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GOVERNING BODY AUTHORIZATION... 3 Compliance Program Introduction... 4 Compliance Officer Introduction... 5 COMPLIANCE POLICY... 6 COMPLIANCE PLAN... 7 COMPLIANCE PROGRAM... 8 Compliance officer... 8 Compliance Program Reporting System... 8 Staff Education and Training... 9 Hiring Practices... 9 Compliance Program Audit and Monitoring Functions... 10 Disciplinary Action... 11 Response and Corrective Action... 11 Retention of Records... 13 Evaluation of Compliance Program... 13 EDUCATION AND TRAINING... 14 Compliance Self Study... 14 What is a compliance program?... 14 Why do we have a compliance program?... 14 Hospice Risk Areas... 14 What are the components of the Compliance Program?... 15 When to use the reporting system... 15 What to expect... 15 Enforcement and Discipline... 15 Compliance Post Test... 16 HOSPICE RISK AREAS RELATED TO THE MEDICARE CONDITIONS OF PARTICIPATION FOR HOSPICE CARE... 18 Risk Area: Uninformed consent to elect the Medicare Hospice Benefit... 19 Risk Area: Admitting patients to hospice care who are not terminally ill... 20 Risk Area: Under utilization... 21 Risk Area: Falsified medical records or plans of care... 22 Risk Area: Inadequate or incomplete services rendered by the interdisciplinary group.... 23 Risk Area: Insufficient oversight of patients, in particular, those patients receiving more than six months of consecutive hospice care... 24 Risk Area: Hospice incentives to actual or potential referral services that may violate the anti kickback statute or similar federal or state statute or regulation... 25 Risk Area: Overlap in the services that a nursing home provides, which results in insufficient care provided by a hospice to a nursing home resident... 26 Risk Area: Improper relinquishment of core services and professional management responsibilities to nursing homes, volunteers and privately paid professionals... 27 Risk Area: Providing hospice services in a nursing home before a written agreement has been finalized... 28 Risk Area: Pressure on a patient to revoke the Medicare Hospice Benefit when the patient is still eligible and desires care but the care has become too expensive for the hospice to deliver.... 29 Compliance Manual 1

Risk Area: False dating of amendments to records.... 30 Risk Area: Inadequate management and oversight of subcontracted services, which results in improper billing... 31 Risk Area; Sales commissions based upon length of stay on hospice... 32 Risk Area: Failure to comply with applicable requirements for verbal orders for hospice services.... 34 Risk Area: Non response to late hospice referrals by physicians... 35 Risk Area: Knowing misuse of provider certification numbers, which result in improper billing.... 36 Risk Area: Failure to adhere to hospice licensing requirements and Medicare conditions of participation.... 37 Risk Area: Knowing failure to return overpayments made by federal healthcare programs.... 38 HOSPICE RISK AREAS RELATED TO BILLING... 39 Risk Area: Billing for a higher level of care than was necessary.... 39 Risk area: Arrangement with another healthcare provider who a hospice knows is submitting claims for services already covered in the Medicare Hospice Benefit... 40 COMPLIANCE PLAN EFFECTIVENESS TOOL... 42 Standards of Conduct... 42 Compliance Officer... 43 Policies and Procedures and Hospice Risk Areas... 44 Staff Education and Training... 45 Reporting System... 46 Audits and Monitoring... 47 Enforcement, Discipline and Hiring Practices... 48 Response and Corrective Action... 49 INVESTIGATIONS... 50 Report Activity Log... 50 Compliance Oral Inquiry Log... 51 Report Investigation and Follow Up Log... 52 Summary... 53 AUDIT TOOL... 54 Certification/Recertification... 54 Notes... 54 Certification/Recertification... 55 Utilization of Service... 56 Utilization of Service... 57 Nursing facility Program Compliance... 58 Nursing facility Program Compliance (cont)... 59 Hospice Marketing Materials Compliance... 60 Contract Compliance... 61 COMPLIANCE HOTLINE... 62 Compliance Manual 2

GOVERNING BODY AUTHORIZATION The Governing body assumes full legal responsibility for approving, implementing, and monitoring policies governing Compassionate Care Hospice. The Governing body is committed to ensuring that individuals and entities associated with Compassionate Care Hospice comply with all legal and ethical obligations and that all services provided are consistent with accepted standards of practice. As evidence of this commitment, the Governing body authorizes the creation of a compliance program to detect, prevent, and correct violations of law. In particular, the compliance program will respond to the areas of concern outlined in the Office of the Inspector General s Compliance Program Guidance for Hospices. The Governing body resolves to allocate sufficient financial and personnel resources to ensure the effectiveness of Compassionate Care Hospices compliance plan. Milton Heching, Chief Executive Officer Date Judy Grey MPA, RN, C Chief Operating Officer Date Cathy Stauffer MPA Senior Vice President Date Compliance Manual 3

