to have written copies of the notice of rights
available in the language(s) that are commonly spoken in the hospice’s
service area.
In a language and manner that the patient understands; and
make all reasonable efforts to secure a professional, objective translator
for hospice-patient communications, including those involving the notice
of patient rights.
During the initial assessment visit in advance of furnishing care.
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418.52 Patient’s rights
Interpretive Guidelines (IG)
Pt refers to patient or patient representative
Family members can serve as interpreters only when an objective
translator cannot be obtained or the patient requests it.
Procedures and Probes (PP)
Ask for copies of material
Ask patients if, who and when informed
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418.52 Patient’s rights
(a) Standard: Notice of rights and responsibilities.
Advance directives
‘‘The hospice must obtain the patient’s or representative’s signature
confirming that he or she has received a copy of the notice of rights
and responsibilities.’’
Interpretive Guidelines (IG)
Admission does not require an advance directive
Policies and Procedures
Procedures and Probes (PP)
Review clinical record for evidence
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418.52 Patient’s rights
(b) Standard: Exercise of rights and respect for property
and person.
Patients have the right to: exercise their rights, be treated with
respect, voice grievances, and be protected from discrimination or
reprisal for exercising their rights
Process for dealing with alleged violations:
Report violations to hospice administrator
Investigate violations & complaints
Take corrective action if violation is verified
Report verified significant violations within 5 working days of
becoming aware of incident
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418.52 Patient’s rights
Interpretive Guidelines (IG)
Definitions of various types of abuse
Procedures and Probes (PP)
Review admission information for instructions on making a
compliant
Review prior 12 months documentation of complaints – how
received, investigated, resolved
Ask patient if they know how to make a complaint and treatment
Determine if staff can ID various forms of abuse and if they know
how to report
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418.52 Patient’s rights
(c) Standard: Rights of the patient
Pain management and symptom control.
Interpretive Guidelines
Patients should not have to experience long waits for pain and symptom
management, medication, interventions
Hospice should have methods to assure 24 hours/7 days response in all
settings and where ever pt resides
Procedures and Probes
Ask to describe policies
Determine how hospice assures timely response
Ask patients how quickly hospice responds
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418.52 Patient’s rights
(c) Standard: Rights of the patient
Be involved in developing plan of care.
Probes
Ask staff how they facilitate pt/family involvement
Ask patient/family if they are involved.
Refuse care or treatment.
Interpretive Guidelines
Probes further if particular trend is identified, i.e. a majority of patients
is refusing a particular service, to assure that hospice is fully prepared to
provide the service with qualified personnel.
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418.52 Patient’s rights
(c) Standard: Rights of the patient
Choose attending physician.
Interpretive Guidelines
Pts have right to choose physician and have this person involved in their
medical care in all settings
Probes
Is there evidence that the hospice does not allow the patient to choose
their physician?
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418.52 Patient’s rights
(c) Standard: Rights of the patient
Confidential clinical record/ HIPAA.
Interpretive Guidelines
Safeguarding content, paper and electronic, from unauthorized
disclosure without consent
Observe whether staff shows evidence of protecting confidentiality
Is patient information posted in public places
Are clinical records accessible for reading or removing?
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418.52 Patient’s rights
(c) Standard: Rights of the patient
Be free of abuse, neglect, mistreatment
Interpretive Guidelines
If issue identified during survey, investigate and report
Ensure that the hospice addresses the incident immediately
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418.52 Patient’s rights
(c) Standard: Rights of the patient
Receive information about hospice benefit.
Interpretive Guidelines
Fully inform on covered services (Medicare and non-Medicare)
Procedures and Probes
Is pt/family aware of all covered services?
Has hospice described any services for which pt might have to pay?
Consider pts ability to understand and retain information
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418.52 Patient’s rights
(c) Standard: Rights of the patient
Receive information about scope and limitations of hospice
services.
Procedures and Probes
Ask pt/family what services they are receiving
Are they aware of any limitations to those services
Hospices are required to provide all services necessary for palliation and
management of terminal illness and should not accept a patient if they
cannot provide all services.
40
418.54 Initial/Comprehensive
assessment
Conduct 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 Initial/Comprehensive
assessment
(a) Standard: Initial assessment.
Completed by RN
Election can be another IDG member
Must occur within 48 hours after election of hospice care
Need staffing to address needs that require a shorter than 48 hours
assessment and weekends/holidays
This is an initial overall assessment of the patient/family needs
If there are significant issues in one area, then it is recommended that the
specialty IDG member complete the comprehensive assessment
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418.54 Initial/Comprehensive
assessment
(a) Standard: Initial assessment – cont.
Initial contact cannot be substituted for initial assessment
Cannot wait until comprehensive assessment is complete to
formulate Plan of Care and provide services
Initial assessment guides decisions about who comprehensively
assesses patient/family needs
Document the IDG formulation of the POC based upon initial
assessment
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418.54 Initial/Comprehensive
assessment
(a) Standard: Initial assessment – cont.
Interpretive Guidelines
Purpose is to gather critical information necessary to treat immediate
care needs
In the location where the hospice services are being delivered
Not a ‘meet and greet’ visit
RN must conduct, other IDTS can be involved
Procedures and Probes
Determine through interview, observation and record review if
immediate care needs met
Did RN complete initial assessment?
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418.54 Initial/Comprehensive
assessment
(b) Standard: Time frame for completion of the
comprehensive assessment.
Completed by the hospice IDG in consultation with the attending
physician.
Attending not required to sign, but they do need to be involved – how to
document
Completed within 5 calendar days after the patient elects hospice
care, based upon patient needs. – IN TOP 10 DEFIENCIES FOR THE
LAST 3 YEARS
Ensure imminently dying patients receive appropriate and timely
assessments despite their short length of stay
45
418.54 Initial/Comprehensive
assessment
b) Standard: Time frame for completion of the comprehensive
assessment.
All members of the IDG do not necessarily need to visit the
patient/family to complete the comprehensive assessment.
Comprehensive assessment is about assessing WHAT the
patient needs, not all about WHO completes the
assessment.
CMS does not dictate how the comprehensive assessment is completed
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418.54 Initial/Comprehensive
assessment
b) Standard: Time frame for completion of the comprehensive
assessment.
Interpretive Guidelines
If no attending, hospice physician must assume role
If attending, must be consulted
Consultation occurs through phone calls, fax, emails, text messages,
etc.)
Attending often has history and family dynamics
Election may be signed with a later date, but not earlier
May be completed earlier than 5 days
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418.54 Initial/Comprehensive
assessment
Election of
hospice
• Patient/
represent
ative
signs
form
Initial
assessment
• RN
completes
• Within 48
hours of
election of
hospice
Comprehensive
assessment
• All needs of
patient/
family
• Completed
within 5
days of
election of
hospice
Update
comprehensive
assessment
• Updates
identified
needs of
patient/family
• Every 15 days
of as necessary
48
418.54 Initial/Comprehensive
assessment
c) Standard: Content of the comprehensive assessment.
Physical, Psychosocial, Emotional, Spiritual needs related to the
terminal illness and related conditions
Ensure that assessment and POC address actual as well as potential
problems
Interpretive Guidelines
Identifies minimum symptoms to be assessed
Pain, dyspnea, N&V, constipation, restlessness, anxiety, sleep disorders, skin
integrity, confusion, emotional distress, spiritual needs, support systems, need
for counseling/education
Identifies components of comprehensive pain assessment
History, characteristics, physical exam, current meds, goals
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418.54 Initial/Comprehensive
assessment
c) Standard: Content of the comprehensive assessment
Must take into consideration the following 8 factors:
1) Nature and condition causing admission
2) Complications and risk factors that affect care planning
3) Functional Status including the patient’s ability to understand
and participate in his/her own care (structure, function, activity)
4) Imminence of death as evidenced by….
50
418.54 Initial/Comprehensive
assessment
c) Standard: Content of the comprehensive assessment
5) Severity of symptoms
Use rating scales for consistency
Document pt’s self-identified threshold (SIT score)
All IDG members need to ask and report symptoms at every visit
Procedures and Probes
Ask staff how they complete comprehensive assessment
Evidence in clinical record?
51
418.54 Initial/Comprehensive
assessment
c) 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
IN TOP 10 DEFIENCIES FOR THE LAST 3 YEARS
52
418.54 Initial/Comprehensive
assessment
c) Standard: Content of the comprehensive assessment
7) Bereavement
incorporated into POC and considered in the bereavement POC
Interpretive Guidelines
Assess grief/loss issues through-out care
Scope of assessment – history of previous losses, family problems,
legal/financial concerns, communication issues, drug/alcohol abuse,
health concerns, support system, mental health issues
Procedures and Probes
What evidence is present in assessment and POC?
53
418.54 Initial/Comprehensive
assessment
c) Standard: Content of the comprehensive assessment
8) Need for referrals
For further evaluation by appropriate health professionals
Related/Unrelated
Procedures and Probes
Ask staff how they determine need for referral
54
418.54 Initial/Comprehensive
assessment
(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.
