The National Hospice and Palliative Care Organization

1. The National Hospice and Palliative Care Organization Navigating the New Medicare Hospice CoPs

2. The new CoPs • Focus of new CoPs • Patient centered • Emphasizes quality improvement and patient outcomes • The new CoPs are effective December 2, 2008. • Hospice providers are responsible to be compliant with the current regulations and its requirements until December 2, 2008. • 1983 CoPs with the updates to Subparts B, F, & G • Effective January 2006 • Link to current version • http://www.nhpco.org/i4a/pages/index.cfm?pageid=5494

3. Sec. 418.3: Definitions • New in the final rule • Comprehensive assessment • Dietary counseling • Initial assessment • Physician designee

4. § 418.52 Patient’s rights • (a) Standard: Notice of rights and responsibilities. • Verbally and in writing; • In a language and manner that the patient understands; and • During the initial assessment visit in advance of furnishing care. • Advance directives • Must obtain patient’s/ representative’s signature confirming receipt of copy of the notice of rights and responsibilities

5. § 418.52 Patient’s rights • (b) Standard: Exercise of rights and respect for property and person. • Report violations to hospice administrator • Investigate violations & complaints • Take corrective action if violation is verified • Report verified significant violations to State/ local bodies within 5 days of incident

6. § 418.52 Patient’s rights • (c) Standard: Rights of the patient • Pain management and symptom control. • Be involved in developing plan of care. • Refuse care or treatment. • Choose attending physician. • Confidential clinical record/ HIPAA. • Be free of abuse. • Receive information about hospice benefit. • Receive information about scope and limitations of hospice services.

7. § 418.54 Initial and comprehensive assessment of the patient • (a) Standard: Initial assessment. • Completed by RN • Must occur within 48 hours after election of hospice care • This is an assessment of the patient/family immediate needs • The purpose of the initial assessment is not to determine the patient’s eligibility for the hospice benefit, which is addressed in 418.22 and 418.24, or to orient the patient to the hospice benefit and obtain the election statement.

8. § 418.54 Initial and comprehensive assessment of the patient • The comprehensive assessment is not a single static document, a symptom and severity checklist, or a set of generic questions that all patients are asked. • It is a dynamic process that needs to be documented in an accurate and consistent manner for all patients. • Comprehensive assessment is about assessing WHAT the patient needs, not all about WHO completes the assessment.

9. § 418.54 Initial and comprehensive assessment of the patient • (b) Standard: Time frame for completion of the comprehensive assessment. • Completed by the hospice IDG in consultation with the attending physician. • Completed within 5 calendar days after the patient elects hospice care. • CMS does not dictate how the comprehensive assessment is completed

10. § 418.54 Initial and comprehensive assessment of the patient • (b) Standard: Time frame for completion of the comprehensive assessment. • Completed by the hospice IDG in consultation with the attending physician. • Completed within 5 calendar days after the patient elects hospice care. • CMS does not dictate how the comprehensive assessment is completed

11. § 418.54 Initial and comprehensive assessment of the patient • (c) Standard: Content of the comprehensive assessment. • Physical, psychosocial, emotional, and spiritual needs related to the terminal illness and related conditions • Nature and condition causing admission • Complications and risk factors • Functional status • Imminence of death • Symptom severity • Drug profile • Identify ineffective drug therapies- §418.54(c)(6)(i). • Bereavement • Referrals

12. § 418.54 Initial and comprehensive assessment of the patient • (d) Standard: Update of the comprehensive assessment. • Updated by the IDG • As frequently as the patient’s condition requires • At a minimum every 15 days • Update those sections of the comprehensive assessment that require updating. • Patient condition change - comprehensive assessment must be updated to reflect changes. • Hospices are free to choose the method that best suits their needs when documenting the comprehensive assessment and the updates to that assessment.

13. § 418.54 Initial and comprehensive assessment of the patient • (e) Standard: Patient outcome measures. • Patient level data elements must be included in each patient assessment • Data elements must be used in patient care planning and evaluation AND in the hospice’s QAPI program • Data elements must be collected and documented in a consistent, systematic, and retrievable way.

14. § 418.56 Interdisciplinary group, care planning, and coordination of services (a) Standard: Approach to service delivery • Hospice designates an IDG • Hospice designates an IDG RN to provide program coordination, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation and revision of the plan of care. • Hospice identifies a specifically designated IDG to establish day-to-day policies and procedures.

