Objectives. Hospice Benefit Overview: SNF/NF. Hospice in Skilled Nursing Facilities: 2018 Landscape 10/29/2018

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Hospice in Skilled Nursing Facilities: The 2018 Kimberly Skehan, RN, MSN Director, Regulatory & Quality Consulting kskehan@simione.

1 Hospice in Skilled Nursing Facilities: The 2018 Kimberly Skehan, RN, MSN Director, Regulatory & Quality Consulting Objectives Describe Medicare regulations care in skilled nursing facilities as well as CMS updates to Long Term Care Surveyor Guidance and Long Term Care RoPs applicable to hospices. Describe industry trends and additional compliance and regulatory requirements which impact care of hospice patients in the skilled nursing facility. Identify best practice recommendations for documentation, collaboration and coordination of care between hospice/skilled nursing facility providers. Q&As Hospice Benefit Overview: SNF/NF Hospice Levels of Care Routine General Inpatient Respite Continuous Home Care LLC. All Rights Reserved 1

2 Routine Home Care Primary hospice level of care provided in the home or SNF. Interdisciplinary approach to symptom management. Includes DME, supplies and medications needed for palliative level of care related to the terminal illness. Includes supplemental care, support and education for patient, family and caregivers. Bereavement Services (inc. SNF residents/staff). Continuous Home Care Short term care (minimum 8 hours) that is provided in the home/residence setting. Utilized for acute symptom management for short intervals (24 72 hours). Alternative to inpatient symptom management. Skilled nursing care must comprise more than 50% of service in 24 hour period. CANNOT be used for a patient in a SKILLED Nursing Facility bed. General Inpatient Care (GIP) Utilized for acute symptom management in a contracted inpatient facility. Requires 24 hour nursing supervision. Requires collaboration of plans of care between hospice and facility. Hospice retains primary management. Need documentation to support GIP level of care. Only utilized until symptoms are under control. LLC. All Rights Reserved 2

3 Respite Care Short term care in a contracted inpatient setting to provide relief for caregivers in the home. Allows up to 5 consecutive days. Facility must follow the hospice IDG plan of care. Hospice team should visit daily to assess patient and support staff. Caution: frequent use of respite or unusual patterns of respite may be a red flag. Documentation MUST justify the reason for caregiver relief! Medicare Conditions of Participation (CoPs) Hospices that provide hospice care to residents of a SNF/NF or ICF/IID. NOTE: this CoP is applicable to: Skilled Nursing Facilities (SNF). Nursing Facilities (NF). Intermediate Care Facilities (ICF) for Individuals with Intellectual Disabilities (IID). Medicare Conditions of Participation (CoPs) Standard: Professional Management The hospice must assume full responsibility for professional management of the resident s hospice care, in accordance with the Medicare CoPs. Standard: Written Agreement Specifies the provision of hospice services to be provided in the facility and charges for such services. Specifies the method of communication between the hospice and the SNF/NF and how this will be documented. LLC. All Rights Reserved 3

4 Medicare Conditions of Participation (CoPS) The SNF/NF or ICD/IID notifies the hospice of: Significant change in patient (physical, mental, social or emotional) or clinical complications that may require change in the plan of care. The need to transfer a patient from SNF/NF to another facility or level of care. Patient death. The hospice assumes responsibility for determining the appropriate course of care including the determination to change the level of services provided. Medicare Conditions of Participation (CoPS) Hospice is responsible for all IDG services, medical supplies, DME, drugs related to terminal illness, bereavement services. Hospice must designate IDG member responsible for overall communication. Hospice must report all alleged violations of mistreatment, abuse, neglect or misappropriation of property to the SNF Administrator within 24 hours. Medicare Hospice Conditions of Participation (CoPs) SNF/NF or ICD/IID Responsibilities: Continue to provide 24 hr room and board care. Meet the personal care and nursing needs that the primary caregiver at home would have provided. SNF staff provides the same level of care provided before hospice was elected. Provide medical direction and management for patient s medical needs not related to the terminal illness. Participate in the plan of care with the hospice along with the patient/family to the extent possible. Implement changes in the hospice plan of care. Criminal background checks. LLC. All Rights Reserved 4