55
418.54 Initial/Comprehensive
assessment
(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
56
418.54 Initial/comprehensive
assessment cycle
Change in
patient status
Update the
comprehensive
assessment
Update of
patient plan of
care
57
418.54 Initial/Comprehensive
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 integral part of comprehensive assessment
Data elements must be collected and documented in a consistent,
systematic, and retrievable way.
Interpretive Guidelines
Data elements for patient reported outcomes on symptoms
Procedures
Interview key staff and have them explain
58
418.54 Initial/Comprehensive
assessment
Documentation – SOAPIER clinical notes
Subjective
Objective
Assessment
Plan
Intervention
Evaluate
Reassess
*Weatherbee Resources, Inc.
59
418.54 Initial/Comprehensive
assessment
Techniques for compliance
WHAT HAS WORKED FOR YOUR HOSPICE
PROGRAM?
60
418.56 IDG, care planning, and
coordination of services
Interpretive Guidelines
Physician member may be hospice medical director
Nurse, social worker and counselor members must be hospice
employees
If hospice is sub-division of organization, must be appropriately
trained and assigned to hospice
Probes
Ask how POC is developed by full IDG with attending
Request documentation that verifies
4 L-tags in this condition were in the TOP 10 DEFICIENCES
IN 2011
61
418.56 IDG, care planning, and
coordination of services
(a) Standard: Approach to service delivery
Hospice designates an IDG who work together to meet the
needs of the patient and family.
IDG in entirety must supervise care and services
Interpretive Guidelines
Supervision may be accomplished by face-to-face, telephone,
conferences, evaluations, discussions, general oversight, direct
observations
Procedures
Ask RN Coordinator to describe developing goals, facilitating
exchange of information with pt and IDG
62
418.56 IDG, care planning, and
coordination of services
(a) Standard: Approach to service delivery
The hospice designates a registered nurse who is member
of the IDG 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.
Procedures and Probes
Ask administrator to identify RN coordinators
How does this person assure coordination of care with IDG?
63
418.56 IDG, care planning, and
coordination of services
(a) Standard: Approach to service delivery
Required members of the IDG:
Doctor of medicine or osteopathy (employee/contract)
Registered nurse;
Social worker; and
Pastoral or other counselor
Interpretive Guidelines
Number of individuals is not important, it is qualifications – i.e.,
dually licensed individuals
Procedures
Determine that all disciplines contribute to assessments and POC
64
418.56 IDG, care planning, and
coordination of services
If there is more than one IDG, the hospice must identify a
specifically designated IDG to establish day-to-day policies
and procedures.
Interpretive Guidelines
Does not need to be the same group that works together to care for
patients.
65
418.56 IDG, care planning, and
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.
MOST FREQUENT DEFICIENCY FOR LAST 3 YEARS
66
418.56 IDG, care planning, and
coordination of services
(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
Individualized written POC for each patient
TOP 10 DEFICIENCES FOR THE PAST 3 YEARS
67
418.56 IDG, care planning, and
coordination of services
(c) Standard: Content of the plan of care
Procedures 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?
68
418.56 IDG, care planning, and
coordination of services
(c) Standard: Content of the plan of care
1. Interventions to manage pain and symptoms
Interpretive Guidelines
Goal is quality of life
Ongoing assessment of all needs
Evidence of interventions, including alternative therapies
Procedures and Probes
Ask staff for specific patient information
Is there evidence of proactively anticipating side effects
Ask pt if satisfied with level of comfort? What was response when
pain escalated?
Investigate when not managed
69
418.56 IDG, care planning, and
coordination of services
(c) Standard: Content of the plan of care
2. 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
If requires frequent use of PRN, POC should update frequency
to meet current need
Standing orders must be individualized
70
418.56 IDG, care planning, and
coordination of services
(c) Standard: Content of the plan of care
2. Detailed statement of the scope and frequency of services
to meet the patient’s and family’s needs
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
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
71
418.56 IDG, care planning, and
coordination of services
(c) Standard: Content of the plan of care
3. Measurable outcomes
Interpretive Guidelines
Outcomes should be measurable result of implementation of POC
Using data elements to see if they are meeting goals
Probes
Are outcomes measurable and documented?
Look for movement towards expected outcomes and revisions to
POC
72
418.56 IDG, care planning, and
coordination of services
(c) Standard: Content of the plan of care
4. Drugs and treatments
Interpretive Guidelines
References 418.52 (c) (1) – Rights of pt to effective pain &
symptom management
5. Medical supplies and appliances
6. Documentation (in the clinical record) of the patient’s or
representative’s level of understanding, involvement and
agreement with the plan of care
IG - do not need to be present at IDG meetings
73
418.56 IDG, care planning, and
coordination of services
(d) Standard: Review of the plan of care
Plan of care must be reviewed as frequently as the patient’s
condition requires, but no less frequently than every 15 calendar
days
Revised plan of care includes:
Information from the updated comprehensive assessment
Information regarding the progress toward achieving specified outcomes
and goals
Completed by the IDG in collaboration with the attending physician
(if any)
TOP 10 DEFICIENCES FOR THE PAST 3 YEARS
74
418.56 IDG, care planning, and
coordination of services
(d) Standard: Review of the plan of care
Interpretive Guidelines
Communication with attending may be through various means
according to policy and patient needs
Procedures and Probes
Ask the hospice to describe the POC review process
How does the hospice ensure the review process occurs by the IDT
no later than 15 days from the prior review?
75
418.56 IDG, care planning, and
coordination of services
(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
TOP 10 DEFICIENCES IN 2011
Care and services are based on assessments of the patient and
family needs
76
418.56 IDG, care planning, and
coordination of services
(e) Standard: Coordination of services – cont.
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.
77
418.56 IDG, care planning, and
coordination of services
(e) Standard: Coordination of services – cont.
Probes
What systems are in place to facilitate exchange of information
among staff and with non-hospice providers?
How does the hospice ensure that coordination of care occurs
between services provided directly and those under arrangement?
Is there documentation of the sharing of information between all
disciplines and other providers?
78
418.56 IDG, care planning, and
coordination of services
Techniques for compliance
Establish methods of communication to ensure that modalities are
adequate, efficient and reliable.
Define term ‘change in condition’
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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418.56 IDG, care planning, and
coordination of services
Techniques for compliance
WHAT HAS WORKED FOR YOUR HOSPICE
PROGRAM?
80
418.58 Quality assessment and
performance improvement
Develop, implement and maintain an effective, ongoing,
hospice-wide data-driven QAPI program.
Reflect complexity of organization
Involves all services
Focuses in indicators to improved palliative outcomes
Takes action to demonstrate improvement
The hospice must maintain documentary evidence of its
QAPI program and be able to demonstrate its operation to
CMS
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418.58 QAPI
Interpretive Guidelines
Each hospice develops its own QAPI program
Methods used are flexible – documentation, direct
observation, incident reports, complaints, surveys, interviews
Information gathered should be based on measures generated
by medical/professional staff
Reflect best practices, staff performance and patient
outcomes
Ongoing means continuous and periodic collection and
assessment of data
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418.58 QAPI
Interpretive Guidelines
QAPI program should have following elements
Program objectives
All patient care disciplines
Description of how administered and coordinated
Method for monitoring and evaluating quality of care
Priorities for resolution of problems
Monitoring to determine effectiveness of action
Oversight responsibility reports to governing body
Documentation of review of QAPI program
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418.58 QAPI
Interpretive Guidelines
Fundamental purpose is to set a clear expectation of proactive
approach to improve performance and focus on improved care
Stresses improvement in systems in order to improve processes and
patient outcomes
All components of QAPI in place hospice wide
Must be ongoing and have written plan of implementation
Performance Improvement fosters a ‘blame free’ environment
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418.58 QAPI
Procedures and Probes
Request the following:
Aggregated data and its analysis of data
QAPI plan
Individuals responsible for QAPI program
Evidence the QAPI has been implemented and is functioning effectively
Regular meetings, investigation of sentinel and adverse events
Recommendations for systemic change
Identified performance measures that are tracked and analyzed
Regular review and use of QAPI analysis by management and governing body
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418.58 QAPI
Procedures and Probes
Match data provided with actual experiences of hospice staff and
patients
Focus on how and why quality measures chosen, how it ensures
consistent data collection, how it uses data in patient care planning
and how it aggregates and analyzes data
Documentation of analysis can be meeting minutes, reports,
recommendations for change
CMS Preamble – “Tools must allow hospices to document
information in a systematic and retrievable way for each patient.”
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418.58 QAPI
Operates on 2 levels
Patient
Hospice
Focuses on
Collecting data to assess quality
Using data to identify opportunities for improvement
Patient focused – outcome oriented
Two related process
Quality Assessment
Performance Improvement
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418.58 QAPI
(a) Standard: Program scope
Show measurable improvement in indicators related to improved
palliative outcomes and hospice services
Must measure, analyze, and track quality indicators, including
adverse pt events
CMS Preamble- Failure to meet the quality assurance condition is
consistently one of the top 10 deficiencies cited by Medicare
surveyors nationwide.