Compliance Program Introduction Dear Employee, I am pleased to announce Compassionate Care Hospice s development and implementation of a Corporate Compliance program under the direction of Stella Hardy, RN, CHPN. The compliance program will be important in our organizational structure to detect and prevent violations of federal and state laws and regulations. The compliance program will assure that the organization s policies and procedures provide for operations in accordance with regulatory requirements as well as ethical and professional standards of conduct. Shortly you will be receiving an introductory letter from Stella which will include an introduction to the compliance program and its benefit to Compassionate Care Hospice. I am sure you will join me in welcoming Stella to this new role. Sincerely Judy Grey MPA, RN, C Chief Operating Officer Compliance Manual 4

Compliance Officer Introduction Dear Staff Member, By now you should have received a letter from Judy Grey, Chief Operating Officer announcing Compassionate Care s development of a Compliance plan. This letter is to introduce the program and let you know more about the compliance plan. I am very excited to share with you the compliance plan and program. The compliance program demonstrates an organization s commitment to conducting business according to the highest ethical standards. The compliance program will provide the program with additional processes to ensure the integrity o f the hospice s mission and that values are maintained by every person and entity involved in Compassionate Care s business. Over the next few months I will be auditing all our offices and providing you more information about the compliance program. In the interim I would ask you to review and sign the attached Standards of Conduct and policy for reporting suspected wrongdoing or violations of the standards of conduct and complete the compliance self study test. These should then be returned to your supervisor. If you have any questions or concerns please be assured that all employees identities are protected by law, without fear of retaliation and that all complaints or reports will be investigated thoroughly. You may choose to speak with your supervisor or a member of the compliance team can be contacted at: 140 Littleton Road Parsippany NJ 07054 Office 973 402 4715 Stella Hardy Cell 201 218 8589 Lillian Montalvo 201 281 6859 Or Email at shardy@cchnet.net lmontalvo@cchnet.net Sincerely Stella Hardy RN CHPN Director of Corporate Compliance Compliance Manual 5

COMPLIANCE POLICY PURPOSE Defines the program and procedures implemented to maintain compliance. POLICY In an effort to conduct business according to the highest ethical standards and in compliance with federal and state laws and regulations, the organization maintains a compliance program that is described in the organization s compliance plan. Compliance Manual 6

COMPLIANCE PLAN The compliance plan demonstrates a commitment to comply with federal, state, and private insurer standards. The plan identifies and corrects any instances of non compliance. The compliance plan comprises the following: Standards of conduct to which all employees must adhere; Designation of a compliance officer to oversee the compliance plan A reporting system is available for employees to report violations of the standards of conduct without fear of retribution; A comprehensive staff education and training program; Auditing and monitoring functions; Enforcement of the compliance plan and disciplinary actions for violators; Commitment to not hiring individuals or working with business entities that have been sanctioned, debarred, or otherwise excluded from participating in federal healthcare programs; Commitment to corrective action; Adherence to the compliance plan is a condition of employment for all hospice personnel. Compliance Manual 7

COMPLIANCE PROGRAM Compliance officer POLICY A compliance officer is designated to implement, maintain and evaluate the compliance program. The compliance officer provides direction and accountability for the plan. The compliance officer reports to the governing body The compliance officer s duties and responsibilities are detailed in the Director of corporate compliance job description. Compliance Program Reporting System POLICY An open line of communication between hospice employees and the compliance officer is facilitated by a reporting system that hospice personnel may use to ask questions, raise concerns, or voice complaints. PROCEDURE Hospice employees are educated on and encouraged to use available direct communication channels with supervisors, the compliance officer or other involved persons to raise questions and concerns. All reports receive prompt and thorough attention, consideration and investigation if warranted Assurance of anonymity Assurance of no retribution Hospice personnel are responsible to report any suspected violation or wrongdoing. Compliance Manual 8

Staff Education and Training POLICY Compassionate care hospice provides an ongoing program for the training of employees, physicians, independent contractors and other significant agents on matters related to the compliance program, fraud and abuse, ethical practices, and compliance with federal and state hospice regulations. PROCEDURE A compliance education program is developed and implemented on an annual basis. Compliance training is included in the orientation of all new employees and volunteers. In service records are maintained. Attendance and participation in the staff education and training program is a condition of employment and failure to participate may result in disciplinary act Hiring Practices POLICY Employment will only be offered to individuals who meet the organization s hiring criteria as detailed in Policy 4001. PROCEDURE All potential employees will be required to meet the requirements in policy 4001 of pre employment checks and possession of appropriate licenses and documentation. Compliance Manual 9

Compliance Program Audit and Monitoring Functions POLICY Compassionate Care Hospice conducts ongoing, comprehensive, and integrated self assessment of the quality and appropriateness of hospice operations, including the regular auditing and monitoring of compliance activities. The findings are used by the hospice to identify and resolve problems and make suggestions for improving operations and the compliance program. PROCEDURE Compassionate Care Hospice programs will be audited at least annually by the Director of Corporate Compliance. The audit will be based on the Office of the Inspector Generals identified twenty eight risk area for hospice related to four categories: Related to Medicare conditions of participation for hospice care; Related to marketing; Related to billing; Related to provision of care in nursing facilities. A plan of correction will be developed by the program director and implemented to correct and comply with applicable statutes, regulations, and federal requirements. Reports of auditing and monitoring of compliance activities are included in the annual review of the hospice program. Compliance activities are maintained by the director of compliance and reported to the governing body. The regular auditing and monitoring activities of the compliance activities are included in the annual review of the hospice. Compliance Manual 10

