8/14/2017. Learning From Our Hospice Past For A More Compliant Future. Objectives. Importance

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Janel Snow
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1 Learning From Our Hospice Past For A More Compliant Future Utilizing an Interdisciplinary Approach to Avoid Common Survey Deficiencies Objectives Identify the difference in a standard level deficiency and a Condition level deficiency Identify the deficiencies cited during a Medicare certification/re-certification survey Discuss strategies to avoid common deficiencies that lead to a Condition level finding Importance In order to participate in the Medicare program, an agency must maintain significant compliance with the Medicare Conditions of Participation IMPACT Act now requires all Medicare certified agencies to have a Medicare re-certification survey every 3 years until 2025 All surveying bodies (states or accrediting organizations) must survey for compliance with the Medicare Conditions of Participation 1

2 Regulatory Framework Federal Medicare Conditions of Participation State Operations Manual Conditions of Participation Standards L-tags State Licensure requirements Accrediting Organization Standards Condition vs Standard Condition level deficiency is when the entire condition is out of compliance or enough L- tags are deficient that it is felt the health and safety of patients is affected Requires another on-site survey Standard level deficiency is not as severe Requires a Plan of Correction Focus Areas Initial and Comprehensive Assessment of the Patient Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services Condition of Participation: Hospice Aide and Homemaker Services 2

3 Initial and Comprehensive Assessment of the Patient Developing and documenting a patientspecific comprehensive assessment that address the physical, psychosocial and emotional and spiritual needs of the patient and family. Initial & Comprehensive Assessment (a) Standard: Initial Assessment (b) Standard: Time Frame for Completion of the Comprehensive Assessment (c) Standard: Content of the Comprehensive Assessment (d) Standard: Update of the Comprehensive Assessment (e) Standard: Patient Outcome Measures Initial & Comprehensive Assessment L522 Initial assessment: The registered nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with is complete (unless the physician, patient or representative requests that the initial assessment be completed in less than 48 hours) 3

4 Initial & Comprehensive Assessment L523 Timeframe for the completion of the comprehensive assessment The hospice interdisciplinary group, in consultation with the individual s attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after the election of hospice care in accordance with Initial assessment was not completed in the location where hospice services are to be delivered Weekends and holidays were not taken into consideration Initial is not a meet and greet Timeframe is after the signing of the Election of the Hospice Medicare Benefit Initial assessment is through enough to capture all information required for the comprehensive assessment 4

5 Initial & Comprehensive Assessment The patient was admitted on 8/15/16. The primary caregiver declined social services and spiritual care visits. There is no evidence of a psychosocial assessment, bereavement assessment or spiritual care assessment on the patient/family. There is no evidence these areas were assessed by the RN Staff other than admission staff complete the admission Ensure the admission RN can appropriately describe the remaining disciplines/idt approach Ensure all IDT members are involved in completing the comprehensive assessment, even if declined by the patient 5

6 Initial & Comprehensive Assessment L525 The comprehensive assessment must take into consideration the following factors: (1) The nature and condition causing admission (including the presence or lack of objective data and subjective complaints). Documentation doesn t support eligibility Quantifiable data Forms or software Check boxes Utilize text/narrative option Ensure policy, practice, forms are in compliance Staff need to have an understanding of the relationship between their documentation and reimbursement All disciplines have a responsibility to document towards eligibility Paint the picture Be descriptive 6

7 Initial & Comprehensive Assessment L528 The comprehensive assessment must take into consideration the following factors: Imminence of death Common PItfalls Staff do not have the experience needed to accurately assess disease trajectory Knowledgeable staff Need to have a broad range of experience and disease process 7

8 Initial & Comprehensive Assessment L530 The comprehensive assessment must take into consideration the following factors: Drug Profile: A review of all of the patient s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following: effectiveness of drug therapy drug side effects actual or potential drug interactions duplicate drug therapy drug therapy currently associated with laboratory monitoring O2 not on medication profile SW documented that the patient reported that his difficulty sleeping was better since he started taking Melatonin 5 mg daily Communication among staff regarding the requirement to have an up to date medication profile Medication is added/changed/discontinuedmedication profile needs to be adjusted as well Language used with the patient and caregiver 8