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418.58 QAPI
(a) Standard: Program scope
Interpretive Guidelines
Assess quality in all areas of operations
Specific requirement to track adverse events and reduce occurrence
Show, using quantitative data, that quality is improved as measured
by own indicators or measures
Procedures and Probes
Does hospice adhere to its own definition of adverse event
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418.58 QAPI
(b) Standard: Program data
The program must utilize quality indicator data, including patient
care, and other relevant data, in the design of its program
Interpretive Guidelines
Not limit data collection to patient assessments
Examine all facets of hospice operations
Procedures and Probes
Is the hospice’s QAPI program data driven?
Is there evidence it uses data to identify opportunities for
improvement?
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418.58 QAPI
(b) Standard: Program data
Hospice 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
Interpretive Guidelines
Governing Body may assume hands-on control or delegate
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418.58 QAPI
(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
Performance activities must track adverse patient events, analyze their
causes and implement preventive actions and mechanisms that include
feedback and learning throughout the hospice
Interpretive Guidelines – hospice may choose to develop own
definition for adverse event or use one developed by national
accrediting organization
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418.58 QAPI
(c) Standard: Program activities (cont’d)
Take action aimed at performance improvement
Measure success of action
Track performance of action to ensure that improvements are
sustained
Interpretive Guidelines
Consider how often certain quality issues arise and severity of
potential harm
Procedures and Probes
Determine if hospice has taken appropriate action to correct
identified problems
Evidence performance continually monitored?
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418.58 QAPI
(d) Standard: Performance improvement projects (PIP)
The number and scope of projects conducted annually must reflect
the scope, complexity and past performance of the hospice’s
services and operations
Document what quality improvement projects are being conducted,
reasons for conducting the projects and measurable progress
achieved on these projects
Interpretive Guidelines
No requirement for specific number of PIPs
Procedures and Probes
Do the number and scope of PIPs reflect scope, complexity and past
performance of hospice?
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418.58 QAPI
(e) Standard: Executive responsibilities
Governing body ensures:
That an ongoing program for QI and patient safety is defined,
implemented and maintained. (Board needs to approve details.)
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.
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418.58 QAPI
(e) Standard: Executive responsibilities
Probes
Do hospice records indicate that the hospice’s governing body is
involved in oversight of the QAPI program?
Is there an individual appointed by the governing body who is
responsible for operating the QAPI program
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418.58 QAPI
Patient – level QAPI
Collect data on what happened to an individual patient
Assessment/reassessment (418.54)
Care Plan (418.56)
Visit Notes
Use the data to improve quality of care and outcomes for that
patient (418.56)
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418.58 QAPI
Hospice – level QAPI
Clinically focused
Aggregate patient level data
Collect satisfaction data
Non Clinically focused
Administrative data
Marketing – referral source contact
Outreach to community
Profitability
Fund raising
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418.58 QAPI
Quality Assessment requires quantitative information
Numbers OR
Uniform variables (yes/no, increased/decreased)
Performance Improvement requires qualitative information
Narrative data
Detail behind quantitative
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418.58 QAPI
Visualize – QAPI Hospice
SEE – quality data is posted
FEEL – culture of quality
Quality of assessment is a core activity across the organization
Positive questioning, not finger pointing or blaming
Reliance on data for decision making
PI, not criticism or punishment, is the organizational response to errors
and problems.
READ – QAPI plan, PIP report, Board meeting minutes
WATCH - Everybody participates
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418.58 QAPI
Initial Steps to QAPI
Appoint individual/team responsible for QAPI program
Generate buzz about QAPI
Educate everyone about QAPI and their role
Develop a QAPI Plan – to be reviewed/evaluated yearly
Implement Plan
Develop Performance Improvement Project teams to
address identified areas for improvement (this can take 4 –
6 months)
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418.58 QAPI
Redesign
Act
Do
Plan
Study
102
Patient Level – The Cycle of Care
Assess (data)
Reassess (data)/
Change POC
ID Problems
Intervention (POC)
QAPI
103
Hospice Level – The QAPI Process
Gather data
ID areas for
improvement
Institutionalize
improvements
Performance
Improvement
Projects (PIP)
QAPI
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418.58 QAPI
QAPI Leaders - Governing body retains responsibility
Appoint one or more to manage day to day
At least part-time defined hours/days
Chairs committee (CQO)
Monitor compliance with the QAPI plan
Manages collection of indicator data
Oversee analysis and reporting
Supports PI teams
QAPI Committee
Clinical and non-clinical (include medical records)
Managers and staff
Generate Buzz and Celebration
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418.58 QAPI
Use available quality measurement tools
Agency satisfaction survey tools
NHPCO – National Data Set, FEHC, STAR, QP
Agency for Healthcare Research and Quality – EOL outcomes
National Quality Forum – Standards for symptom
management and EOL care
excelleRx – pharmaceutical tools
Multiview – financial
OCS – QAPI snapshot
Deyta – FEHC and other satisfaction surveys
CMS Pilot to determine outcomes currently underway in New
York
106
418.60 Infection control
Must maintain and document effective infection control
program that protects patients, families, visitors and
hospice personnel by preventing and controlling infections
and communicable diseases
Interpretive Guidelines
IC program must identify risks in all settings where pts reside
System to communicate with all staff, pts/families, visitors about
infection prevention and control
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418.60 Infection control
Interpretive Guidelines
IC program may include, but not limited to:
Educating staff
Protocols related to infusion therapy, urinary tract care, respiratory tract
care and wound care
Guidelines on caring for pts with multi-drug resistant organisms
Policies on protection from blood borne or airborne pathogens
Monitoring for compliance
Protocols for educating in standard precaution and prevention/control
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418.60 Infection control
Procedures and Probes
Ask what steps it takes to assure staff take appropriate prevention
and control precautions
How does the hospice ensure timely instructions regarding standard
precautions
If providing inpatient care directly, observe for appropriate infection
prevention and control precautions including signage or other
posted information or materials in pt rooms or staff area.
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418.60 Infection control
(a) Standard: Prevention
Follow accepted standards of practice to prevent transmission,
including standard precautions
Interpretive Guidelines
Accepted standards of practice are typically developed by
government agencies, professional organizations and
associations
Standard Precautions are based on principle that all body
fluids may contain transmissible infectious agents
These include hand hygiene, gloves, mask, gown, eye
protection, face shield and safe injection practices
Procedures
During home visit, observe practices
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418.60 Infection control
(b) Standard: Control
Maintain a coordinated, agency-wide program for
surveillance, identification, prevention, control, and
investigation of infectious and communicable diseases
That is an integral part of QAPI program
Includes method of identify infectious and communicable disease
problems and
A plan for implementing appropriate actions that are expected to
result in improvement and disease prevention
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418.60 Infection control
(b) Standard: Control
Interpretive Guidelines
Examples of infection control practices are monitoring work related
employee illness and infections
Analyzing them in relation to patient infections
Taking appropriate actions when an infection or communicable
disease is present to prevent spread
Procedures and Probes
Ask hospice to explain methods it uses to ID problems
Does the hospice redesign its strategies to improve when it
identifies problems?
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418.60 Infection control
(c) Standard: Education
Infection control education provided to staff, patients, families, and
other caregivers
Probes
Is hospice staff aware of infection control principles and
procedures?
Do they demonstrate this knowledge during home visits?
During home visit ask pt/family to describe infection control
education they have received.
113
418.62 Licensed professional services
(a) Standard: Services, whether provided directly or under
arrangement, must be authorized, delivered, and
supervised by qualified personnel
(b) Standard: Professionals must actively participate in
coordinating patient care (includes: patient assessment;
care planning and evaluation; and patient and family
counseling and education)
(c) Standard: Professionals must participate in the hospice’s
QAPI and in-service training programs
114
418.62 Licensed professional services
Interpretive Guidelines
Would include, but not be limited to: skilled nursing care, physical
therapy, speech language pathology, occupational therapy and
medical social services
Procedures and Probes
Interview key staff to determine how hospice ensures the licensed
professionals participate in QAPI and in-service training
What evidence is there that all employees have been properly
oriented to tasks, participate in in-service training programs and
demonstrate appropriate skills
115
418.64 Core services
Routinely provide substantially all core services directly by
hospice employees.
These services include nursing, medical social services and
counseling.
May use contracted staff, if necessary, to supplement
hospice employees in order to meet needs of pts under
extraordinary or other non-routine circumstances.
May also enter into an agreement with another Medicare
certified hospice
Reasons: unanticipated periods of high patient loads
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418.64 Core services
Reasons to contract
Unanticipated periods of high patient loads or CC level
Staffing shortages due to illness or other short-term
temporary situations
Pts evacuated due to disaster
Temporary travel of a patient outside the service area
Interpretive Guidelines
Employee definition – works for hospice/organization and
receives a W-2 or is a volunteer
Probes
How does hospice assure that all contract providers receive
training in hospice philosophy and care before providing
services
117
418.64 Core services
(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
Probe
Is there evidence that the medical needs of pts are being met by
hospice physician when no attending or attending unavailable?