Disciplinary Action POLICY Disciplinary action is taken against corporate officers, managers, employees, or other healthcare employees who fail to comply with the hospice s Standards of Conduct, policies and procedures, or federal and state regulations governing hospice programs. PROCEDURE It is the responsibility of supervisory staff to counsel staff when performances, behavioral or personal conduct problems affect their work, or when policy has been violated. Under most circumstances, an employee will receive constructive feedback and ample opportunities to overcome deficiencies. Under certain circumstances an employee may be terminated with little or no opportunity to overcome deficiencies. Staff may be disciplined by verbal discussion/counseling, written guidance, second written guidance/probation or discharge. The severity of the disciplinary action must be in proportion to the seriousness of the infraction, the employee s overall performance record and the type of action that would best impress the need for improvement [Policy 4010]. Response and Corrective Action POLICY Reports of potential wrongdoing or suspected fraud and abuse are thoroughly investigated, and documented, and if appropriate reported to federal or state authorities. If warranted, immediate corrective action is applied to prevent further occurrences. PROCEDURE Reports of potential wrongdoing or suspected fraud or abuse will be investigated promptly by the director of corporate compliance, documented and reported to the governing body. When appropriate, under the direction of legal counsel prompt reporting to federal or state authorities. Corrective action protocols to prevent further occurrences. If overpayments are identified, prompt repayment to the source. Compliance Manual 11

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Retention of Records POLICY To comply with applicable law and regulation regarding the retention of medical records. PROCEDURE The clinical record will be retained for a period of years as stipulated by state law in which the service was delivered. For minors the retention requirement begins upon reaching age 21. Compliance investigation reports and audit results will also be retained for the same period as the clinical record. Evaluation of Compliance Program POLICY The compliance program is monitored and evaluated on a continual basis to ensure that it is effective in identifying and correcting instances of potential wrongdoing, fraudulent activity and violations of the standards of conduct. PROCEDURE The compliance program will be evaluated annually using the Compliance Program Effectiveness audit tool. Outcomes will be reported to the governing body. Compliance Manual 13

EDUCATION AND TRAINING Compliance Self Study What is a compliance program? Systems and procedures that help to ensure compliance federal and state regulations that pertain to hospice. An attempt to do the right things well. An attempt to detect, prevent and correct any wrongdoing, illegal activity or fraud and abuse; and A compliance program is voluntary, just like accreditation is voluntary. However, compliance with laws and regulations is mandatory and a compliance program helps a hospice make sure it is not breaking any laws or committing fraud. Why do we have a compliance program? Most sectors of healthcare have developed or are in the process of developing them. The Office of the Inspector General [OIG] has identified certain areas in which healthcare providers are at risk for committing fraud and abuse. The OIG provided guidelines for hospices that wished to develop a compliance program. The compliance program helps improve hospice operations; An effective compliance program can reduce fines and penalties if wrongdoing is discovered and reported to the government. Hospice Risk Areas OIG discovered certain fraudulent practices and identified areas of vulnerability for hospice programs. Examples include but are not limited to; Informed consent Eligibility for hospice care Underutilization Falsifying documentation Nursing home program problems Inappropriate marketing practices Billing irregularities. Compliance Manual 14

What are the components of the Compliance Program? Standards of conduct Policies and procedures Staff education A reporting mechanism A compliance officer Careful hiring practices Regular audits and monitoring Enforcement and discipline Response to and corrective action of any wrongdoing. Compliance Officers The compliance officers of Compassionate Care Hospice are Stella Hardy RN CHPN and Lillian Montalvo RN BSN The compliance officer can be reached by phone confidentially at 973 402 4715. By Email at shardy@cchnet.net or lmontalvo@cchnet.net When to use the reporting system When other communication channels are not appropriate To seek clarification of the hospice policies and procedures and legal requirements To report suspected fraud, abuse and waste To report violations of the Standards of Conduct, federal and state laws and regulations or hospice policies and procedures To report anything that seems suspect and damaging to the hospice reputation or integrity. What to expect Prompt investigation of the claim if deemed pertinent to the compliance program confidentiality. Enforcement and Discipline All employees must follow the Standard of Conduct Any employee, no matter what their position who violates the Standard of Conduct is subject to the same level of discipline. Compliance Manual 15

