The National Hospice & Palliative Care Organization

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

2. Objectives At the conclusion of the session, the participant will: • Learn important highlights of the final Medicare • hospice Conditions of Participation (CoP) • requirements for Subpart C & D. • Know where to locate resources for implementation.

3. 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

4. Sec. 418.3: Definitions Revised based on public comments received: Bereavement counseling Clinical note Employee Hospice care Licensed professional Multiple location Restraint Seclusion • No changes: • Attending physician • Cap period • Same as proposed rule • Hospice • Palliative care • Physician • Representative • Terminally ill

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

6. SUBPART C: PATIENT CARE SEC. 418.52: PATIENT RIGHTS Replaces the existing CoP, Informed consent, at § 418.62.

7. § 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

8. § 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

9. § 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.

10. SUBPART C: PATIENT CARE SEC. 418.54: INITIAL AND COMPREHENSIVE ASSESSMENT OF THE PATIENT

11. § 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.

12. § 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 initial overall assessment of the patient/family needs • Significant issues in one area, recommend that the specialty IDG member complete the comprehensive assessment

13. § 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

14. § 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

15. § 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

16. § 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

17. § 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.

18. § 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.

19. SUBPART C: PATIENT CARE SEC. 418.56: INTERDISCIPLINARY GROUP, CARE PLANNING, AND COORDINATION OF SERVICES

20. § 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.

21. § 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.

22. § 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

23. § 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)

24. § 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

25. § 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.

26. SUBPART C: PATIENT CARE SEC. § 418.58: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT

27. § 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”.

28. § 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

29. § 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

30. § 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

31. § 418.58 Quality assessment and performance improvement • (d) Standard: Performance improvement projects • Begins 240 days after publication date of final rule • Effective date: February 2, 2009 • 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

32. § 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.

33. SUBPART C: PATIENT CARE § 418.60 INFECTION CONTROL § 418.62 LICENSED PROFESSIONAL SERVICES

34. § 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

35. § 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

36. SUBPART C: PATIENT CARE § 418.64 CORE SERVICES § 418.66 NURSING SERVICES – WAIVER

37. § 418.64 Core services • (a) Standard: Physician services • Employee or contracted • (b) Standard: Nursing services • 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 • (d) Standard: Counseling services • Bereavement counseling: under the supervision of a qualified professional with experience or education in grief or loss counseling • Development of the bereavement plan of care starts before the patient’s death.

38. § 418.64 Core services • (d) Standard: Counseling services • 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.

39. § 418.66 Nursing services – Waiver • Unlimited 1 year extensions • Difference between nursing service waiver and nurse shortage waiver • § 418.66 – • Statutory • Short term relief • Addresses need in times of peak patient loads • Nursing shortage waiver – • Chronic lack of nurses in service area • Implemented in 2004, renewed in 2006

40. SUBPART C: PATIENT CARE § 418.70 NON-CORE SERVICES §418.72 PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND SPEECH-LANGUAGE PATHOLOGY §418.74 WAIVER OF REQUIREMENT- PT, OT, SLP, AND DIETARY COUNSELING

41. Non-core Services • § 418.70 Non-core services (Same) • §418.72 Physical therapy, occupational therapy, and speech-language pathology (Same) • §418.74 Waiver of requirement- PT, OT, SLP, and dietary counseling • Unlimited 1 year extensions

42. § 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)

43. § 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

44. § 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

45. § 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

46. SUBPART D: ORGANIZATIONAL ENVIRONMENT

47. § 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

48. § 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)

49. § 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

50. § 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