9 Initial & Comprehensive Assessment L531 The comprehensive assessment must take into consideration the following factors: Bereavement. An initial bereavement assessment of the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment must be incorporated into the plan of care and considered in the bereavement plan of care. The patient was admitted on 8/15/16. The primary caregiver declined social services and spiritual care visits. There is no evidence of a psychosocial assessment, bereavement assessment or spiritual care assessment on the patient/family. There is no evidence these areas were assessed by the RN Same patient no evidence of a bereavement assessment being completed as part of the comprehensive assessment Staff other than admission staff complete the admission, i.e. on-call staff Discipline bias Scope of practice, boundary issues Ensure all staff are knowledgeable and comfortable completing the required components of the comprehensive assessment if other disciplines are not accepted by the patient and the caregiver 9

10 Initial & Comprehensive Assessment L533 Update of the comprehensive assessment The update of the comprehensive assessment must be accomplished by the hospice interdisciplinary group (in collaboration with the individual s attending physician, if any) and must consider changes that have taken place since the initial assessment. It must include information on the patient's progress toward desired outcomes, as well as a reassessment of the patient s response to care. The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days. Members of IDT do not routinely visit patients every 2 weeks and RN documentation only supports nursing needs. Ensure policy, practice, forms are in compliance to capture all of the issues faced by the patient and caregiver RN comfort level with identifying needs other than medical needs 10

11 Interdisciplinary Group, Care Planning, and Coordination of Services The interdisciplinary team approach to ensure the patient and family needs are identified and addressed on an ongoing basis. Interdisciplinary Group, Care Planning, Coordination of Services (a) Standard: Approach to Service Delivery (b) Standard: Plan of Care (c) Standard: Content of the Plan of Care (d) Standard: Review of the Plan of Care (e) Standard: Coordination of Services Interdisciplinary Group, Care Planning, Coordination of Services L539 Approach to service delivery The hospice must designate an interdisciplinary group or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. 11

12 All members of the IDT are to be available to the visiting members to support the needs of the patient and caregiver All members must be actively engaged in the IDT process to support the needs of the patient and caregiver Interdisciplinary Group, Care Planning, Coordination of Services L540 The hospice must designate a registered nurse that is a member of the interdisciplinary group to provide coordination of care and to ensure continuous assessment of each patient s and family's needs and implementation of the interdisciplinary plan of care. 12

13 Case managers responsibility to ensure the care and services are delivered in accordance with plan of care and continue to meet the patient and caregiver needs Not just responsible for their individual visit and visit note documentation Ensure IDT members are providing care to support the needs of the patient and caregiver Plan of care is updated to support newly identified needs Interdisciplinary Group, Care Planning, Coordination of Services L543 Plan of care All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient s needs if any of them so desire. 13

14 Plan of care is not individualized Every plan of care appears to meet the needs of each patient Plan of care is established to meet the patient and caregiver needs; not to be convenient for staff When problems are resolved, remove from the plan of care Do not have PGIs that are not issues for this patient Interdisciplinary Group, Care Planning, Coordination of Services L545 Content of the plan of care The hospice must develop an individualized written plan of care for each patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions 14

15 Need orders for all services being provided to meet the needs of the patient and family Includes volunteers Alternative therapies Ensure the plan of care includes all disciplines providing care to the patient and family as well as treatment orders Interdisciplinary Group, Care Planning, Coordination of Services L547 A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. 15

16 The volunteer visit frequency was indicated as PRN The skilled nurse visit frequency was indicated at 1x/week and 15 PRN and the social worker visit frequency was indicated at 1x/month and 30 PRN Visit frequencies Ranges can be used Cannot use 0 Range should be small PRN needs a quantifier and the quantifier should be small Frequent use of PRN requires an adjustment to the standing orders Interdisciplinary Group, Care Planning, Coordination of Services L549 Drugs and treatment necessary to meet the needs of the patient. 16