Compliance Post Test Name Date 1. The purpose of the compliance program is: A. To detect, prevent, and correct any potential wrongdoing. B. To make sure all employees follow the Standards of Conduct. C. To make sure Compassionate Care complies with federal, state laws and Regulations D. All of the above. 2. My role in the compliance program is: A. To understand and follow the agency s Standard of Conduct B. To report any wrongdoing C. To ask any questions when I am not sure of the right thing D. All of the above 3. The primary purpose of the reporting system is for me: A. To complain about my supervisor B. To complain about my job C. To report to the compliance officer anything I suspect might be unlawful, Wrong, or in violation of the Standards of Conduct D. All of the above 4. What is the name of the compliance office and how can you contact her? 5. If a hospice manager violates the Standard of Conduct or commits fraud they will A. Receive the same level of discipline as everyone else B. Have a chance to correct the mistake C. Be disciplined more severely D, None of the above 6. Name two areas of risk Compliance Manual 16

7. A good way to think about whether something might be wrong or illegal is if: A. I would not want to hear about it on the evening news B. I would not want to read about it in the newspaper C. I would not want to tell my family or friends D. All of the above. 8. The reason Compassionate Care has a compliance program is because: A. The government says we have to B. It will help us make sure we are doing the right things C. Every other hospice does D. Without it, we would be surveyed more often. SCORE /8 SIGNED DATE Compliance Manual 17

HOSPICE RISK AREAS RELATED TO THE MEDICARE CONDITIONS OF PARTICIPATION FOR HOSPICE CARE The Office of the Inspector General s Guidance document identifies 28 hospice risk areas and states that additional risk areas may be assessed by individual hospice programs and incorporated into their policies and procedures. While there is no requirement that a hospice compliance plan include policies and procedures for each risk area, they identify areas of vulnerability for hospice programs to consider. This section documents the risk areas specified by the OIGs guidance statement and are referenced to Compassionate Care Hospices current policy and procedures. Appendix A contains hospice related documents from the OIG which helps explain why the OIG provides scrutiny in certain areas. The risk areas are organized according to four categories; Related to the Medicare Conditions of Participation for Hospice Care Related to marketing Related to billing Related to the provision of care in nursing homes Compliance Manual 18

Risk Area: Uninformed consent to elect the Medicare Hospice Benefit Policy: Compassionate Care Hospice policy # 2012 OIG Statement A hospice must ensure that an individual or authorized representative is in formed about the palliative nature of the care and services that may be provided if the individual desires to elect the Medicare Hospice Benefit.42CFR 418.62. The decision to elect the Medicare Hospice Benefit has significant consequences because the patient waives the right to receive standard Medicare benefits related to the terminal illness, included all treatment for the purpose of curing the terminal illness. A patient s hospice election must include the following items of information:[1] identification of the particular that will provide care to the individual;[2] the individual s or representative s acknowledgement that he or she has been given a full understanding of hospice care;[3] the individual s acknowledgement that he or she understands that certain services are waived by the election;[4] the effective date of the election and [5]the signature of the individual or representative. Compliance Manual 19

Risk Area: Admitting patients to hospice care who are not terminally ill Policy: Compassionate care Hospice policy # 2006 OIG Statement For a hospice patient to receive reimbursement for hospice services under Medicare, the patient must be terminally ill. A patient is considered to be terminally ill if the individual has a life expectancy of six months or less if the disease runs its natural course. 42 CFR 418.3 Compliance Manual 20

Risk Area: Under utilization Policy: Compassionate Care Hospice policy # 1022 OIG Statement In other words, knowing denial of needed care in order to keep costs low. A hospice is accountable for the appropriate allocation and utilization of its resources in order to provide optimal care consistent with the needs of the patient, family and or representative. When a patient is receiving hospice care, the hospice is paid a predetermined fee for each day during the length of care, no matter how much care the hospice actually provides. This means that a hospice may have a financial incentive to reduce the number of services provided to each patient, because the hospice will be paid regardless. The OIG has received complaints about hospices neglecting patients needs and ignoring reasonable requests for treatment, including complaints about limited availability of durable medical equipment for patients as their medical condition decreases, and failure to provide continuous care during periods of crisis due to staff shortages. The OIG has also been alerted to improper utilization of services that occurs when a hospice encourages a patient to revoke the Medicare Hospice Benefit for the purpose of obtaining expensive services under standard Medicare benefits, only to reelect the Medicare Hospice benefit when expensive care is no longer needed. Compliance Manual 21

Risk Area: Falsified medical records or plans of care Policy: Compassionate Care Policy #2010 and #5001 OIG Statement OIG investigations have revealed that certain hospices have falsified patient medical records and plans of care to exaggerate the negative aspects regarding a hospice patient s condition to justify reimbursement. Compliance Manual 22

Risk Area: Inadequate or incomplete services rendered by the interdisciplinary group. Policy: Compassionate Care Hospice policy # 2010 and # 1022 OIG Statement Each hospice is required to have an interdisciplinary group of personnel. Failure of the team to meet its responsibilities may result in substandard care. In addition, inadequate review of a patient may result in improper reimbursement for services provided to a patient who may be eligible for Medicare Hospice Benefit. Compliance Manual 23

