/4: Why? HOSPICE SURVEY READINESS AND PREPAREDNESS. Historically no survey frequency requirement
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1 /4: 4/20/2015 HOSPICE SURVEY READINESS AND PREPAREDNESS I,. C. n& ILr. Katie Wehri, CHC CHPC Hospice Operations Expert Theresa Forster Vice President for Hospice Policy & Programs April 22, 2015 Why? Historically no survey frequency requirement For some hospices most recent survey predates 2008 CoPs IMPACrAct Implementation April 6, 2015 Federal recertification surveys every 36 months through 2025 Survey process not changed
2 - Types of Surveys Initial certification survey Recertification survey Complaint survey Revalidation survey Post-survey revisit BEFORE SURVEY READ and know the regulations! wwwcmsnov> Regulations and Guidance> Hospice Center> Conditions of Participation Surveyors utilize the Hospice Interpretive Guidelines from the State Operations Manual (SOM) Guidance/Guidance/Manuals/downloads/sonno7ap m hospice.pdf SHARE with staff Orientation Continuing Education 2
3 What To Plan For Prior to Survey Provide the surveyors a place to work : Provide them a person who can explain the chart layout/contents and navigate EMR : Assign a go to person for the survey with alternates >Be able to retrieve requested items timely Practice running lists and printing documents If electronic, have back-up Professionalism Practice survey interviews with stnff Information hospices need to provide 1. Organizational Chart Lines of authority, especially if multiple locations 2. Total # of unduplicated admissions in the past 12 months 1. List of current hospice patients with the a. Election date b. Services received (all disciplines) i.e. RN, Hospice Aide, etc. c. Diagnosis c. Location of services provided, i.e. residential home, SNF, ALF, etc. d. For the IPE, what level of care the patient is receiving e. Date Initial Assessment completed f. Date Comprehensive Assessment completed
4 Information hospices need to provide 4. List or access to name of patients scheduled for visits during the days of the survey 4. Admission packet 4. List of contracted facilities helpful to include address and Medicare provider number Identify in which facilities inpatient acute care and respite care are provided 5. List of contracted vendors (DME, Pharmacy, etc.) 4. List of paid staff to include DOH and job title, need to specify which are contracted staff Information hospices need to provide 9. List of volunteers with start date, job function/role i.e. patient-care, administrative patient care, or administrative non-patient 10. Bereavement Program supervisor/coordinator and access to records of individuals who have received services in the past 12 months 9. List of governing body members name, credentials and address of each officer governing body meeting minutes 9. Date(s) and time(s) of IDG reviews and Plan of Care updates 4
5 What Additional Documents You Can Expect Surveyors to Ask For: i. Current Hospice License and/or Application i. CLIA Waiver, if applicable i. Expiration date of Hospice CUA Waiver 2. CLIA Waiver and expiration date for any labs used by the Hospice 2. Contracts/Agreements and accompanying documentation: Orientation Job Description (if individual) Ongoing education (especially infection control and patient rights) Special requirements for DME, Pharmacy, etc. 5. Complaint/Grievance Records (including documentation of when Administrator notified) What Additional Documents You Can Expect Surveyors To Ask For: 6. Reports of Patient Rights Violations 7. All QAPI documents Self Assessments Plan Meeting minutes or other documentation PIPs, etc. Evidence in Assessments, POC, and visit notes Proof that improvements have taken place/ability to improve