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418.64 Core services
(b) Standard: Nursing services
Care provided by or under the supervision of a 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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418.64 Core services
(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 and pt/family needs and acceptance of services
Interpretive Guidelines
Assessment should include adjustment to terminal illness,
social/emotional factors, coping mechanisms, family
dynamics, communication patterns, financial resources,
caregiver’s ability, risk factors, support systems
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418.64 Core services
(c) Standard: Medical social services
Probes
How does the hospice introduce and offer medical social services?
Ask the SW or CM to describe factors included in psychosocial
assessment, how is info used in care planning
Is there evidence that each patient receives SW services, unless
refused?
121
418.64 Core services
(d) Standard: Counseling services
Counseling services must be available to pt/family to assist in
minimizing the stress and problems that arise from terminal illness,
related conditions and dying process
Include, but are not limited to:
Bereavement
Dietary
Spiritual
Broad language includes CAM therapy providers
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418.64 Core services
(d) Standard: Counseling services - Bereavement
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.
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418.64 Core services
(d) Standard: Counseling services – Bereavement
Interpretive Guidelines
Supervisor may be IDG social worker or other professional
with documented evidence of experience or education in grief
or loss counseling
Procedures and Probes
Ask the hospice to explain how and when they incorporate
bereavement assessment into comprehensive assessment
What services are provided to reflect needs of pt/family?
How does hospice evaluate outcomes and effectiveness of
bereavement services?
Select and sample 2 – 3 bereavement POC from pts who have died in
past 12 months. Determine if bereavement follow-up was
appropriate.
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418.64 Core services
d) Standard: Counseling services - Dietary
Dietary counseling: preformed by a qualified individual such as
dieticians and nurses
Interpretive Guidelines
RN can provide dietary counseling within scope of practice
If needs exceed RN expertise, then must have an appropriately
trained and qualified registered dietician or nutritionist
125
418.64 Core services
d) Standard: Counseling services - Dietary
Procedures and Probes
Ask the clinical manager how hospice meets the needs of pts/family
who experience challenges and conflict with EOL dietary issues.
Ask clinical manager how hospice meets the needs of pts who
experience dysphasia, problematic enteral feedings, unresolved
nutritional issues secondary to N&V or the dying process.
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418.64 Core services
d) Standard: Counseling services - Spiritual counseling
Spiritual counseling: Make all reasonable efforts to facilitate visits
from local clergy, pastoral counselors, or other individuals who
support the patient’s spiritual needs.
Interpretive Guidelines
Evidence in record that spiritual counseling was offered and/or
provided in accordance with pt/family desires.
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418.64 Core services
d) Standard: Counseling services - Spiritual counseling
Procedures and Probes
Determine through record review, interview and home visits how
the hospice addresses the spiritual needs of pt/family
How does the hospice introduce the availability of spiritual
counseling?
What mechanisms are in place to meet the spiritual needs?
128
418.66 Nursing services – Waiver
Applies only to hospices in existence on or before Jan. 1,
1983 in non-urbanized areas
129
418.70 Non-core services
Services in 418.72 thru 418.78 are provided directly or
under arrangements. Services must be consistent with
current standards of practice
Interpretive Guidelines
Must ensure all staff are aware of and follow professional standards,
laws, policies, procedures. If question arises during home visit, ask
staff what the policies are regarding the issue
Procedure
Ask how hospice monitors professional skills to determine if
appropriate and adequate for its patients.
130
418.72 PT, OT, and SLP
PT, OT, SLP services must be available and provided in a
manner consistent with accepted standards of practice.
Interpretive Guidelines:
Rehab services, i.e., use of adaptive equipment, home safety
assessment, caregiver instructions in good body mechanics, may be
appropriate/beneficial for the pt.
131
418.74 Waiver of requirement- PT, OT,
SLP, and dietary counseling
Waives 24 hour requirement for non-urbanized programs
Unlimited 1 year extensions
132
418.76 Hospice aide & homemaker
services
All hospice aide services must be provided by individuals
who meet requirements in paragraph (a)
Homemaker services must be provided by individuals who
meet requirements in paragraph (j)
133
418.76 Hospice aide & homemaker
services
(a) Standard: Hospice aide qualifications
Qualified aide has successfully completed one of the
following:
Hospice aide training and competency evaluation as specified in (b)
and (c)
Competency evaluation as specified in (c)
Nurse aide training and competency evaluation approved by state
and is in good standing
State licensure program that meets requirements of (b) and (c)
If there has been a 24 month lapse in furnishing services,
individual must complete another program
134
418.76 Hospice aide & homemaker
services
(b) Standard: Content and duration of hospice aide training
Classroom and supervised practical training
Minimum of 16 classroom hours
Minimum of 16 supervised practical trainings with person,
not mannequin
Total of at least 75 hours
13 training subject areas identified
Maintain documentation that demonstrates requirements
are met
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418.76 Hospice aide & homemaker
services
(b) Standard: Content and duration of hospice aide training
Interpretive Guidelines
May receive training from different organizations if amount of
training totals 75 hours, content addresses all subject areas and all
requirements of regulation are met.
Document that requirements of standard are met
Documentation should include: descriptions of program,
qualification of instructors, record that distinguishes between
classroom and practical training, how additional skills are taught is
hospice requires more complex procedures
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418.76 Hospice aide & homemaker
services
(c) Standard: Competency evaluation
Individual may furnish services only after successfully
completed a competency evaluation program.
Competency evaluation must address all 13 subjects of (b).
Specific subjects are to be with a patient, remaining
subjects can be written, oral or observation
May be provided by any organization, except those
identified in (f)
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418.76 Hospice aide & homemaker
services
(c) Standard: Competency evaluation
Interpretive Guidelines:
Must ensure that skills learned elsewhere can be successfully
transferred in all settings
Review of skills can be done when nurse installs new aide in patient
care situation or during supervisory visit
Mannequin may not be used for this evaluation
138
418.76 Hospice aide & homemaker
services
(c) Standard: Competency evaluation
Must be performed by RN in consultation with other
professionals, as appropriate
Hospice aide not considered competent in any task evaluated as
unsatisfactory and must not perform task without direct
supervision until retrained
If rated unsatisfactory in more than one area, not considered to
have successfully completed competency evaluation. IG –
precluded from functioning as aide
Interpretive Guidelines: No restrictions on number of times or
timeframe for testing in deficient area.
Documentation must demonstrate that requirements of standard
are met
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418.76 Hospice aide & homemaker
services
(d) Standard: In-service training (same)
12 hours of in-service training during each 12 month
period. May occur while furnishing care.
Interpretive Guidelines:
May be calendar year, employment anniversary or rolling 12 month
basis
Training that occurs with pt in place of residence, supervised by RN,
may occur as part of supervisory visit
Should not be repetition of basic skill
Procedures and Probes: Ask how the hospice schedules training to
assure the 12 hours within 12 months
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418.76 Hospice aide & homemaker
services
(d) Standard: In-service training (same)
Training may be offered by any organization and must be
supervised by a registered nurse.
Interpretive Guidelines:
May be calendar year, employment anniversary or rolling 12 month
basis
Training that occurs with pt in place of residence, supervised by RN,
may occur as part of supervisory visit
Should not be repetition of basic skill
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418.76 Hospice aide & homemaker
services
(d) Standard: In-service training (same)
Procedures and Probes:
Ask how the hospice schedules training to assure the 12 hours
within 12 months
Training may be offered by any organization and must be
supervised by a RN
Hospice must maintain documentation demonstrating
requirements of standard are met
Procedures and Probes:
Review a sample of 3 – 4 hospice aides training files to validate aides
are receiving required number of hours. If concerns arise, interview
aides regarding in-service training
142
418.76 Hospice aide & homemaker
services
(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)
Interpretive Guidelines:
2 years experience should be “hands-on” clinical experience such as
providing care or supervising nursing services or teaching nursing
skills in an organized curriculum or in-service program
Other individuals may help with training
143
418.76 Hospice aide & homemaker
services
(f) Eligible competency evaluation organizations
May be offered by any organization except one that has one
of the identified deficiencies in the prior 2 years
(g) Hospice Aide assignments and duties
Assigned specific pt by IDT RN, written patient care
instructions must be prepared by RN who is responsible for
supervision of aide
Interpretive Guidelines:
Written instructions must be patient specific and not generic
144
418.76 Hospice aide & homemaker
services
(g) Hospice Aide assignments and duties
Procedures and Probes: Interview key staff to determine:
if aides are employees or under arrangement, if under arrangement
how ensure competency
How hospice ensures aides are proficient to carry out assignments
in safe, efficient, effective manner
How hospice monitors the assignments of aides to match skills
needed for individual pts
If questions arise as a result of home visits or interviews, ask clinical
managers to respond to specific issues
145
418.76 Hospice aide & homemaker
services
(g) Hospice Aide assignments and duties
Hospice Aide provides services that are ordered by IDG,
included plan of care, permitted by State and consistent
with hospice training
Duties of hospice aid include: provision of hands-on
personal care, performance of simple procedures as
extension of therapy or nursing services, assistance in
ambulation or exercises, assistance in administering
medications that ordinarily self-administered.