15. § 418.56 Interdisciplinary group, care planning, and coordination of services • (b) Plan of Care • The plan of care is one of the most important documents in hospice care. • IDG consults with the following to establish plan of care • Attending physician (if any); • Patient or representative; and • Primary caregiver • All services must follow a written plan of care. • Patient and primary caregiver(s) educated & trained related to their care responsibilities identified in the plan of care.

16. § 418.56 Interdisciplinary group, 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 • Detailed statement of the scope and frequency of services to meet the patient’s and family’s needs • Measurable outcomes • Drugs and treatments • Medical supplies and appliances • Documentation (in the clinical record) of the patient’s or representative’s level of understanding, involvement and agreement with the plan of care

17. § 418.56 Interdisciplinary group, care planning, and coordination of services • (d) Standard: Review of the plan of care • Revised plan of care includes: • Information from the updated comprehensive assessment • Information regarding the progress toward achieving specified outcomes and goals • Plan of care must be reviewed as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days • Completed by the IDG in collaboration with the attending physician (if any)

18. § 418.56 Interdisciplinary group, 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 • Care and services are based on assessments of the patient and family needs

19. § 418.56 Interdisciplinary group, care planning, and coordination of services • (e) Standard: Coordination of services (cont’d) • Sharing information between all disciplines providing care and services, in all settings, whether provided directly or under arrangement • Sharing information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions.

20. § 418.58 Quality assessment and performance improvement • (a) Standard: Program scope • Show measurable improvement in indicators for which there is evidence that improvement in those indicators will improve palliative outcomes and end of life support services • Replaces the existing § 418.66, ‘‘Condition of participation-Quality assurance”.

21. § 418.58 Quality assessment and performance improvement • (b) Standard: Program data • Must utilize quality indicator data, including patient care, and other relevant data, in the design of its program • Must use data collected to monitor effectiveness and safety of services and quality of care and identify opportunities and priorities for improvement • Frequency and detail of the data collection must be specified by the hospice’s governing body

22. § 418.58 Quality assessment and performance improvement • (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

23. § 418.58 Quality assessment and performance improvement • (c) Standard: Program activities • The hospice’s performance improvement activities must: • Performance activities must track adverse patient events, analyze their causes and implement preventive actions and mechanisms that include feedback and learning throughout the hospice • Take action aimed at performance improvement • Measure success of action • Track performance of action to ensure that improvements are sustained

24. § 418.58 Quality assessment and performance improvement • (d) Standard: Performance improvement projects • Hospice providers have until February 2, 2009 to demonstrate active performance improvement projects. • The number and scope of projects conducted annually must reflect the scope, complexity and past performance of the hospice’s services and operations. • Be prepared to show an operational QAPI program by December 2, 2008.

25. Quality Partner Self-Assessments • The self-assessments can help you decide where to start your Performance Improvement Projects. • Provide a 3600 assessment of your hospice operations. • Based on NHPCO’s “Standards of Practice for Hospice Programs” (2006) • Can be used by any provider member.

26. § 418.58 Quality assessment and performance improvement • (e) Standard: Executive responsibilities • Governing body ensures: • That an ongoing program for QI and patient safety is defined, implemented and maintained. • The QAPI efforts address quality of care and patient safety, and all improvement actions are evaluated for effectiveness. • That an individual(s) is designated to lead QAPI efforts.

27. § 418.60 Infection control • (a) Standard: Prevention • Follow accepted standards of practice, including standard precautions • (b) Standard: Control • Maintain a coordinated, agency-wide program for surveillance, identification, prevention, control, and investigation of infectious and communicable diseases • (c) Standard: Education • Infection control education provided to staff, patients, families, and other caregivers

28. § 418.62 Licensed professional services • (a) Services, whether provided directly or under arrangement, must be authorized, delivered, and supervised by qualified personnel • (b) Professionals must actively participate in coordinating patient care (includes: patient assessment; care planning and evaluation; and patient and family counseling and education) • (c) Professionals must participate in the hospice’s QAPI and in-service training programs

29. § 418.64 Core services • Hospice must routinely provide substantially all core services directly by hospice employees. • Nursing • Medical Social Services • Counseling • May use contracted staff, if necessary, to supplement hospice employees in order to meet the needs of patients under extraordinary or other non-routine circumstances.

