Transcript Medicare COPS 2013 - Hospice of the Bluegrass

Introduction to the Medicare
Conditions of Participation
Mandatory In-Service
2013
Medicare Conditions of
Participation
• Written in 1983
• Few changes since 1983 despite changes
in the hospice industry
• Revised in 2006 by the Center for
Medicare and Medicaid Services (CMS)
Revisions to the CoPs
• Subparts, B,F,G were updated effective
January 2006
• Subparts A,C,D were revised and became
effective in December 2008
• The new CoPs are
– Patient centered
– Focused on quality improvement and patient
outcomes
Conditions of Participation
• Important to know because if hospices do
not comply with the conditions then they
could lose Medicare certification.
• Medicare covers over 80% of our patients
Hospice of the Bluegrass
• Licensed by the State of Kentucky and
adheres to Hospice State Regulations:
902 KAR 20:140, KRS 216B.042
• Medicare Certified and complies with the
Medicare Conditions of Participation
• Accredited by Joint Commission
• Governed by a Board of Directors
Staff Must Know the CoPs
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Because we must be in compliance with CMS
Because of fraud and abuse initiatives
Because they assure a certain standard of care
Because they provide a foundation for a strong
hospice program
• Because all except two conditions apply to all
hospice patients regardless of payer source.
• Those two are 1) continuation of care; 2) the 80-20
inpatient rule
Eligibility for the Medicare Hospice
Benefit
• A prognosis of six months or less if the disease
follows its expected course
• Entitle to Part A of Medicare
• Election of the Medicare Hospice Benefit from a
Medicare certified hospice
• Hospice only admits a patient on the
recommendation of the hospice’s Medical
Director in consultation with the patient’s
attending MD
Electing the Medicare Hospice
Benefit
• Medicare beneficiaries must have the
hospice benefit thoroughly explained to
them
• In “electing” to receive hospice care, other
Medicare benefits related to the terminal
illness are waived.
Patient Rights
• Hospices must provide the patient and family
notice of their rights at the time of the initial
assessment in advance of providing careverbally and in writing
• The rights must be in a language and manner
that the patient understands
• Hospice must obtain patient’s/representative’s
signature confirming receipt of copy of the notice
of rights and responsibilities
Patient Rights
• Hospice providers must
– Report violations to hospice administrator
– Investigate violations and complaints
– Take corrective action if violation is verified
– Report verified significant violations to
state/local bodies within 5 days.
What You Need to Know About
Hospice Eligibility and Election
• How to assess for and document eligibility
of patients with non-cancer diagnoses
(Local Coverage Determinants, NHPCO
Guidelines)
• How to explain the Medicare Hospice
Benefit to patients and caregivers
• That the patient’s attending physician and
the Hospice Medical Director must certify
that the patient is terminally ill
Benefit Periods
• Initial period of 90 days
• Second benefit period of 90 days
• Unlimited number of 60 day periods when
continued to be certified as terminally ill by
the Hospice Medical Director
What You Need to Know About
Benefit Periods
• Number of benefit periods
• The process for assessing continued hospice
eligibility & recertification
• The system for tracking recertification dates for each
patient
• Recertification of terminal illness signed by the
Medical Director within 2 days of a new benefit
period
• The hospice provider should determine if a patient
has ever enrolled in hospice care to determine their
benefit period
Levels of Care
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Routine Home Care
Inpatient Respite Care
General Inpatient Care
Continuous Care
Routine Home Care
• Care provided in the patient’s place of
residence
• Reimbursement is approximately $137 per
day.
• Most commonly billed level of care
Continuous Care
• Provided during times of crisis in an attempt to
keep a patient at home
• The hospice must provide a minimum of 8 hours
of care during a 24-hour day beginning/ending at
midnight
• Care need not be continuous
• Nursing services (RN,LPN) must comprise more
than half of the care and care must be provided
by employees of the hospice
• Reimbursement at approximate rate of $33/hour
Situations that may require
Continuous Care
• Uncontrolled, severe symptoms that require continuous
skilled assessment, intervention, evaluation.
• When a medical intervention that needs monitoring is
implemented (ex. IV)
• Highly unstable vital signs, e.g., diabetic management
• Severe anxiety, agitation or confusion that poses a
safety threat
• Suicide ideation or related action
• The patient’s condition is deteriorating rapidly to the
extent that death is imminent and the care needs are
beyond the physical and emotional resources of the
family.
Respite Care
• Designed to provide respite for caregivers
• Must be provided in a contracted inpatient
unit- Do not need a RN in the facility 24
hours a day
• Hospice retains professional management
responsibilities.
• Reimbursement is approximately $144 per
day and is available for a maximum of 5
days at a time
Inpatient Care
• Sometimes needed for pain and symptom
management
• Reimbursement rate is $620 per day in
contracted facility
• Treatment must conform to the patient’s
plan of care and hospice retains
professional management responsibilities.
What You Need to Know About
Inpatient Care
• How important it is to educate patient/families on
calling hospice before 911
• How to determine if a hospitalization is related or
unrelated to the terminal illness
• What hospitals the hospice contracts with
• What your responsibilities are in managing a
patient’s care while hospitalized
• The hospitalization does not mean the same as
discharge
What You Need to Know About
Inpatient Care
• Staff should educate patients and families
about hospitals that have a contractual
arrangement with Hospice of the
Bluegrass.
• If a patient is admitted to a hospital where
no contractual arrangement exists, the
hospice can either discharge the patient
using Condition Code 52 or the patient
may revoke the hospice benefit.