146
418.76 Hospice aide & homemaker
services
(g) Hospice Aide assignments and duties
Interpretive Guidelines:
Administering medication is based upon needs of pt/family,
training/competency of aide, policies, state law and rules.
If allowed, hospice is required to provide training in medication
administration and assure that aide is competent before assigned to
patient
147
418.76 Hospice aide & homemaker
services
(g) Hospice Aide assignments and duties
Hospice Aides must report changes in pt’s medical, nursing,
rehab or social needs to RN, as changes related to POC and
QAPI
Must complete documentation in compliance with P&P
Procedures:
During home visit, be observant for changes in pts needs that aide
should be reporting to RN
Through record review, look for documentation by aide describing
changes and to whom reported
Clinical notes should be dated and signed
148
418.76 Hospice aide & homemaker
services
(h) Standard: Supervision of hospice aides
RN 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
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 while the patient receives care (observation of aide)
If concerns are verified, the aide must complete a competency
evaluation
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418.76 Hospice aide & homemaker
services
(h) Standard: Supervision of hospice aides
The RN must make an annual onsite visit to observe and
assess each aide while performing care
Interpretive Guidelines:
Aide must be directly supervised one time annually on one patient
(no requirement to assess each patient annually)
Procedures and Probes:
Interview key staff to determine how hospice assures all aides are
supervised on-site annually
150
418.76 Hospice aide & homemaker
services
(h) Standard: Supervision of hospice aides
Assess and document satisfactory performance in meeting
outcomes that include, but not limited to:
Following plan of care
Creating successful interpersonal relationship with pt
Demonstrating competency with assigned tasks
Complying with infection control P&P
Reporting changes in pt’s condition
Interpretive Guidelines: Supervisory visits may be made in
conjunction with professional visit
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418.76 Hospice aide & homemaker
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(h) Standard: Supervision of hospice aides
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418.76 Hospice aide & homemaker
services
(i) Standard: Individuals furnishing Medicaid personal care
aide-only services under a Medicaid personal care benefit
(COPES)
May be provided on behalf of the hospice agency – must
demonstrate competency in services provided
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
153
418.76 Hospice aide & homemaker
services
(i) Standard: Individuals furnishing Medicaid personal care
aide-only services under a Medicaid personal care benefit
(COPES)
Interpretive Guidelines:
State defines optional Medicaid personal services benefit and
determines if benefit is more extensive that H/HA benefit provided
under Medicare hospice benefit
State pays for covered Medicaid personal care services that exceed
scope of Medicare hospice benefit
154
418.76 Hospice aide & homemaker
services
(j) Standard: Homemaker qualifications
A qualified homemaker is an:
Individual who meets the standards in 418.202(g) and has
successfully completed hospice orientation OR
A hospice aide as described in 418.76
Interpretive Guidelines:
Homemaker services may include assistance in maintaining a safe
and healthy environment and services to help the pt/family carry
out the treatment plan
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418.76 Hospice aide & homemaker
services
(j) Standard: Homemaker qualifications
418.202(g)
Home health aide services furnished by qualified aides as designated in
Sec. § 418.76 and homemaker services. Home health aides (also known
as hospice aides) may provide personal care services as defined in
§409.45(b) of this chapter. Aides may perform household services to
maintain a safe and sanitary environment in areas of the home used by
the patient, such as changing bed linens or light cleaning and
laundering essential to the comfort and cleanliness of the patient. Aide
services may include assistance in the maintenance of a safe and
healthy environment and services to enable the individual to carry out
the treatment plan.
156
418.76 Hospice aide & homemaker
services
(k) Standard: Homemaker supervision and duties
Homemaker services must be coordinated and supervised
by a member of the IDG
Instructions for homemaker duties must be prepared by a
member of the IDG
Homemakers must report all concerns to member of IDG
who is coordinating homemaker services
157
418.76 Hospice aide & homemaker
services
(k) Standard: Homemaker supervision and duties
Procedures and Probes:
Interview key adm staff regarding which member of the IDG is
responsible for coordination and supervision of homemaker
services
Through interview, home visits and record reviews assure that there
are written instructions and that concerns are being reported
Duties and services must be documented
158
418.78 Volunteers
Must use volunteers to the extent specified in section (e).
Must be used for defined roles and under supervision of
designated hospice employee
Interpretive Guidelines
Volunteers are considered hospice employees to facilitate
compliance with the core services requirement (418.64)
Procedures and Probes
Conduct an interview with the individual designated to supervise
the volunteers regarding use, training and supervision of volunteers.
159
418.78 Volunteers
(a) Standard: Training
The hospice must maintain, document and provide
volunteer orientation and training that is consistent with
industry standards.
Interpretive Guidelines
All required volunteer training should be consistent with specific
tasks that volunteers perform
160
418.78 Volunteers
(a) Standard: Training
Probes
How does the hospice supervise volunteers?
Is there documentation supporting that all volunteers have received
training and orientation before being assigned to a patient/family?
What evidence is there that the volunteers are aware of:
Duties/responsibilities; person to whom they report or contact
for concerns; hospice goals/philosophy; confidentiality; HIPAA,
family dynamics, coping mechanisms and psychological issues
surrounding terminal illness, death and bereavement; procedures
to follow in emergency or after death of pt; guidance related to
individual responsibilities
161
418.78 Volunteers
(b) Standard: Role
Volunteers must be used in day-to-day administrative
and/or direct patient care roles
Interpretive Guidelines:
Qualified volunteers who provide professional services must meet
all requirements associated with their specialty area
Duties of volunteers in direct patient care services must be evident
in plan of care
There should be documentation of time spent and services provided
Probes:
What evidence exists that the IDG conducts an assessment of
the pt/family’s need for a volunteer?
162
418.78 Volunteers
(c) Standard: Recruiting and retaining
Must document and demonstrate viable and ongoing efforts
to recruit and retain volunteers
(d) Standard: Cost savings
Must document the cost savings achieved through the use
of volunteers. Must include:
ID of each position that is occupied by volunteer
Work time spent in occupying these positions
Estimates of the dollar costs that the hospice would have incurred if
filled by paid employees
Interpretive Guidelines: There is no requirements for what the
costs savings must be, only on how it is computed
163
418.78 Volunteers
(e) Standard: Level of activity
Volunteers must provide a minimum hours worked that of
equals 5% of total patient care hours of all paid and
contract staff
Hospice must maintain records on use of volunteers
including type of service and time worked
Hospices may count volunteer driving hours in the 5%
calculation as long as they count staff driving hours. Board
and fund raising hours do not count.
Total paid hours (minus fund raising) x 1.05 = number of hours
needed to meet 5% calculation.
164
SUBPART D: ORGANIZATIONAL
ENVIRONMENT
Conditions:
Organization and administration of services
Medical Director
Clinical Records
Drugs, Biologicals, Medical Supplies, DME
Short Term Inpatient Care
Hospices that provide inpatient care directly
Hospice that provide care to residents in SNF/NF
Personnel qualifications
Compliance
165
418.100 Organization & administration
of services
Hospice must organize, manage, and administer its
resources to provide hospice care and services for
palliation and management of terminal illness and related
conditions
(a) Standard: Serving the patient and family
Optimizes comfort and dignity
Consistent with patient and family goals
Patient’s needs and goals are hospices primary consideration
166
418.100 Organization & administration
of services
(b) Standard: Governing body and administrator
Governing body (or designated person) assumes full legal
authority and responsibility
Qualified Administrator is appointed by and reports to the
governing body
Must be employee and possess education and experience required
by governing body
167
418.100 Organization & administration
of services
(b) Standard: Governing body and administrator
Interpretive Guidelines:
If hospice part of larger organization and the governing body is the
same, there must be documented evidence that the governing body
is assuming full authority and responsibility for operations, services
and QAPI program
If Administrator not available, must identify another individual to
assume assigned duties
Procedures and Probes
How is governing body informed of ongoing operations, service
delivery issues and QAPI activities?