Risk Area: Insufficient oversight of patients, in particular, those patients receiving more than six months of consecutive hospice care Policy: Compassionate care Hospice policy # 2010 OIG Statement Since the enactment of the Balanced Budget Act of 1997, the Medicare Hospice Benefit is divided into the following benefit periods:[1] initial 90 day; [2] subsequent 90-day; and [3] unlimited 60 day benefit periods as long as patient meets program eligibility requirements. At the beginning of each subsequent benefit period the hospice physician must recertify that the patient is terminally Ill. If the necessary oversight is not performed a provider may receive improper reimbursement for services to a patient no longer eligible for hospice care. Compliance Manual 24

Risk Area: Hospice incentives to actual or potential referral services that may violate the anti kickback statute or similar federal or state statute or regulation. Policy: Compassionate care hospice policy # 1009 OIG Statement: Examples of arrangement that may run afoul of the anti-kickback statute includes practices in which a hospice pays a fee to a physician for each certification of terminal illness, or provides nursing, administrative and other services for free below market value to physicians, nursing homes, hospitals and other referral sources with intent to influence referrals. See 42 U.S.C 1320a-7b;60fr40847 {1995} The OIG has also observed instances of potential kickbacks between hospices and nursing homes to unlawfully influence the referral of patients. In general, payments by a hospice to a nursing home for room and board provided to a Medicaid hospice patient should not exceed what the nursing home would receive directly from Medicaid, if the patient had not been enrolled in hospice. Compliance Manual 25

HOSPICE RISK AREAS RELATED TO MARKETING Risk Area: High pressure marketing of hospice care to ineligible beneficiaries Policy: Compassionate care hospice policy # 1014 and 1009 OIG Statement Hospices should not utilize prohibited or inappropriate conduct [e.g. offer free gifts or services to patients] designed to maximize business growth and patient retention, to carry out their initiatives and activities. Also, any marketing information offered by hospices should be clear, correct, non deceptive, and fully informative. Through ORT, it was discovered that hospice marketing materials had placed considerable emphasis on the availability of hospice benefits for the long term care patients and considerably downplayed the terminal status eligibility. Hospices should not engage in marketing and sales strategies that offer incomplete or inadequate information about Medicare entitlement under the Medicare hospice benefit. Marketing statements should not create the perception that the initial terminal prognosis is of limited importance and that hospice benefits may routinely be provided over an indefinite period. Risk Area: Overlap in the services that a nursing home provides, which results in insufficient care provided by a hospice to a nursing home resident. Policy: Compassionate care hospice policy #1022 OIG Statement There may be some overlap in the services that the nursing homes and hospices provide thereby providing one or the other the opportunity to reduce services and costs. Recent OIG reports found that residents of certain nursing homes receive fewer services than those who receive hospice care in their own homes. Upon review it was found that many nursing home patients were receiving only basic nursing and aide visits that were provided by the nursing home when the hospice was not present. Other additional treatments provided by hospice staff, such as nursing and aide visits were often clearly within the professional skills provided by the nursing home staff. The reports found that the nature of the services provided by the hospice, while appropriate and efficacious appeared to differ little from services a nursing home would have provided had the patient not enrolled in hospice. Compliance Manual 26

Risk Area: Improper relinquishment of core services and professional management responsibilities to nursing homes, volunteers and privately paid professionals Policy: Compassionate care hospice policy #1014, 1022 OIG Statement Certain of the hospice services [i.e., core services such as medical, nursing, social and counseling services] must be provided directly to the patients by employees of the hospice, while other non core services may be provided at fair market value in accordance with contracts with other providers. However, the hospice must retain professional management for all contracted services. Compliance Manual 27

Risk Area: Providing hospice services in a nursing home before a written agreement has been finalized. Policy: Compassionate care hospice policy #4017 OIG Statement A person who resides in a skilled facility may elect the Medicare hospice benefit if the residential care is paid for by a] beneficiary or private insurance; b] Medicaid; c] the hospice and facility have a written agreement under which the hospice takes full responsibility for the professional management of the individuals hospice care and the facility agrees to provide room and board. Compliance Manual 28

Risk Area: Pressure on a patient to revoke the Medicare Hospice Benefit when the patient is still eligible and desires care but the care has become too expensive for the hospice to deliver. Policy: Compassionate care hospice policy # 2024 and 2025 OIG Statement Fiscal intermediaries have informed OIG that hospices rarely offer the reasons supporting the revocation of a patients Medicare Hospice Benefit. Although a hospice may discharge a patient if it discovers the patient is not terminally ill, hospices should not encourage a patient to revoke merely to avoid the obligation to pay for hospice services that have become too costly. Compliance Manual 29

Risk Area: False dating of amendments to records. Policy: Compassionate care hospice policy #5001 and 1009 OIG Statement If additions or corrections need to be made to a clinical record, hospices should make such entries according to standards of practice and applicable state law. For example hospices might correct a medical record by drawing a single line through the erroneous entry, writing error next to the entry, initialing and dating the correction, writing the correct information near the entry or writing where the correct information can be found. Compliance Manual 30