5 Medicare Hospice Conditions of Participation (CoPs) Hospice must provide the SNF with current certifications, medication profiles, physician orders and plans of care. Contact information for hospice personnel. On call information. Medicare Hospice Conditions of Participation (CoPs) Orientation and Training (CFR (c)(10): Hospice staff must assure that basic orientation for SNF/NF or ICF/IID staff furnishing care to hospice patients. The orientation can include, but is not limited to: Methods of comfort. Pain control. Symptom management. Principles about death and dying. Individual responses to death. Patient rights. Appropriate forms and record keeping requirements. CMS Proposed Rule 9/17/18: Regulatory Relief establishes hospice as a joint responsibility with the nursing facility. Medicare Conditions of Participation (CoPs) Plan of Care: A written hospice plan of care must be established and maintained in consultation with SNF/NF or ICF/IID representatives and with the patient/family and in accordance with CFR To implement changes in the hospice plan of care: Any changes must be discussed with the patient or the patient s representative. Any changes must be discussed with the SNF/NF or ICF/IID representatives. All changes must be approved by the hospice before implementation. LLC. All Rights Reserved 5

Medicare Hospice Benefit: Dually Eligible Residents in a SNF For services provided to patients in nursing homes, hospices receive the Medicare routine home care rate.

6 Medicare Hospice Benefit: Dually Eligible Residents in a SNF For services provided to patients in nursing homes, hospices receive the Medicare routine home care rate. Fixed amount per day for the services provided by the hospice, regardless of the volume or intensity of the service provided. Does not include the SNF room & board charges. Most states have pass through billing requirements. CMS Requirements of Participation (RoPs) for Long Term Care Facilities The compliance date for the nursing facility interpretive guidelines: November 28, F849: (o) Hospice Services (o)(1) Hospice Service Provision: A hospice facility may arrange for provision of hospice services through written agreement with Medicare certified Hospice(s) OR Not arrange for hospice services at the facility and assist the resident in transferring to a facility that will arrange for hospice services upon resident request for transfer (o)(2) Written Agreement Contents (o)(3) Orientation and Training (o)(4) Plan of Care. Source: CMS SOM Appendix PP: Enrollment and Certification/GuidanceforLawsAndRegulations/Downloads/Appendix PP State Operations Manual.pdf Top Survey issues: Hospice/SNF Professional Management. Coordination of Care. Plan of Care. Clinical Record Documentation SNF. Service Delivery. SNF Orientation and Training. After Hours/On Call. Bereavement Services. LLC. All Rights Reserved 6

ADDITIONAL Medicare REGULATIONS IMPACTING HOSPICE/SNF Mega Rule. Prescribing of Antipsychotic Medications. Restraint Reduction Requirements for Nursing Homes.

Ensure written agreements meet Hospice/SNF requirements.

7 ADDITIONAL Medicare REGULATIONS IMPACTING HOSPICE/SNF Mega Rule. Prescribing of Antipsychotic Medications. Restraint Reduction Requirements for Nursing Homes. SO WHAT IS A HOSPICE TO DO?? Ensure SNFs/LTC facilities understand their obligations to hospice patients. Provide orientation and training as required. Ensure written agreements meet Hospice/SNF requirements. Conduct regular communication with SNF DON/staff to ensure patient s hospice needs are being met and address any concerns between the Hospice/SNF regarding service delivery and regulatory compliance. Establish Hospice/SNF oversight program. Compliance and Documentation LLC. All Rights Reserved 7

Who s Watching? Program Integrity Contractors (Auditors) Medicare Administrative Contractors (MACs). Recovery Audit Contractors (RACs). Zone Program Integrity Contractors (ZPICs).

Centers for Medicare and Medicaid Services (CMS). U.S. Department of Justice (DOJ) United States Attorneys Offices (USAOs). Federal Bureau of Investigations (FBI).

8 Who s Watching? Program Integrity Contractors (Auditors) Medicare Administrative Contractors (MACs). Recovery Audit Contractors (RACs). Zone Program Integrity Contractors (ZPICs). Unified Program Integrity Contractors (UPICs). Medicaid Integrity Contractors (MICs). State Attorneys General Offices Assistant U.S. Attorneys in the Medicaid Fraud Control Units (MFCUs). U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG). Centers for Medicare and Medicaid Services (CMS). U.S. Department of Justice (DOJ) United States Attorneys Offices (USAOs). Federal Bureau of Investigations (FBI) MedPac Recommendations for HHS/OIG Investigation: Prevalence of financial relationships between hospices and SNFs/Assisted Living Facilities. Patterns of SNF referrals to hospices. Appropriateness of enrollment patterns. Marketing materials and admission practices OIG Recommendations: Monitor Hospices that Depend Heavily on Nursing Facility Residents. Modify the Payment System for Hospice Care in Nursing Homes. Not yet LLC. All Rights Reserved 8