Ask administrator/clinical supervisor to describe relationship
between governing body, management and staff
168
418.100 Organization & administration
of services
(c) Standard: Services
Hospice must be primarily engaged in providing:
Nursing, medical social, and physician
Counseling (spiritual, dietary and bereavement)
Hospice aide, volunteer, homemaker
PT, OT, SLP
Short-term inpatient care
Medical supplies (including drugs) and medical appliances
Nursing, physician and drugs must be provided 24/7
Other services on 24 hour basis when reasonable and
necessary
169
418.100 Organization & administration
of services
(d) Standard: Continuation of care
Hospice may not discontinue or reduce care provided to a
Medicare or Medicaid beneficiary because of beneficiary’s
inability to pay for that care
Interpretive Guidelines:
Applies to Medicare and Medicaid beneficiaries only
170
418.100 Organization & administration
of services
(e) Standard: Professional management responsibility
Must retain oversight of staff and services for all arranged
services
Arranged services must be supported by written
agreements that require all services be:
Authorized by hospice
Furnished in safe and effective manned by qualified personnel
Delivered in accordance with pt’s POC
171
418.100 Organization & administration
of services
(e) Standard: Professional management responsibility
Interpretive Guidelines:
Hospice must retain administrative, financial management and
oversight of staff and services provided under arrangement.
For Medicare services, hospice is responsible for payment
For non-Medicare services, hospice is responsible for establishing
how payment for those services will occur
172
418.100 Organization & administration
of services
(e) Standard: Professional management responsibility
Procedures and Probes: Ask how the hospice:
Assures that all contracted personnel provide care that is in
accordance with POC?
Assures that all services are authorized?
Monitors and exercises control over services?
Assure professional management of pts receiving inpatient
care under arrangement?
Communicates with contracted individuals, agencies,
organizations?
Assure that services are furnished by qualified staff?
173
418.100 Organization & 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 (provider)
number
Lines of authority and control must be clearly delineated
All locations must comply with CoPs
Interpretive Guidelines: Several pages of these to review prior
to doing this
174
418.100 Organization & administration
of services
(g) Standard: Training
Must provide orientation to all employees (includes volunteers)
and contracted staff who have patient and family contact,
addressing specific job duties
Must assess skills and competencies of employees
Must have written P&P describing methods of assessment of
competency
Maintain written description of in-service training and education
provided during the previous 12 months
175
418.100 Organization & administration
of services
(g) Standard: Training
Procedures and Probes:
Review sample of personnel records to verify initial orientation,
assessment of skills/competency, and in-service training was
provided to all employees, contracted staff and volunteers
furnishing care/services to pts
Review written agreements and training programs provided for
contracted personnel
If concerns are identified, interview the administrator/staff
regarding the specific issue.
176
418.102 Medical Director
Must designate a physician to serve as medical director.
Must be an MD or DO who is employee or under contract
When medical director not available, physician designated
by the hospice assumes the same responsibilities
Interpretive Guidelines:
There is only one medical director, including multiple locations. May
be FT/PT, may be volunteer
All other hospice physicians functions under the supervision of the
medical director
177
418.102 Medical Director
(a) Standard: Medical director contract
May contract for medical director with self-employed
physician OR a physician employed by a professional entity
or physicians group.
When contracting with group, must specify the physician who
assumes the medical director responsibilities
Interpretive Guidelines:
May be volunteer, a long as person meets all Federal and State
requirements
178
418.102 Medical Director
(b) Standard: Initial certification of terminal illness
Reviews clinical information for each patient and provides
written certification of terminal illness
Factors to examine when making terminal illness
determination
Primary terminal condition
Related diagnoses
Current subjective/objective medical findings
Current medications and treatment orders
Information about medical management of unrelated conditions
179
418.102 Medical Director
(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
Interpretive Guidelines:
Single individual assumes overall responsibility for medical
component of pt’s care.
Extends to all multiple locations
Includes overseeing implement of care for entire IDG
180
418.104 Clinical records
Correct past and current clinical information available to
attending physician and hospice staff
May be maintained electronically
181
418.104 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
182
418.104 Clinical records
(b) Standard: Authentication
Entries 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
183
418.104 Clinical records
(b) Standard: Authentication
Procedures 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 dated
184
418.104 Clinical records
(c) Standard: Protection of information
Must 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
185
418.104 Clinical records
(c) Standard: Protection of information
Procedures 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?
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.
186
418.104 Clinical records
(d) Standard: Retention of records
6 years after death or discharge unless State law says longer
If the hospice discontinues operation, it must still comply and notify
State agency and CMS Regional Office (RO) of where records will be
stored
187
418.104 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
188
418.104 Clinical records
(f) Standard: Retrieval of clinical record
Whether hard copy or electronic, the clinical record must
be readily available on request by appropriate authority
Interpretive Guidelines:
Appropriate authority includes representatives from the Surveying
Authority or other authorized entity who visit the hospice for the
purpose of determining whether the hospice is meeting all CoPs.
If EMR, the hospice must provide all equipment necessary to read
the record in its entirety. Must also produce a paper copy of the
entire record, if requested by the surveyor.
Ascertain how the hospice ensures that the record is up-to-date
including documentation of recent services/visits or handwritten
notes held by staff that were not included in the record when the
paper copy was produced.
189
418.106 Drugs/biologicals, medical
supplies, and DME
Medical Supplies, Appliances, DME, drugs and biologicals
related to the palliation and management of the terminal
illness and related conditions, as identified in the hospice
POC, must be provided by the hospice while the patient is
under hospice care.
190
418.106 Drugs/biologicals, medical
supplies, and DME
(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.
Employee or under contract
Interpretive Guidelines:
Pharmacist, Physicians or Nurses certified in palliative care
Or others who complete a specific palliative care drug management.
Must demonstrate the individual has the training.
May take place in person or through other means
191
418.106 Drugs/biologicals, medical
supplies, and DME
(a) Standard: Managing drugs and biologicals
Inpatient care directly: Pharmacy services under direction of
licensed pharmacist, including evaluation of patient’s response to
medication therapy, identification of potential adverse drug
reactions, and recommended appropriate corrective actions.
(Ensure that no drugs are obtained through Medicare Part D.)
192
418.106 Drugs/biologicals, medical
supplies, and DME
(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
193
418.106 Drugs/biologicals, medical
supplies, and DME
(c) Standard: Dispensing of drugs and biologicals
Obtain drugs from community or institutional pharmacists
or stock itself (no Canadian pharmacies)
Inpatient care directly: Written policy to promote
dispensing accuracy; accurate records
(Ensure no conflict of interest – Access/performance
rebates should not drive patient care decisions)
Interpretive Guidelines:
Biological is any medicinal preparation made from living organisms
and their products including, but not limited to serums, vaccines,
antigens and antitoxins
194
418.106 Drugs/biologicals, medical
supplies, and DME
(d) Standard: Administration of drugs and biologicals
IDG must determine, as part of POC, patient/family ability
to safely administer drugs
Inpatient care directly-Administered by licensed nurse,
physician, other health care professionals in accordance
with State requirements(family intentionally left out)
Patient may self administer upon approval by IDG
Interpretive Guidelines:
Individualized written POC should identify if pt and/or family are
self-administering. If not capable, IDG must address this in POC
195
418.106 Drugs/biologicals, medical
supplies, and DME
(e) Standard: Labeling, disposing, and storing of drugs and
biologicals
Labeled in accordance with accepted standards, including
appropriate instructions and expiration date
Interpretive Guidelines:
Must have system to ensure that outdated, mislabeled, or
otherwise unusable drugs are not provided
196
418.106 Drugs/biologicals, medical
supplies, and DME
(e) Standard: Labeling, disposing, and storing of drugs and
biologicals (cont’d)
Written policies and procedures for managing and
disposing of drugs in patient’s home
At the time when controlled drugs are first ordered, must
provide these P&P to family in a language and manner the
patient and family can understand, document discussion in
clinical record
Interpretive Guidelines:
Must also address safe use and disposal of controlled drugs at
other times, such as when discontinued, new drug ordered, or
patient dies
197
418.106 Drugs/biologicals, medical
supplies, and DME
(e) Standard: Labeling, disposing, and storing of drugs and
biologicals (cont’d)
Inpatient care directly- Dispose in compliance with hospice
policy and Federal and State requirements, maintain
current and accurate records
Inpatient care directly- Stored in secured areas in locked
compartments, only authorized personnel may have access
(double locked)
Inpatient care directly: Investigate discrepancies and report
to appropriate State authority, document investigation and
make available to appropriate authorities as required
198
418.106 Drugs/biologicals, medical
supplies, and DME
(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, must be able to demonstrate
May contract for all DME services; must only contract with
supplier meeting Medicare DMEPOS Standards
199
418.106 Drugs/biologicals, medical
supplies, and DME
(f) Standard: Use and maintenance of equipment and supplies
Interpretive Guidelines:
Instruction on use of DME and supplies must be documented
in the clinical record as well as the pt/family’s understanding
of the safe use of
Procedures and Probes:
During home visit ask the pt/family to describe any instructions
received regarding use of DME/supplies.
Has the pt/family had any problems?