Risk Area: Inadequate management and oversight of subcontracted services, which results in improper billing. Policy: Compassionate care hospice policy # 4017 OIG Statement The balanced budget act of 1997 amended the Social Security act so that hospices will no longer be required to routinely provide all physician services by employing a physician. Because the OIG has received reports of limited involvement displayed by contracted physicians, as opposed to hospice employed physicians, hospices should consider having oversight mechanisms in place to ensure that hospice physicians are thoroughly reviewing re- certification documentation. Compliance Manual 31

Risk Area; Sales commissions based upon length of stay on hospice. Policy: Compassionate care hospice policy # 1009 OIG Statement Through ORT activities it was discovered that hospice sales staff often were paid on commission based on the patients length of stay. For example, commission amounts were determined by multiplying the total number of days of hospice patient days by a factor that reflected the level of achievement of sales performance achievements. Some of these tactics encouraged the recruitment of long term patients. Compliance Manual 32

Risk Areas: Deficient coordination of volunteers. Policy: Compassionate care hospice policy # 2003.8 OIG Statement Hospices rely heavily upon volunteer support. In fact, the Medicare Hospice Benefit is the only federally funded program that mandates the provision of volunteer services. Appropriately hospices need to attend to adequate screening, training, disciplining, supervising and monitoring. Compliance Manual 33

Risk Area: Failure to comply with applicable requirements for verbal orders for hospice services. Policy: Compassionate care hospice policy #2007 and 2002 OIG Statement Hospice staff must make appropriate entry in the patient chart as soon as they receive a verbal certification of terminal illness and file. State regulations may require that verbal and written orders may only be accepted by those authorized by state law. The OIG recommends that authorized individuals accepting verbal telephone orders should record, date, and sign these orders and countersign them no later than the time required by state regulations. Compliance Manual 34

Risk Area: Non response to late hospice referrals by physicians Policy: Compassionate Care Hospice PI plan OIG Statement We have received comments expressing concern over late hospice referrals by physicians. While the onus of a timely hospice referral may be on a physician, a hospice should identify untimely referrals and provide adequate follow-up to the physician. When hospice referrals are late, terminally ill patients may be unnecessarily denied access to the Medicare Hospice Benefit, hospices may have to admit patients at the costliest stage of their illness. This may affect quality of care because of patients being too far along to receive optium benefits of hospice care. Hospices need to work closely with physicians to educate and remind them as to the sensitivities and risks of untimely referrals. OIG supports appropriate efforts to increase access to hospice care for eligible individuals. Compliance Manual 35

Risk Area: Knowing misuse of provider certification numbers, which result in improper billing. Policy: Compassionate care hospice policy # 2023, 2001 OIG Statement An example is to transfer a patient from hospice to another hospice owned by the same company to circumvent applicable reimbursement caps. Compliance Manual 36

Risk Area: Failure to adhere to hospice licensing requirements and Medicare conditions of participation. Policy: Compassionate care hospice policy and procedures. OIG Statement See 42 CFR 418.50-418.100 for the Medicare conditions of participation that apply to hospices. Compliance Manual 37

Risk Area: Knowing failure to return overpayments made by federal healthcare programs. Policy: Compassionate care hospice policy, see billing manual. OIG Statement An overpayment is the amount of money a hospice may have received in excess of the amount due and payable under a healthcare program. Examples of overpayments include but are not limited to instances where a hospice is a]paid twice for the same services by either Medicare, Medicaid and other insurers; b]paid for care rendered to patients who are not terminally ill or are otherwise ineligible for the Medicare Hospice benefit. The OIG strongly suggest that hospices implement procedures to detect overpayment and to promptly remit such overpayments to the affected payor. See U.S.C. 1320a-7b, which provides criminal penalties for failure to disclose an overpayment. Compliance Manual 38

HOSPICE RISK AREAS RELATED TO BILLING Risk Area: Billing for a higher level of care than was necessary. Policy: Compassionate care hospice policy # 1022, 2004, 2005, and 2006. OIG Statement Billing for unnecessary services involves knowingly seeking reimbursement for services that are not reasonable and necessary for the palliation or management of terminal illness. Because HCFA establishes different payment amounts for specific categories of covered hospice care, a hospice must ensure that it provides services to hospice patients that are reasonable and necessary. Otherwise, the hospice may be reimbursed for a higher level of care than was necessary: e.g., a hospice that provides and bills for continuous care when only routine care was necessary. Compliance Manual 39

Risk area: Arrangement with another healthcare provider who a hospice knows is submitting claims for services already covered in the Medicare Hospice Benefit. Policy: Compassionate Care Hospice policy # 2009 and #1022 OIG Statement When an individual makes an election to receive services covered by the Medicare Hospice Benefit, that individual waives the right to receive Medicare reimbursement for any treatment related to his or her terminal illness. Accordingly, a hospice should ensure it is not involved with a healthcare provider who the hospice knows submits claims for the following services [1]Standard Medicare benefits for the treatment of the terminal illness;[2] treatment by another hospice, not arranged by the patients hospice;[3]care from another which duplicates services that the hospice is required to furnish. It is expected that the hospice provider will coordinate the care with other providers. Compliance Manual 40