9 OIG Work Plan for FY 2013 Hospices Marketing Practices and Financial Relationships with Nursing Facilities Cites 2011 OIG Report 82% of hospice claims in SNFs did not meet coverage requirements and MedPAC report that hospices and SNFs may be involved in inappropriate enrollment and compensation Of note: There was no same review for patients not residing in NFs. MedPAC has also highlighted instances in which hospices aggressively marketed services to nursing facility residents. U.S. Department of Health and Human Services Office of Inspector General Vulnerabilities in the Medicare Hospice Program Affect Quality Care and Program Integrity: An OIG Portfolio Portfolio in Brief July 2018 OEI Recommended that CMS implement 15 specific actions that relate to 7 areas for improvement. Outlines compendium of OIG Reports related to Hospice since OIG states in this report: Most beneficiaries in assisted living facilities (60%), SNFs (54%) and nursing facilities (54%) had diagnoses that typically require less complex care. Government (contractor) Reviews Most prevalent currently: Unified Program Integrity Contractor (UPIC)/Zone Program Integrity Contractor (ZPIC). Goal of UPIC/ZPIC is to identify cases of suspected fraud; investigate; take action to ensure any inappropriate Medicare payments are recouped. Fraud may include things such as: Billing for services not furnished. Billing that appears to be deliberate for duplicate payment. Altering claims or medical records to obtain a higher payment amount. Soliciting, offering, or receiving a kickback or rebate for patient referrals. Billing non covered or non chargeable services as covered. LLC. All Rights Reserved 9

Hospice ZPIC/UPICs Almost exclusively the requests seen involve: Long lengths of stay. Nursing home patients. Non cancer diagnoses. (see the connection??!!) What are they focused on?

10 Hospice ZPIC/UPICs Almost exclusively the requests seen involve: Long lengths of stay. Nursing home patients. Non cancer diagnoses. (see the connection??!!) What are they focused on? Documentation to prove ELIGIBILITY of terminal prognosis (versus appearance of chronic and/or custodial). Hospice ZPIC/UPICs What are the results? a) Denials based on ineligibility b) Additional technical denials related to CTIs, F2F. c) Denials for insufficient physician narratives (CTIs). Ineligibility 1) The patient is chronic/custodial with long standing advanced diagnoses but no recent episode/series of changes to substantiate a terminal prognosis (at admission or recert). 2) The patient is in fact weakly to strongly eligible based on long standing advanced/end stage diagnoses with recent changes to substantiate a terminal prognosis but the hospice clinicians do not understand and/or have not captured the reasons for eligibility (at admission and/or at recertification). AKA: Poor Documentation 3) Patient is eligible and documentation demonstrates such but denial occurs as matter of course. LLC. All Rights Reserved 10

11 Technical Denials Requirements for regulatory forms are precise: Election of Benefits. Certification of Terminal Illness (initial and recertifications). Face to Face documentation. If these forms are lacking one or more of the required components (language, attestations, placement of statements) denials occur. Hospice/SNF Coordination: Best Practices The provision of high quality coordinated end of life care is a win win scenario for: A patient and his/her family. A nursing facility and their staff. A hospice and their staff. Patient & Family Collaboration Communication Coordination Facility & Staff Hospice & Staff Best Practice = Compliance and Quality In each hospice setting, without the 3 Cs, best practice cannot exist: Collaboration/Communication/Coordination Patient Family Hospice team. Facility administration. Facility care staff. Attending physician. At admission. With phone calls. On each visit. In response to each new symptom, change in condition, change in medication, (infection). With every change in plan of care and goal of care. LLC. All Rights Reserved 11

12 It s All About the Care Facility patients require and are entitled to the same care as all patients: Evaluation of eligibility/terminal status and recent changes. Ongoing assessment of palliative needs. Timely response to those needs. Follow up assessments of status following changes. Education of facility staff to ensure proper response to patient needs. Care Plan oversight What are the patient s and family s goals of care. Continuous education of facility staff to ensure respect of those goals of care. It s All About the Care Assessment of patients at varying times. Collaboration with other hospice team members to ensure oversight of patient care at varying times. Physical assessment; not assessment through report of a facility staff member (or reading the facility chart). Acknowledgement of roles of hospice versus facility; collaboration with facility care staff while taking responsibility and advocating for excellence in palliative care. Family meetings which include facility staff to ensure advocacy for patient wishes. Frequently Noted: Reviews of Records and Joint Visits (Predictable) visit by SN same day or week, same time for months. No adjustments made to ensure assessment of patient at another time of day (while eating etc.). Hospice patient admitted to nursing home, assessed on admission and not seen for another 7 10 days by SN. SW and Chaplain visits done on same day, monthly; or a day apart. LLC. All Rights Reserved 12

Frequently Noted: Chart Reviews and Joint Visits RN documents wound(s) as per wound care nurse at facility; does not adjust schedule to be present weekly during dressing change.

Documentation Three places that should consistently show eligibility and what you are doing for the patient: 1) Visit notes: What do you see/observe with all your senses? What do you assess?