Does the DME function as required and intended
Clinical record should support their responses
200
418.108 Short Term In-Patient Care
Inpatient care must be available for pain control, symptom
management and respite purposes
(a) Standard: Inpatient care for symptom management and
pain control
Provided in a Medicare-certified facility
Hospice that meets CoPs of 418.100
Hospital that meets CoPs of 418. (b) and (e)
LTC with 24 hour nursing (RN) services
201
418.108 Short Term In-Patient Care
(b) Standard: Inpatient care for respite purposes
Same 3 locations as (a)
Nursing services must meet patient needs (does not require
24 hour RN)
Typo in CoPs- Reference SHOULD be to 418.110(e) NOT (f)
Interpretive Guidelines:
Must assure that the facility has enough nursing personnel
present on all shifts to guarantee adequate safety measures
and routine, special and emergency needs of all patient are
met at all times.
202
418.108 Short Term In-Patient Care
(c) Standard: Inpatient care provided under arrangements
with written agreement
Hospice must: provide copy of the plan of care, specify services, retain
responsibility for ensuring training of facility personnel, and have a
method for verifying that the requirements of this section are met.
Facility must: have copy of plan of care, have patient care policies
consistent with the hospice, and have an identified individual
responsible for implementation of the written agreement.
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
203
418.108 Short Term In-Patient Care
(c) Standard: Inpatient care provided under arrangements
with written agreement
Interpretive Guidelines:
May have arrangements with more than one facility
Procedures and Probes
Ask the clinical manager what facility they use and how they
monitor care. If concerns, ask to review the written
agreement.
Ask how the hospice assures that all staff caring for hospice
patients have been trained in hospice philosophy and are able
to provide care according to POC. If necessary, contact or visit
the facilities to verify compliance.
204
418.108 Short Term In-Patient Care
(d) Standard: Inpatient care limitation
Total number of inpt days used by Medicare beneficiaries over 12
month period may not exceed 20% of total number of hospice days in
the aggregate.
Interpretive Guidelines:
Applies to Medicare beneficiaries only
(e) Standard: Exemption from limitation
Exemption applied between 1975 and 1986
205
418.110 Hospices that provide in-pt
care directly
(a) Standard: Staffing
Reflects volume, acuity, and intensity of services needed by
patients to achieve patient care outcomes and avoid
negative outcomes
Interpretive Guidelines
Adequate staffing means that the numbers and types of
qualified, trained and experienced staff on the inpt unit meet
the care needs of every patient.
206
418.110 Hospices that provide in-pt
care directly
(a) Standard: Staffing
Procedures and Probes:
How does the hospice assure there is adequate staff,
especially during evenings, nights, weekends and holidays?
Interview pt/family to determine if they were satisfied with
the care and services
Observe if staff is responsive to needs and if call bells are
answered promptly
Do pts frequently call for assistance?
Are pts checked frequently?
207
418.110 Hospices that provide in-pt
care directly
(a) Standard: Staffing
Procedures and Probes:
Ask hospice management for inpt staffing schedules and pt
census for the past month to determine if staffing was
adequate to meet needs
How does the hospice determine the staff-to-patient ratios on
each shift?
Review at least one clinical record to evaluate if staff provided
treatments, medications, personal care and diet in compliance
with POC
If questions arise concerning staffing patterns (illness,
tardiness), review staffing schedule and/or timecards
208
418.110 Hospices that provide in-pt
care directly
(b) Twenty-four hour nursing services
24 hour nursing services to meet patient needs
Each pt must received nursing services prescribed and must be kept
comfortable, clean, well-groomed and protected from accident, injury
and infection
If at least one patient is receiving GIP, then each shift must include a RN
who provides direct patient care
Interpretive Guidelines:
General Inpatient Care for pain control, symptom management,
which cannot be managed in other settings, is a different level of
care than respite care.
Procedures and Probes: Ask for schedule of RN personnel for past
month, inquire about mechanism to ensure RN provides direct pt care.
209
418.110 Hospices that provide in-pt
care directly
(c) Standard: Physical environment
Maintain a safe environment free of hazards
Procedures and Probes:
Ask what security mechanism are in place and being followed
Review and analyze incident and accident reports, expand
review if suspect a problem.
If hospice has identified problems, did it evaluate and take
steps to ensure a safe patient environment?
How does hospice assure staff follows current standards of
practice for environmental safety, infection control and
security?
210
418.110 Hospices that provide in-pt
care directly
(c) Standard: Physical environment
Written disaster preparedness plan for emergencies that
affect ability to provide care. Plan must be periodically
reviewed and rehearsed with staff
Interpretive Guidelines:
There should be documentation of LSC fire drills at varied
times on all shifts
211
418.110 Hospices that provide in-pt
care directly
(c) Standard: Physical environment
Procedures and Probes:
Request a copy of the disaster plan and determine if content
addresses power failures, natural disasters and other potential
emergencies
Request a copy of staff orientation/training on components of the
disaster plan
What is the procedure for notification of staff, pts, physicians and
others in the case of an emergency?
Interview random staff to assess their knowledge of specific
responsibilities during a disaster or drill
Are evacuation diagrams posted and visible?
Review evidence of planning
212
418.110 Hospices that provide in-pt
care directly
(c) Standard: Physical environment
Procedures to control trash, light, temperature, ventilation,
gas, water, and equipment
Interpretive Guidelines:
Trash refers to garbage and biohazardous waste
Disposal should be in accordance with laws and regs
Must have system to provide emergency gas and water as needed
Procedures and Probes:
Ask for explanation of system for providing emergency water and
gas and routine maintenance. Determine that maintenance
inspections are performed
How does hospice assure reliability and quality of light,
temperature, ventilation/air?
213
418.110 Hospices that provide in-pt
care directly
(d) Standard: Fire protection- compliance with 2000 edition
of the Life Safety Code
Procedures and Probes:
Is there documentation of compliance with LSC or state
requirements?
Request to see evidence that drills have been held on all shifts at
varied times
Where does the hospice document and store its dated, written
report and evaluation of each drill?
Request evidence of latest checks of fire extinguishers, sprinkler
systems, smoke alarms and observe location of each
Are there functional smoke alarms in each patient room?
Does a preventive maintenance program exist?
214
418.110 Hospices that provide in-pt
care directly
(e) Standard: Patient areas
Home-like, family accommodations, visitors at any hour
Privacy during stay and after death
Interpretive Guidelines:
Homelike de-emphasizes the institutional character of the setting to
the extent possible.
Procedures:
Interview pt/family to validate visiting hours not restricted and
accommodations during the night are provided
Observe pt areas for above requirements
Are window treatments and floor coverings homelike?
215
418.110 Hospices that provide in-pt
care directly
(f) Standard: Patient rooms
Rooms designed for nursing care, dignity, comfort and
privacy
Accommodate request for private room whenever possible
Details rooms specifics in standard and IG
No more than 2 patients per room with a waiver available if
there is an unreasonable hardship for facilities in existence
prior to Dec. 2, 2008.
Procedures:
Does each bed have flame retardant cubicle curtains, movable
screen or other means of providing full visual privacy?
216
418.110 Hospices that provide in-pt
care directly
(g) Standard: Toilet / bathing facilities- In the patient room or
nearby.
(h) Standard: Plumbing facilities- Adequate hot water supply
with temperature control valves
(i) Standard: Infection control- Program that meets § 418.60
(j) Standard: Sanitary environment– Current standards of
practice
Interpretive Guidelines/Procedures and Probes:
Review full IG/PP for above standards
217
418.110 Hospices that provide in-pt
care directly
(k) Standard: Linen Adequate supply of clean linens available; handled in a
manner to prevent spread of infection
(l) Standard: Meal service and menu planning
Consistent with patient plan of care
Palatable and attractive
Prepared under sanitary conditions
Interpretive Guidelines/Procedures and Probes:
Review full IG and PPs for above standards
218
418.110 Hospices that provide in-pt
care directly
(m) Standard: Restraint or seclusion
All patients have the right to be free from restraint or
seclusion imposed as a means of coercion, discipline,
convenience, or retaliation
Only imposed to ensure safety of patient, staff, or others
when less restrictive interventions have not succeeded
Discontinued at the earliest possible time
In accordance with a modification to the patient’s plan of
care AND a physician’s order
Interpretive Guidelines:
No standing orders or PRN
219
418.110 Hospices that provide in-pt
care directly
(m) Standard: Restraint or seclusion
Medical Director notified ASAP if attending did not order
Implemented with safe techniques
No more than 24 hours total; orders renewed every 4 hours
for adults (shorter time for pediatrics)
Face to face assessment after 24 hours before writing a new
order
Monitored by trained staff
Face-to-face evaluation every hour for violent or selfdestructive behavior
220
418.110 Hospices that provide in-pt
care directly
(n) Standard: Restraint or seclusion staff training
requirements
Staff trained before implementing seclusion or restraint
techniques, at orientation, and on a periodic basis
thereafter
Training addresses all relevant areas
Training documentation in personnel records
Interpretive Guidelines:
Review IGs and Standards for details on training and documentation
221
418.110 Hospices that provide in-pt
care directly
(o) Standard: Death reporting requirements
Report deaths associated with use of or within 24 hours
after removed from seclusion or restraint
Report deaths within 1 week of seclusion or restraint use
when reasonable to assume a relationship.