Payment for Hospice Care
• Based on a per diem or daily rate
according to a patient’s level of care.
• All services related to the terminal illness
are included in the per diem rate.
What The Per Diem Rate
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RN visits
Social Worker visits
Spiritual Care
Certified Nursing Assistants
PT, OT, Speech Therapy, Dietician
Volunteers
Bereavement Care
All medications related to the terminal diagnosis
DME services
Medical Supplies
24-hour on-call services
Inpatient care
Labs
Ambulance
Discharge & Revocation
• Other than death, there are two ways a
hospice can end hospice services
– The hospice can discharge the patient
– The patient can revoke the Medicare Hospice
Benefit
– To revoke the benefit, a patient must sign the
revocation
– The patient may revoke for any reason
Discharge & Revocation
Continued
• Reasons for discharge may include:
– The patient no longer has a prognosis of 6 months or less
– The patient moves out of the service area or transfers to
another hospice
– Discharge for cause- the patient’s behavior or situation is
such that care cannot be provided to the patient even
though all efforts have been made to resolve the situation
– When a hospice discharges a patient, there must be
documentation in the patient’s documentation in the
patient’s clinical record of the reason for the discharge, a
physician’s order for the discharge and evidence of
discharge planning.
General Provisions
• Compliance- a hospice must comply with the CoPs in
order to be or remain certified.
• Required Services- a hospice must provide required
hospice services including bereavement counselingBereavement must begin before the patient dies
– Some of the services, like nursing, MD and
pharmacy, must be available 24 hours/day
– Services must conform to accepted standards of
practice
Governing Body
• Assumes legal responsibility for the
hospice’s operations
• Designates administrator
• Ensures quality of care
• Approves policies and procedures
Medical Director
• A hospice must have one Medical Director
• The hospice may contract with a self-employed
physician or a physician employed by a professional
entity or a physician group
• The Medical Director may also be a volunteer
• The Medical Director is responsible for the initial
certification and recertifications
• They are responsible for the medical component of the
hospice’s patient care program
Professional Management
• Continuity of care in all settings
• Written contracts for arranged services that include:
– How services are to be provided, coordinated,
supervised and evaluated
– Delineation of roles and documentation requirements
– Professional management and financial
responsibilities for hospice
– Contracts for care
What You Need to Know
• The four levels of hospice care available to
hospice patients
• How to communicate with staff at
contracted facilities
• How to ensure that the patient’s plan of
care is followed
• How to maintain continuity of care in all
treatment settings
Initial & Comprehensive
Assessment of the Patient
• The comprehensive assessment is not a single
static document, a symptom & severity checklist,
or a set of generic questions that all patients are
asked
• It is a dynamic process that needs to be
documented in an accurate and consistent
manner for all patients
• Comprehensive assessment is about assessing
what the patient needs, not all about who
completes the assessment
Initial Assessment
• Completed by RN
• Must occur within 48 hours after election
of hospice care
• This is an initial overall assessment of the
patient and family needs
– Significant issue in one area, recommend that
the specialty IDG member complete the
comprehensive assessment
Comprehensive Assessment
• Time frame for completion of the
comprehensive assessment:
– Competed by the hospice IDG in consultation
with the attending MD
– Completed within 5 calendar days after the
patient elects hospice care
– Must be updated at least every 15 days
Plan of Care
• The plan of care is one of the most important documents
in hospice care
• All services must follow a written plan of care
• Patient and primary caregiver are educated and trained
related to their care responsibilities identified in the plan
of care
• IDG consults with the following to establish plan of care
– Attending physician
– Patient and/or representative/primary caregiver
Review of the Plan of Care
• Revised plan of care includes information from the
updated comprehensive assessment
• Information regarding the progress toward achieving
specified outcomes & goals
• Plan of care must be reviewed as frequently as the
patient’s condition requires but no less frequently than
every 15 days
• Completed by IDG in collaboration with the attending MD
More You Need To Know
• The plan of care tells the story of how and
how well the patient was cared for. That
the plan of care follows the patient from
admission through discharge regardless of
the treatment setting.
In-Service Training
• Ongoing educational/training programs
must be provided for hospice employeeswhether directly employed or under
contract.
Quality Assessment and PI
• Mechanisms for the ongoing assessment
of the quality and appropriateness of care
provided.
• Use of defined quality improvement
programs that identifies and resolves
problems and improves the care provided.
Interdisciplinary Group
• Must include MD, RN, SW and pastoral or
other counselor
• Establishes and updates the plan of care
• The RN coordinates the plan of care
Volunteers
• Hospice providers must utilize volunteers
and volunteer services must, at a
minimum, equal 5% of total patient care
hours of all paid hospice staff and
contracted employees
• Must document recruitment, retention,
orientation and training of volunteers
• Must document cost-savings
Licensure
• The hospice must be licensed if it is a
requirement of the state in which it is
located
• Employees must be licensed, certified or
registered in accordance with applicable
Federal or State law
Central Clinical Records
• One for each patient
• Entries for All services provided
– Document, Document, Document
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Initial and comprehensive assessments
Plan of Care
Identification data
Consents, election forms
Medical history
Hospice Care for Nursing Facility
Residents
• Hospice assumes responsibility for professional
management of the resident’s hospice care
• Must have a written agreement with the facility
• Hospice designates IDG member to coordinate
implementation of plan of care with facility
representatives
• Must orient facility staff to hospice care
• Hospice provides all services to nursing facility patients
that is provided in the home setting
Two Final Regulations
• Patients must be informed of their right to
formulate advance directives
• The Medicare Secondary Payer
questionnaire must be completed