30. § 418.64 Core services • May also enter into a written arrangement with another Medicare certified hospice program for the provision of core services to supplement hospice employee/staff to meet the needs of patients. • Circumstances under which a hospice may enter into a written arrangement for the provision of core services include: • Unanticipated periods of high patient loads • Staffing shortages due to illness • Other short-term temporary situations that interrupt patient care • Temporary travel of a patient outside of the hospice’s service area.

31. § 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

32. § 418.64 Core services • (b) Standard: Nursing services • Role of the registered nurse • Highly specialized nursing services maybe provided under contract • (c) Standard: Medical social services • Provided by a qualified social worker under the direction of a physician • Services to patient and family based on psychosocial assessment

33. § 418.64 Core services • (d) Standard: Counseling services • Bereavement counseling: under the supervision of a qualified professional with experience or education in grief or loss counseling • Available to family and other individuals, including residents of a SNF/NF or ICF/MR, when appropriate and identified in the bereavement plan of care • Development of the bereavement plan of care starts before the patient’s death.

34. § 418.64 Core services (d) Standard: Counseling services (cont’d) • Dietary counseling: preformed by a qualified individual such as dieticians and nurses • Spiritual counseling: Make all reasonable efforts to facilitate visits from local clergy, pastoral counselors, or other individuals who support the patient’s spiritual needs.

35. Requirements to qualify for a waiver • The location of the hospice’s central office is in a non- urbanized area as determined by the Bureau of the Census. • There is evidence that a hospice was operational on or before January 1, 1983. • Hospice made a good faith effort to hire nurses. • Waiver request is deemed to be granted unless it is denied within 60 days after it is received. • Waivers will remain effective for 1 year at a time from the date of the request. § 418.66 Nursing services – Waiver

36. Allows hospices to contract for nursing staff in a chronic nurse shortage situation • “Extraordinary Circumstance” Exemption • Hospice must notify the State Survey Agency (SSA) responsible for licensing and certification that it intends to elect an exception under the "extraordinary circumstance" authority. (written notice) • Must follow instructions in the letter; include specified detail. • Policy ends September 30, 2008. • CMS S&C-06-28 letter Nursing Shortage Exemption

37. § 418.76 Hospice aide and homemaker services • (a) Standard: Hospice aide qualifications • Completed hospice aide training and competency evaluation OR Competency evaluation, OR nurse aide training and competency evaluation, OR State licensure program • (e) Standards: Qualifications for instructors conducting classroom and supervised practical training • Training performed by RN, at least 2 years experience, with at least 1 year in homecare (home health or hospice)

38. § 418.76 Hospice aide and homemaker services (h) Standard: Supervision of hospice aides • RN onsite visit to assess the quality of care and services provided by the hospice aide (hospice aide does not have to be present during this visit) • Every 14 days • If concerns related to care and services provided by the hospice aide are noted by the supervising RN, the hospice must make an on-site visit to the location where the patient receives care • If concerns are verified the aide must complete a competency evaluation • The RN must make an annual onsite visit to observe and assess each aide while performing care • Aide must be supervised one time annually

39. § 418.76 Hospice aide and homemaker services • (i) Standard: Individuals furnishing Medicaid personal care aide-only services under a Medicaid personal care benefit • Medicaid personal care benefit services are used to the extent that the hospice would use the patient’s family in delivering care • Coordinate hospice aide services with Medicaid personal care benefit • (j) Standard: Homemaker qualifications (Reformatted) • (k) Standard: Homemaker supervision and duties • Homemaker services must be coordinated and supervised by a member of the IDG

40. § 418.78 Volunteers • (a) Standard: Training • (b) Standard: Role • (c) Standard: Recruiting and retaining • (d) Standard: Cost savings • (e) Standard: Level of activity • Hospices may count volunteer driving hours in the 5% calculation as long as they count staff driving hours

41. § 418.100 Organization and administration of services • (a) Standard: Serving the patient and family • (b) Standard: Governing body and administrator • Administrator appointed by the governing body • (e) Standard: Professional management responsibility

42. § 418.100 Organization and administration of services • (f) Standard: Multiple locations • Medicare approval before providing services to Medicare patients • The multiple location must share administration, supervision, and services with the hospice issued the certification number • Lines or authority and control must be clearly delineated • Initial determination (appeals)