Report by phone to CMS no later than the close of the next
business day after death; document reporting in patient’s
clinical record
Interpretive Guidelines:
Review IGs for details regarding this standard
222
418.112 Hospices that provide care in
SNF/NF
There will eventually be companion regulations in the
SNF/NF rules.
These rules apply to SNF residents on Routine Home Care
(a) Standard: Resident eligibility, election, and duration of
benefits
Same as for other hospice patients
223
418.112 Hospices that provide care in
SNF/NF
(b) Standard: Professional management
Hospice assumes responsibility for professional
management of resident’s hospice care
Hospice arranges for hospice-related inpatient care
Interpretive Guidelines:
Professional management for a pt who resides in a SNF has the
same meaning as the pt living in his/her own home – all services are
provided
Involves assessing, planning, monitoring, directing, and evaluating
hospice care across all settings
Core services cannot be delegated to the facility
Facility staff should immediately notify hospice of unplanned
interventions
224
418.112 Hospices that provide care in
SNF/NF
(c) Standard: Written agreement
Signed written agreement specifying the provision of
hospice services in the facility before services begin
Agreement includes:
Communication and documentation strategy to meet patient needs
24 hours/day
Interpretive Guidelines:
Should be evidence of agreement on how to communicate concerns
and responses 24 hours/day to meet needs of pt identified in POC
225
418.112 Hospices that provide care in
SNF/NF
(c) Standard: Written agreement
Procedures and Probes:
What system is in place to assure that the facility knows how to
notify the hospice 24/7?
Is there evidence that communication is not occurring during
various times of week or specific shifts
How does hospice ensure that facility staff are able to recognize the
individual who are receiving hospice services and know that
services should be in accordance with coordinated POC?
What evidence is there of communication during and between
visits?
Does the hospice staff have access to and ability to communicate
with facility staff as often as needed?
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418.112 Hospices that provide care in
SNF/NF
(c) Standard: Written agreement
Agreement includes:
Provision for notifying hospice if: Significant change in patient
condition, Clinical complications, Need to transfer and hospice
makes arrangements and remains responsible for, Patient dies
Procedures and Probes:
Have there been instances when facility transferred pt to hospital
without notifying the hospice?
Have there been instances when the hospice was unaware of
significant change in pt status or pt death?
How does the hospice ensure that facility staff will contact the
hospice immediately with any change in pt condition?
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418.112 Hospices that provide care in
SNF/NF
(c) Standard: Written agreement
Agreement includes:
Hospice responsibility for determining hospice level of care
Facility responsibility for 24 hour room and board, meeting patient
needs as the primary caregiver (same level of services)
Interpretive Guidelines:
Both providers must comply with their application CoPs
Facility must offer same services to residents who have elected MHB
as those who have not elected MHB
If facility failed to address concerns as advised by hospice, surveyor
is to report concerns to state agency responsible for oversight of
facility.
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418.112 Hospices that provide care in
SNF/NF
(c) Standard: Written agreement (cont’d)
Agreement includes:
Hospice responsibility to provide services to same extent as serving
a patient in a private home (IG - may not delegate services to
facility staff)
Delineation of hospice responsibilities (same as in home care)
Probe:
Is there evidence that the hospice provides the services as needed,
as well as medications, equipment and supplies 24/7?
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418.112 Hospices that provide care in
SNF/NF
(c) Standard: Written agreement (cont’d)
Agreement includes:
Provision to use facility personnel to assist in implementing the plan
of care only to the extent that a hospice would routinely use a
patient’s family, (include how specific crisis situations will be
handled in the plan of care.)
Hospice reports to facility administrator all patient rights violations
by anyone unrelated to the hospice
Bereavement services to SNF/NF staff
Interpretive Guidelines:
Hospice may offer bereavement services to facility staff or residents
that fulfill the role of a pt’s family as identified in the POC
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418.112 Hospices that provide care in
SNF/NF
(d) Standard: Hospice plan of care
Established and maintained for each patient in accordance
with 418.56
Established and maintained in consultation with facility
representatives and patients/families
Interpretive Guidelines:
POC must identify which provider is responsible for performing a
specific service
Procedures and Probes:
Interview pt/family to determine their involvement in development
of POC
Determine whether all interventions have been provided by hospice
and have there been any delays?
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418.112 Hospices that provide care in
SNF/NF
(d) Standard: Hospice plan of care
Changes discussed with patient/ representative and facility
representative, and approved by hospice before
implementation
Interpretive Guidelines:
Must have a process by which information will be exchanged when
updating the POC. Hospice must authorize all changes to hospice
portion
Procedures and Probes:
Based on observations, if concerns are identified or pt/family
indicates that interventions are not meeting needs, interview
hospice and facility staff
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418.112 Hospices that provide care in
SNF/NF
(e) Standard: Coordination of services
Hospice designates IDG member to coordinate
implementation of plan of care with facility representatives
Designated individual provides overall coordination of care
with facility, communicates with facility to implement
hospice plan of care
Interpretive Guidelines:
May or may not be RN, can be any other member of IDG
Coordinate how hospice staff access/communicate with facility staff
over elements of providing services
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418.112 Hospices that provide care in
SNF/NF
(e) Standard: Coordination of services
Procedures and Probes:
Does the hospice’s system for ordering, renewal, delivery and
administration of medications work effectively in the facility?
What procedures are in place to ensure that the pt receives timely
medication and treatments?
Is the evidence that the hospice provides education to the facility on
hospice resident’s pain and symptom management plan?
Does the hospice work with the facility to monitor effectiveness of
treatments related to pain and symptom control?
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418.112 Hospices that provide care in
SNF/NF
(e) Standard: Coordination of services
Hospice ensures IDG communication with outside
physicians, beyond terminal illness
Procedures and Probes:
If problems identified regarding failure to communicate, interview
hospice designated IDG member and facility care plan coordinator in
order to determine system of communication
If concerns related to coordination and implementation of POC,
interview facility nurse aides who provide direct care to patient
Review POC to determine if plan was coordinated
Interview facility staff person who is knowledgeable about needs
and care of pt to determine if needs met
235
418.112 Hospices that provide care in
SNF/NF
(e) Standard: Coordination of services
Hospice provides facility with:
Plan of care
Hospice election form and advance directives
Certification and re-certification forms
Contact information for hospice personnel
Instructions for accessing hospice’s 24-hour on-call system
Patient-specific medication information
Physician orders – hospice and attending
Interpretive Guidelines:
Must have process by which information will be exchanged
Probes: Interview facility staff involved in care of pt on their
knowledge of how to contact hospice 24/7
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418.112 Hospices that provide care in
SNF/NF
(f) Standard: Orientation and training of staff
Hospice assures orientation of facility staff in hospice
philosophy, policies and procedures, pain control and
symptom management methods, patient rights, forms, and
record keeping.
Include rules and processes for hospice/SNF care
coordination
Interpretive Guidelines:
Hospice’s responsibility to assess need and frequency for training
Procedures and Probes:
During observations, if concerns noted, interview hospice staff on
how they provide education to facility staff
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418.114 Personnel Qualifications
(a) Standard: General qualification requirements
All professionals (direct employees, individual contractors,
and those under arrangements) must be legally authorized
to practice in the State in which they work
All professionals must only act within their scope
All professionals must keep their qualifications current at
all times
238
418.114 Personnel Qualifications
(b) Standard: Personnel qualifications for certain disciplines
Physicians- 1861(r) of the Act and §410.20
Hospice aide- Meet requirements of §418.76
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)
Interpretive Guidelines:
Must employ or contract with at least one MSW to serve in
supervisor role, may occur in person, over phone or electronic
239
418.114 Personnel Qualifications
(b) Standard: Personnel qualifications for certain disciplines
Speech-language pathologists
Occupational therapist
Occupational therapy assistant
Physical therapist
Physical therapist assistant
(c) Personnel qualifications when no State licensing,
certification or registration requirements exist
Registered nurse
Licensed practical nurse
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418.114 Personnel Qualifications
(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
WA has less restrictive requirements that meet this standard
241
418.116 Compliance with Federal, State,
and local laws and regulations related to
health and safety of patients
In compliance with all laws and regulations. (Catch all
condition)
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
Interpretive Guidelines:
Review in detail as they apply to this standard
242
Any Final Questions?
Anne Koepsell
WSHPCO
509-990-6380
[email protected]
243
Resources
CMS – http://www.cms.gov/Center/Provider-Type/HospiceCenter.html
NHPCO - http://www.nhpco.org/regulatory
Weatherbee Resources, Inc.
http://www.weatherbeeresources.com
Deyta
http://www.deyta.com
OCS Systems
http://marketing.ocsys.com
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Resources
Agency for Healthcare Research and Quality
http://www.ahrq.gov
National Quality Forum
http://www.qualityforum.org
excelleRx – (Hospice Pharmacia)
http://www.excellerx.com/excelleRx/thecompany.htm
MultiView
http://www.multiviewinc.com
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