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Hospice Survey Certification

Interpretive Guidance

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Hospice Survey Certification

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    1. Hospice Survey & Certification Kim Roche Centers for Medicare & Medicaid Services September 22, 2010

    2. Interpretive Guidance & State Operations Manual S & C 09-19 Advance Copy-Interpretive Guidance S & C 09-58 Advance Copy-State Operations Manual Sections 2080-2089

    3. Survey Frequency No statutory requirement Mission and Priority Document Tier 2- Five % targeted sample Tier 3- 6.5 year interval Tier 4- 6 year average Validation surveys- federal and accrediting organizations

    4. Surveyor Focus Quality of Care Patient Safety Outcomes Interdisciplinary approach on the part of the hospice

    5. Survey Tasks Pre-survey Preparation Entrance Interview Information Gathering Information Analysis Exit Conference Formation of Statement of Deficiencies (2567)

    6. Top 10 Survey Deficiencies-Hospice L545-Individualized written plan of care for each patient. L543 Hospice care and services furnished must follow an individualized written plan of care established by the Interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with pt’s needs.

    7. Top 10 Survey Deficiencies-Hospice L552-IDG must review, revise and document the individualized plan of care as frequently as the pt’s condition requires, but no less frequently than every 15 calendar days. L629-Supervision of hospice aide no less frequently than every 14 days to assess the quality of care and services provided. RN must make an on-site visit to the patient’s home.

    8. Top 10 Survey Deficiencies-Hospice L533- Update of the comprehensive assessment by the IDG , the assessment update must be accomplished as frequently as the condition of the pt requires but no less frequently than every 15 days. L523-Timeline for the completion of the comprehensive assessment-no later than 5 calendar days after the election of hospice care.

    9. Top 10 Hospice Survey Deficiencies L530-Drug Profile. Includes all of the patient’s prescription and over the counter drugs, herbal remedies and other treatments that could affect drug therapy. L547-Plan of care includes a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.

    10. Top 10-Hospice Survey Deficiencies L591-Provide nursing care and services by or under the supervision of a registered nurse. Nursing needs are met as identified in the patient’s initial, comprehensive and updated assessments. L596-Bereavement counseling-organized program, available up to a year following the death, and reflects the needs for the bereaved.

    11. Resources Hospice Center- http://www.cms.gov/center/hospice.asp Federal register notices CMS manuals Open door forums Policy memo’s Enrollment, participation & certification

    12. Contact information Kim Roche -kim.roche@cms.hhs.gov Division of Continuing Care Providers

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