6 What Additional Documents You Can Expect Surveyors To Ask For: 8. Volunteer documents Cost saving documentation Level of Activity (the % rule-know # of hours provided by patient care and # of hours provided by volunteers) Recruitment and Retention evidence Training (orientation and ongoing) Job roles defined staff 9. Job descriptions and personnel files for Medical Director and Alternate Administrator (and proof of appointment by governing body) Clinica Coordinator /RN Coordinator What Additional Documents You Can Expect Surveyors To Ask For: 10. Personnel Files Lice ns u refceitifi cation Orientation Competency Inservice training Criminal history Health requirements as defined by your policy Job description Anything else required by your policy * Hospice Aide Proof of HHA Registry, if applicable Documentation of hospice aide training and/or competency evaluations and in- service training 12 hours of education and proof of S hours in core curriculum If providing care in nursing facility, Hoyer lift training and competency
7 Policies and Procedures Advance Directives Patient Rights / Violation of Rights Governing Body Limitation ofservices* Benefit Election Statement Initial Assessment Comprehensive Assessment IDG policy making and oversight Authentication of medical record entries Pain management and symptom control (L512) Infection Control Information Security Incorporated in Patient Rights Policies and Procedures Provision of Services (for each discipline) Complaint (process) Plan of Care be sure to include collaboration with attending physician Medication review* Clinical records Information security Disposal of drugs QAPI program Disaster/Emergency Plans HR Policies Health Policies Adverse events be sure to define
8 Be able to show how Facility is involved in POC for patient Hospice assessment collaboration Involvement in development, approval, and review of the POC The facility is to collaborate with us on their RAI/MDS Identify which care is related to the terminal dx. and which is not (this is specified in contracts) POC must identify who is providing the service Provide documentation of ongoing communication log/plan of Care Update/Physicians Orders Collaboration DURING THE SURVEY State s Here!! Now What?! Who to call?!?! Goals for every survey, from the Entrance to the Exit Conference i) Have the survey completed in as few days as possible a) Have as little disruption to the day-to-day operations of your organization as possihle 3) Have a successful, deficiency-free outcome. KEY: The Entrance Conference sets the tone of the survey
9 - I 4/20/2015 4MTWft1 0 MIVl lAft Ur4fl anna a. wt.n I 141tC (43 HOSPICE REQUEST FOR CERTIFICATION IN ThE MEDICARE PROGRAM (4Nd V4 Nn C tn 4* ft.n lc&i 4QnM n414040,.s4,i, ftii D14.dk,. 3Il 41fl nat I_a fri a, ) t fin fll4 -nrr.,,_, I. I noa4a404 m.d wj tcfrnk On.) j g & fl 14*. C,,.a.mw. t,_ Iiy I D 404 Aa414.d.t$VwI,a l-q,.,, C C 14414* 1 ( * aoa 4*o 614d Nfl I C fl *c nina. 4 C II. tyfl.4 (44,4.4 I44Nilv fl.. * lly _Nt (( ) I. C CI.4.4daM I 1.0 cell 44,444.4*44*-, 1, $ C Pa14#a444 I Oa., 4.4 N_w4*I I U04 4 CC..n_I 1$ C(4 IC I. 1.I4*44 II. C9-C...p IV. $ b.itø.a. 1 an I. C4*,...$.ln.I.. I flbai.44 QIIb.b-..*.. I I4** b.i$i 1$1fl 144.-a. l Nft.fl II 44 4 CO414l l$ivni 04. 1r Mth i1 (flail v...,._ r II D r44nit.nws C.0 Je.-a :llnoon.0q%l n L... I 4 T470 r- r Ir ir -, Ii r- Na1444N II14414-a n,44sy 4tn 04 tam f.j4..4_n...paai N IWbI..4sM b I1.n. In I and I.$n li.d.anwy id aiim I-.a 14144$ F4.* 1$ a1 I. pa47tii....ltl$4 41*11,4 ndn p4.4-pita. I nnitel &Jn oqnnnan thtn$nI 4rn.VN 4.$a.n*a..spv.p1.I. 441* $4 4* * I4*tNaa 44 I7$44 04 L I $n CMI aug44 01 fig. DURING THE SURVEY > DO: Be Honest. Be exceptionally well organized : Assign someone to be the go-to4 person. > Have someone available (RN. in office) during hours of operation. Ask questions if you dont understand what the surveyor is saying. Pay close attention to everything that is said at the Exit Conference. > DON T: Be surprised when on-call system is checked by surveyor. Provide more information than is asked for.
10 records authority Unduplicated Mm N of Record Mm N of Record Total Record Admissions Reviews Without Review With Reviews Homevisit HomeVisk 4/20/2015 DURING THE SURVEY < or more Surveyor not correct? Surveyor requesting items not under their Surveyor access to various office locations Medical Copying, etc.