COMPLIANCE PLAN EFFECTIVENESS TOOL Standards of Conduct Review Yes NO N/A Follow-Up Has there been high level involvement in the development, review and approval of the Standards of Conduct? Do they include a commitment to comply with all federal, state and insurance standards? Do they contain the mission? Do they include expectations for proper conduct and ethical practice? Are they written in a way that is understandable to the employee? Are they included in the orientation program? Have all employees, volunteers signed a statement to say they have received and read the Standards of Conduct? Do all employee personnel records include a copy of the signed statement? Is there a process to update as laws or regulations may modify? Compliance Manual 42

Compliance Officer Does the compliance officer have sufficient knowledge of billing, clinical records, documentation, and conducting audits to fulfill assigned responsibilities? Has the compliance officer been given sufficient authority within the organization to fulfill her responsibilities? Has the compliance officer been given sufficient financial and personnel resources to fulfill her responsibilities? If the compliance officer has other responsibilities within the organization, does she have enough time to devote to the compliance program? Is an annual evaluation completed by the COO? Does the compliance officer report to the governing body regularly? Yes No N/A Follow Up Compliance Manual 43

Policies and Procedures and Hospice Risk Areas Review Yes No N/A Follow Up Is there a process for regularly updating policies and procedures when new laws are issued? Do the policies and procedures adequately identify areas of risk and vulnerability? Is there a process for ensuring that relevant policies and procedures are distributed and understood by employees? Are the policies and procedures coordinated with relevant staff education programs? Do the policies and procedures reflect the actual practice of the employees? Are relevant policies and procedures communicated to agencies, facilities and contractors? Is there a procedure for annual review of the policies and procedures? Is there evidence of governing body approval in their meeting minutes? Is a log kept of modification and distribution of policies and procedures? Compliance Manual 44

Staff Education and Training Review Yes No N/A Follow Up Is there a written annual staff education program? Are employees required to have a minimal number of educational hours? Are in services related to compliance program provided annually? Are post tests performed? Do employees evidence increased knowledge as a result of compliance training? Are there separate in-services for billing personnel? Is attendance at training a condition of continued employment? Is a log kept of training sessions, topics, dates, trainer and handouts? Is attendance at in-services and other training activities documented in employees personnel record? Are a variety of teaching methods used? Do staff education programs take into account the skills, experience and knowledge of individual trainees? Compliance Manual 45

Reporting System Review Yes No N/A Follow Up Is there ca clearly defined reporting system that employees may use to report potential wrongdoing? Does the reporting mechanism ensure open lines of communication with the compliance officer? Is a random sample of employees able to describe the reporting mechanism and how to access it? Are employees adequately instructed on the types of reports, complaints and issues that should be brought to the compliance officer? Is the reporting system adequately publicized? Does the reporting system protect the employees anonymity to the degree possible? Does the compliance officer maintain a log that records all reports and investigations and their results? Is the reporting system utilized by the employee? Are mechanisms in place to provide feedback to employees who use the reporting system? Are employees reporting issues not related to compliance through the wrong channels? Compliance Manual 46

Audits and Monitoring Review Yes No N/A Follow Up Do audits focus on all pertinent departments of the hospice? Do audits cover compliance with all applicable laws, Medicare conditions of participation, and all identified hospice risks area? Are audits conducted on a regularly scheduled basis? Is there documentation of the outcomes of all audits conducted? Are exit interviews included as a monitoring function and that all employees participate in an exit interview? Are audits conducted by a competent and objective auditor? Are the results of audits reported to the governing body? Are there a variety of tools and techniques used to audit and monitor hospice compliance? Is there evidence that the hospice program has made changes and improvements as a result of its auditing and monitoring activities? Is the effectiveness of the compliance program audited and monitored at least annually? Compliance Manual 47

Enforcement, Discipline and Hiring Practices Review Yes No N/A Follow Up Have appropriate sanctions been applied in instances of compliance misconduct? Do policies and procedures, the Standards of Conduct, and orientation of new employees include a clear description of disciplinary actions applied to those who violate the organizations policies? Are disciplinary actions applied consistently and fairly regardless of employee s stature? Is there documentation of all disciplinary actions applied? Are reasonable and prudent background checks completed for all new employees? Are references checked and documented on all new employees? Does the application for employment include the requirement to disclose any criminal convictions? Are contracts terminated with companies recently convicted of a criminal offense related to healthcare or excluded from participation in federal healthcare programs? Are mechanisms in place to verify the licensure and eligibility of physicians who work with the hospice program? Are managers and supervisors who fail to adequately instruct their subordinates or who fail to detect non compliance with applicable policies and legal requirements appropriately sanctioned? Compliance Manual 48