43. § 418.102 Medical Director • (a) Standard: Medical director contract • A hospice may contract with a self-employed physician OR a physician employed by a professional entity or physicians group. • (b) Standard: Initial certification of terminal illness • (c) Standard: Recertification of the terminal illness- Review clinical information before recertifying • (d) Standard: Medical director responsibility- Responsible for medical component of the hospice’s patient care program • Removed: oversight for QAPI program

44. § 418.104 Clinical records • May be maintained electronically • (a) Standard: Content • (b) Standard: Authentication • (c) Standard: Protection of information • (d) Standard: Retention of records • 6 years after death or discharge unless State law says longer • (e) Standard: Discharge or transfer of care • Another Medicare/Medicaid facility- Forward discharge summary (always) and record (if requested) • Revoke election or discharge- Copy of discharge summary to attending physician (always) and record (if requested) • Discharge summary includes summary of treatments, symptoms, and pain management; current plan of care; recent physician orders; other documentation

45. § 418.106 Drugs and biologicals, medical supplies, and durable medical equipment • (a) Standard: Managing drugs and biologicals • Ensure that IDG confers with individual with education and training in drug management to ensure that drugs and biologicals meet each patient’s needs. • Inpatient care directly: Pharmacy services under direction of licensed pharmacist • (b) Standard: Ordering of drugs • Ordered by physician or NP • Verbal or electronic orders given only to licensed nurse, pharmacist, or physician and must be recorded and signed in accordance with all regulations • (c) Standard: Dispensing of drugs and biologicals

46. § 418.106 Drugs and biologicals, medical supplies, and durable medical equipment • (c) Standard: Dispensing of drugs and biologicals • Obtain drugs from community or institutional pharmacists or stock itself • Inpatient care directly: Written policy to promote dispensing accuracy; accurate records • (d) Standard: Administration of drugs and biologicals • IDG must determine patient/family ability to safely administer drugs • (e) Standard: Labeling, disposing, and storing of drugs and biologicals • Labeled in accordance with accepted standards, including appropriate instructions and expiration date

47. § 418.106 Drugs and biologicals, medical supplies, and durable medical equipment • (e) Standard: Labeling, disposing, and storing of drugs and biologicals • Written policies and procedures for managing and disposing of drugs in patient’s home, discussed with patient and family at the time when controlled drugs are first ordered, document discussion in clinical record • Inpatient care directly- Dispose in compliance with hospice policy and Federal and State requirements, maintain current and accurate records • Inpatient care directly: Investigate discrepancies and report to appropriate State authority, document investigation and make available to appropriate authorities as required

48. § 418.106 Drugs and biologicals, medical supplies, and durable medical equipment • (f) Standard: Use and maintenance of equipment and supplies • Follow manufacturer recommendations for DME maintenance • Ensure policies developed in absence of manufacturer recommendations • DME must be safe and must work as intended • Instruct patient and family in proper use of DME and supplies • Family should be able to demonstrate the proper use of the equipment back to hospice staff • May only contract for DME services with a supplier that meets the Medicare DMEPOS Supplier Quality and Accreditation Standards at 42 CFR § 424.57. • CMS link to DMEPOS accreditation information: http://www.cms.hhs.gov/MedicareProviderSupEnroll/03_DeemedAccreditationOrganizations.asp

49. DME Accreditation • DME providers must be accredited per CMS by September 30, 2009 • Hospice CoPs require contract with accredited DME providers by December 2, 2008 • Disconnect in dates! • Hospice contracted with a DME (that has a Medicare supplier number), must obtain a letter from the DME stating the DME has applied and is waiting for accreditation by the 9/09 date. • Hospice contracted with a DME that only serves hospice, (no Medicare supplier number), the hospice will need to make sure the same type of letter from the DME is in place in their files. •  If the hospice owns its own DME, then no accreditation is needed.

50. § 418.108 Short-term inpatient care • (a) Standard: Inpatient care for symptom management and pain control • Provided in a Medicare-certified facility. • (b) Standard: Inpatient care for respite purposes • Removed 24 hour RN requirement; not effective until December 2, 2008 • (c) Standard: Inpatient care provided under arrangements • Plan of care to facility • Assure facility staff are trained in hospice care • Inpatient clinical record must document all inpatient services and events; • a copy of the inpatient clinical record must be available to the hospice at discharge; and a copy of the discharge summary is provided to the hospice at discharge