11 DURING THE SURVEY Immediate Jeopardy A situation in which the provider s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident DURING THE SURVEY Immediate Jeopardy Only ONE individual needs to be at risk Serious harm, injury, impairment, or death does NOT have to occur before considering Immediate Jeopardy Psychological harm is as serious as physical harm. 11
12 medication consequences and/or failure to corrective or preventive measures. provide medications as prescribed. infections situation to continue which resulted in serious harm or a potential for serious harm, injury, impairment or death to individuals. Past, present, future The entity either created a situation or allowed a The entity had an opportunity to implement Failure to protect from abuse Failure to protect from psychological harm Failure to prevent neglect Failure to protect from undue adverse Failure to provide adequate nutrition and Failure to protect from widespread nosocomial hydration to support and maintain health. Immediate Jeopardy Triggers Immediate Jeopardy DURING THE SURVEY DURING THE SURVEY 4/20/2015
13 DURING THE SURVEY Immediate Jeopardy Triggers Failure to correctly identify individuals Failure to safely administer blood products and safely monitor organ transplantation. Failure to provide safety from fire, smoke and environment hazards and/or failure to educate staff in handling emergency situations. EXIT CONFERENCE +Conducted at the end of the survey +The purpose: inform the hospice of observations and preliminary findings of the survey
14 I 4/20/2015 AFTER SURVEY + If deficiencies are cited, you will know what they are and you will be involved in the plan of correction Statement of Deficiencies CMS Form Depending on the type of deficiency, there maybe a revisit from the surveyors + Your hospice maybe charged for the revisit if one occurs NAMI C flny STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION I SWSI1AOOUtC7TS7AW.WCCO( (flioate $UtYCOMflXTW 1*) C I WMUAAY g.z,mrnr or ttflcenflt% nm 0V CUtflON K TAG RrCI4ATCNYCN It nrnttrimg PhFONMATCII TAG CC1t4rflMrTo ml M O4LA7ttr4CflCfl ArE*h. ntn, q d,ä.a iia.thmd,y,i. 4.NI* 4*%41 aw baabwwibv4.n.#,.dm..e.flnn,,ba *Jl. frnefldq4q4 w*r&dn..nn,lfl% 14q1 14 fl4 I,q*, n4n * 4 pb.øl v4 l t.nl4 4P1M rla...,4 I.InI.W 440&n..,An.,.II N C IWVfllN4L4ttAlA MPPLILNTA1PflWt DAFt PalM ? Dm41 PTS wo,*&it. 44l Shut P.4._at 14
15 AFTER SURVEY Form 2567 Plan of Correction How the deficiency cited has been/will be corrected + How the agency will prevent the deficiency from reoccurring in the future Who is going to be responsible for the above + How agency plans to monitor performance to ensure the improvement is sustained + By what date are you going to have the deficiency corrected + Condition level survey credible allegation of compliance AFTER SURVEY Statement of deficiencies received within 10 working days of survey exit Agency has 10 calendar days from receipt of 2567 to write the plan of correction and submit it for review Standard-level deficiencies no post survey revisit Condition-level deficiencies post-survey revisit
16 Top 25 Survey Deficiencies L543 Plan of Care (POC) L547 Content of POC (5) (1) L552 Review of POC L545 Content of POC (2). L523 Timeframe for L530 Content of Camp. Completion of Assessment (3) Assessment L629 Supervision of L560 QAPI Hospice Aides (7) L625 Hospice Aide L533 Update of Comp. Assignment and Duties Assessment (9) L647 Level of Activity L555 Coord of Svcs. (4) Top 25 Survey Deficiencies L591 Nursing Svcs. (6) L663 Training L553 Review of POC L671 Clinical Records (10) L579 Prevention L626 Hospice Aide L557 Coord of Svcs (8) Assignment and Duties L596 Counseling Svcs L548 Content of Plan of L795 Criminal Background Care Checks L538 IDG, Care Planning, Coord of Svcs L554 Coord of Svcs L651 Governing Body and Administrator
17 Payment Reform Findings/Concerns Beneficiaries dying without skilled visits in the last days of life 28.9% hospice beneficiaries on RHC did NOT receive skilled visit on day of death 14.4% of hospice beneficiaries on RHC did NOT receive skilled visit in last two days of life 6.2% of hospice beneficiaries on RHC did NOT receive skilled visit in last four days of life CMS plan: refer provider-specific data to Survey & Certification Payment Reform Findings/Concerns Utilization of GIP, CHC, Respite 21+% of hospices provided NO GIP; longest GIP stays in hospice-owned facility 40 hospices account for 46% of ALL CRC days; 58% of hospices billed no CRC days 26% of hospices billed NO Respite Care in 2012 Referrals to Survey & Certification Hospice must demonstrate availability of ALL levels of care
18 HOSPICE SURVEY READINESS AND PREPAREDNESS Lsfr Thank you for attending Katie Webri, CHC CHPC Hospice Operations Expert Theresa Forster Vice President for Hospice Policy & Programs April 22,
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