Response and Corrective Action Review Yes No N/A Follow Up Are immediate investigations conducted and documented when a report of misconduct or potential violation is received? Are all documents pertinent to the investigation retained, secured, and protected from destruction? When disciplinary action is warranted, is it imposed promptly in accordance with the agencies written policies? Does the organization promptly report misconduct that violates criminal, civil, or administrative law to state or federal authorities? When overpayments are identified, are they disclosed and returned to the payer promptly? Is a record kept of all corrective responses to overpayments? When wrongdoing is detected, is there evidence that the corrective action imposed will prevent further offenses from occurring? Compliance Manual 49

INVESTIGATIONS Report Activity Log # Date Brief Description of Report Where/How received Resolved Yes No Compliance Manual 50

Compliance Oral Inquiry Log Compliance question Agency contacted Person contacted Response to question Follow-up needed Name and title Date Compliance Manual 51

Report Investigation and Follow Up Log Report # Date Received When/how Detailed description of report: Compliance concern? Yes No If yes describe Legal counsel contacted Yes No Follow - up provided Additional follow up or investigation Signature Date Date Closed Compliance Manual 52

Summary SUMMARY ACTION PLAN Compliance Manual 53

AUDIT TOOL Certification/Recertification Patient Name: Date of Audit: Discharge Date: Patient ID# Status: Active Discharged Reason for Discharge: A. Assessment of terminal illness 1.Patient admitted/recertified according to policies and guidelines 2. Local medical review policies used to determine eligibility a. If LMRP not met, supporting documentation used in assessment b. Hospice Medical Director reviewed supporting criteria for determining 6 month prognosis Certification of terminal illness 1. Initial cert signed by attending and medical director 2. Initial cert a. Documented verbal order to start care b. Initial cert signed prior to billing Medicare 3. Subsequent certifications signed by hospice medical director 5. Subsequent certifications signed within 2 days Yes No N/A COMMENTS Notes Compliance Manual 54

Certification/Recertification Patient Name: Date of Audit: Discharge Date: Patient ID# Status: Active Discharged Reason for Discharge: C. Physician orders 1. Terminal diagnosis complete 2. Appropriate physician orders identified 3.Orders for all disciplines 4.Phsician orders signed within 7 days 5.Orders updated at each benefit period D.Interdisciplinary care plan update 1.Care plan reflects patient current condition 2.Care plan reviewed every 15 days 3. Signature of medical director E. Team Conference 1.IDT conference for admit and recert attended by RN, MSW, Medical director and counselor 2.IDT conference notes for admission/recert 3.IDT signatures on careplans Yes No N/A COMMENTS Summary Signature Title Compliance Manual 55

Utilization of Service PATIENT ID# COMPLETED BY: ADMISSION DATE DATE SECTION I Y N Medicare hospice benefit Y N Medicaid hospice benefit Y N Medicaid room and board Y N Other payment source Section II As of date of this audit Total number of days receiving routine home care at own/family residence Total number of days receiving routine home care in nursing home Total number of days at general inpatient level of care Total number of days at respite level of care Total number of days at continuous care level Total number of days in the hospice program Section III Discipline RN/LPN Social Worker Hospice Aide Chaplain Dietary Volunteer Physical therapy Occupational therapy Speech therapy Bereavement Visit frequency on Plan of care Actual visit From To Compliance Manual 56

Utilization of Service Patient ID# Completed by Admission Date Date Section IV Medications [list from the plan of care] Medication Paid by Hospice Paid by pt/other Section V durable medical equipment [list from plan of care] Dme Paid by hospice Paid by pt/other Section VI Supplies [list from plan of care] Supplies Paid by hospice Paid by pt/other Summary Action Compliance Manual 57

Nursing facility Program Compliance Patient # Facility: Reviewed by: Date: Elements Yes No N/A Comments 1. Patient meets hospice criteria 2. Terminal illness is certified by attending physician and medical director 3. Patient/legal representative signs consent for hospice services 4. The hospice and facility have jointly developed and agreed upon a coordinated plan of care 5. The plan of care is consistent with hospice philosophy 6.Hospice has a designated RN to coordinate the implementation of plan of care 7. The plan of care designates the services which hospice and facility will provide 8. The plan of care addresses the needs of the patient 9. The plan is revised to reflect the changing needs of the patient 10.All covered services are available to meet the patients needs 11.All core services are provided directly by hospice employees 12. Hospice required materials present in SNF record 13. Evidence of collaboration 14. Other Compliance Manual 58

Nursing facility Program Compliance (cont) Patient# Reviewed by: Billing/Reimbursement Section Facility: Date: Contract Yes No N/A Comments 1. Identifies services and supplies that are to be provided as part of the plan of care 2. Identifies payment responsibilities Medical supplies DME Medications Oxygen Tube feedings Therapy X-Ray Lab work Laundry Other Dually eligible patients Room and board Contract states Medicaid room and board rate to be paid to facility % is stated reimbursement rate If > 95% then states which payment for other services is included Other Compliance Manual 59