17 Not all medications or treatments are identified on the plan of care Record did not contain evidence of a wound or wound treatments. During the home visit, the patient's caregiver (son) talked about a wound and the treatment that the nurse provided There was not evidence of an order for oxygen. The record indicated that the patient was on oxygen at 2L/min via nasal cannula Observe staff providing care to ensure all care/treatments are ordered and provided Review the plan of care to ensure orders are complete PRN orders for treatments or medications Wound care orders are complete Interdisciplinary Group, Care Planning, Coordination of Services L552 Review of the plan of care The hospice interdisciplinary group (in collaboration with the individual s attending physician, if any) must review, revise and document the individualized plan as frequently as the patient s condition requires, but no less frequently than every 15 calendar days. 17

18 All IDT not available for team No change Same documentation for each IDT Cut-n-paste feature of electronic medical records Documentation need to validate the professional discipline IDG-not story telling but care planning Format Script Ensure all are included Document the result of the intervention Interdisciplinary Group, Care Planning, Coordination of Services L553 A revised plan of care must include information from the patient's updated comprehensive assessment and must note the patient s progress toward outcomes and goals specified in the plan of care. 18

19 All IDT not available for team No change Same documentation for each IDT Cut-n-paste feature of electronic medical records Documentation need to validate the professional discipline IDG-not story telling but care planning Format Script Ensure all are included Document the result of the intervention Interdisciplinary Group, Care Planning, Coordination of Services L555 Ensure that the care and services are provided in accordance with the plan of care. 19

20 Documentation in the medical record does not support care was provided in accordance with the plan of care Observe staff providing care to ensure all care/treatments are ordered and provided Read the documentation following the ride along visit Hospice Aide & Homemaker Services Ensure that the hospice furnishes aide services are provided by qualified staff in accordance with the plan of care. 20

21 Hospice Aide & Homemaker Services (a) Standard: Hospice Aide Qualifications (b) Standard: Content and Duration of Hospice Aide Classroom and Supervised Practical Training (c) Standard: Competency Evaluation (d) Standard: In-service Training (e) Standard: Qualifications for Instructors Conducting Classroom And Supervised Practical Training Hospice Aide & Homemaker Services (f) Standard: Eligible Competency Evaluation Organizations (g) Standard: Hospice Aide Assignments and Duties (h) Standard: Supervision of Hospice Aides (i) Standard: Individuals Furnishing Medicaid Personal Care Aide-Only Services under a Medicaid Personal Care Benefit (j) Standard: Homemaker Qualifications (k) Standard: Homemaker Supervision and Duties Hospice Aide & Homemaker Services L625 Hospice aide assignments and duties Hospice aides are assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group. Written patient care instructions for a hospice aide must be prepared by a registered nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of this section 21

22 Hospice Aide & Homemaker Services L626 A hospice aide provides services that are: Ordered by the interdisciplinary group Included in the plan of care Permitted to be performed under State law by such hospice aide Consistent with the hospice aide training Hospice Aide & Homemaker Services Not meeting the required frequency/task Written instructions are not specific to the frequency and task Providing care that is not on the plan of care Supervision of the aide plan of care 22

23 AUDIT, AUDIT, AUDIT Use of PRN or Per patient request Script for aide to follow when additional care is requested Supervisory visits of the plan of care; not a performance evaluation of the aide Include the aide Documentation of repeated refused care Aide plan of care adjusted Documentation of continued care Questions? 23

Subpart C Conditions of Participation PATIENT CARE Condition of participation: Patient's rights Condition of participation: Initial

Subpart C Conditions of Participation PATIENT CARE 418.52 Condition of participation: Patient's rights. 418.54 Condition of participation: Initial and comprehensive assessment of the patient. 418.56 Condition