13 Frequently Noted: Chart Reviews and Joint Visits RN documents wound(s) as per wound care nurse at facility; does not adjust schedule to be present weekly during dressing change. SN documents facility weight that appears to be a significant discrepancy; does not do/note a recheck. Plan of care is cookie cutter with entries such as communication with facility. Documentation Three places that should consistently show eligibility and what you are doing for the patient: 1) Visit notes: What do you see/observe with all your senses? What do you assess? What is different? What are you doing to care for the patient? What are you doing to alleviate suffering? What is the plan? Who did you speak with? Who did you educate? What medications have changed? Are changes being made to the POC? This Photo by Unknown Author is licensed under CC BY SA Documentation 2) Care Plan: The care plan problems, goals and interventions (PGIs) should be living and changing as does the patient. The interventions should reflect what is current for the hospice and facility responsibilities. There should be a specific problem with goals and interventions for all patients in facilities to ensure understanding of responsibility of services and cares. This Photo by Unknown Author is licensed under CC BY SA LLC. All Rights Reserved 13

Documentation 3) IDG meeting notes: The notes scribed during this meeting should reflect discussion between team members (and facility staff) to show current goals and collaboration to meet these

This Photo by Unknown Author is licensed under CC BY Documentation Standards Documentation by hospice professionals must show: Collaboration, coordination and communication with Hospice team members.

14 Documentation 3) IDG meeting notes: The notes scribed during this meeting should reflect discussion between team members (and facility staff) to show current goals and collaboration to meet these goals. (IDG meeting notes should not be duplicative/redundant visit notes). This Photo by Unknown Author is licensed under CC BY Documentation Standards Documentation by hospice professionals must show: Collaboration, coordination and communication with Hospice team members. Facility staff. Physician(s) Patient/Family. Follow up Goals of care discussions*. Family meeting discussions*. This Photo by Unknown Author is licensed under CC BY NC ND Documentation Standards A hospice record should read like a book; Chapters should not be missing: The book of a patient transitioning to dying should have a brief chapter by the chaplain who notes being called by the RN due to the change in condition. The book of a patient who moves to a NF should not have a note from the SW 3 weeks later noting the move without any previous notes/involvement. A Hospice RN who notes that patient improved after antibiotic should occur after a previous chapter which documented signs or symptoms of an infection and/or the notification from facility regarding change in patient condition. There should also be a medication entry on the hospice med list regarding an antibiotic. Discharge from hospice; be it revocation, discharge or death should rarely happen without a story leading up to or surrounding the scenario. When the story is not told, the hospice likely was not doing their job. LLC. All Rights Reserved 14

15 Excellence in Facility Hospice Care Building Successful Partnerships: Common goal is excellent care for the patient What does the patient and family want? Collaborative needs team work when on site. Understanding that the residents may be family to the facility staff. Warmly acknowledging and respecting staff and other residents/family members. Educating through conversation and through role modeling. Staff orientation/training and support to encourage discussion and questions; hospice eligibility. Excellence in Facility Hospice Care Building Successful Partnerships: Identification of care plan in both the SNF and the hospice clinical record. SNF staff become part of the IDG when a resident elects hospice care. Communication/Dispute resolution. Collaborative hospice care plan development. Physician order. Therapies Notification of changes in status, injury, death. Bereavement services. Hospice SNF Oversight/Trending Clinical Record Review. Look at Timeliness/Accuracy of Documentation. Documentation of related/unrelated diagnoses, medications, supplies and DME. Use of LCDs Compliance with Documentation. Hospice CAHPS. Hospice Compare: HQRP Measures and benchmarking. GIP Utilization. SNF Coordination. Contract Compliance. LLC. All Rights Reserved 15

16 Food for Thought Approximately 41.9% of hospice patients reside in nursing facilities. (NHPCO Facts and Figures 2017) (Inclusive of skilled nursing facilities, nursing facilities, assisted living facilities and RHC days in a hospice inpatient facility. Is this a huge percentage based on longevity from exceptional medical care now available? Do your facility patients receive the same oversight, services and palliative care and follow up that your home care patients do? Hospice/SNF Coordination: Best Practices Consistent communication, collaboration, coordination and documentation are the keys to success! Questions? Contact Information Kimberly Skehan, RN, MSN Director, Regulatory & Quality Consulting kskehan@simione.com Simione Healthcare Consultants, LLC 4130 Whitney Avenue Hamden, CT (office) (toll free) LLC. All Rights Reserved 16

NURSING FACILITIES: FRIENDS OR FOES? Marie C. Berliner Joy & Young, LLP Austin, Texas (512)

NURSING FACILITIES: FRIENDS OR FOES? Marie C. Berliner Joy & Young, LLP Austin, Texas (512) 330-0228 Program Overview Status of Hospice Nursing Facility Relationships Multiple contact points and transactions