CoPs/IGs: The Rules We Live By

1. CoPs/IGs: The Rules We Live By Anne Koepsell, RN, BSN, MHA, CLNC Executive Director WA State Hospice & Palliative Care Org.

2. Course Objectives Learner will be able to: • Identify the components of certification/recertification. • Identify the elements of the Comprehensive Assessment. • Describe how the IDT care planning process improves patient care. • Describe the cycle of care process. • Restate the role of the Medical Director.

3. Focus of CoPs • Patient centered • Emphasizes quality improvement • Emphasizes patient outcomes • Non-prescriptive, organization policy determines process

4. Components of Rule • List of Subjects/Authority • Subpart A. General Provision and Definitions • Subpart B. Eligibility, Election and Duration of Benefits • Applies to Medicare patients only • Subpart C. Patient Care • Applies to all patients served • Subpart D. Organizational Environment • Applies to all patients served

5. State Operations Manual • Part I – Investigative Procedures • Read thoroughly • Review regularly • Will guide you through survey experience • Defines what surveyors will be looking for • Part II – Interpretive Guidelines • Subpart C. Patient Care • Subpart D. Organizational Environment • http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_m_hospice.pdf

6. SUBPART A: General Provisions Section 418.3 Definitions • Always review definitions and refer back to them when reading a condition or standard • Bereavement counseling • means emotional, psychosocial, and spiritual support and services provided before and after the death of the patient to assist with issues related to grief, loss, and adjustment.

7. Section 418.3 Definitions – cont • Clinical note: • Clinical note means a notation of a contact with the patient and/or the family that is written and dated by any person providing services and that describes signs and symptoms, treatments and medications administered, including the patient's reaction and/or response, and any changes in physical, emotional, psychosocial or spiritual condition during a given period of time.

8. Section 418.3 Definitions – cont • Employee: • Employee means a person who works for the hospice and for whom the hospice is required to issue a W–2 form on his or her behalf, or if the hospice is a subdivision of an agency or organization, an employee of the agency or organization who is appropriately trained and assigned to the hospice or is a volunteer under the jurisdiction of the hospice.

9. Section 418.3 Definitions – cont • Hospice care: • Hospice care means a comprehensive set of services described in 1861(dd)(1) of the Act, identified and coordinated by an interdisciplinary team to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care.

10. Section 418.3 Definitions – cont • Licensed professional: • Licensed professional means a person licensed to provide patient care services by the State in which services are delivered. • No list of examples because CMS felt it was unnecessary and may be confusing. • States vary in titles and licensure requirements • Must be familiar with state requirements

11. Section 418.3 Definitions – cont • Multiple location • means a Medicare-approved location from which the hospice provides the same full range of hospice care and services that is required of the hospice issued the certification number. A multiple location must meet all of the conditions of participation applicable to hospices.

12. Section 418.3 Definitions – cont • Restraint • (1) Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely, not including devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort); or • (2) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.

13. Section 418.3 Definitions – cont • Seclusion: • Seclusion means the involuntary confinement of a patient alone in a room or an area from which the patient is physically prevented from leaving.

14. Section 418.3 Definitions • Comprehensive assessment: • Comprehensive assessment means a thorough evaluation of the patient’s physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions. This includes a thorough evaluation of the caregiver’s and family’s willingness and capability to care for the patient.

15. Section 418.3 Definitions • Dietary counseling: • Dietary counseling means education and interventions provided to the patient and family regarding appropriate nutritional intake as the patient’s condition progresses. Dietary counseling is provided by qualified individuals, which may include a registered nurse, dietitian or nutritionist, when identified in the patient’s plan of care.

16. Section 418.3 Definitions • Initial assessment: • means an evaluation of the patient’s physical, psychosocial and emotional status related to the terminal illness and related conditions to determine the patient’s immediate care and support needs.

17. Section 418.3 Definitions • Physician designee: • means a doctor of medicine or osteopathy designated by the hospice who assumes the same responsibilities and obligations as the medical director when the medical director is not available.

18. SUBPART B: Eligibility, election and duration of benefits • Eligibility requirements • Duration of hospice care coverage – Election periods • Certification of terminal illness • Election of hospice care

19. Section 418.20 & 418.21 418.20 – Eligibility requirements • Entitled to Medicare Part A • Certified as Terminally Ill in accordance with 418.22 418.21 – Election periods • Initial 90-day period • Subsequent 90-day period • Unlimited number of subsequent 60-day periods

20. Section 418.22Certification of Terminal Illness (a) Timing • Written certification for each of the periods in 418.21 • Must be obtained before submitting claim • Exceptions: • If not obtained within 2 calendar days after period begins, must obtain oral certification within 2 days and written prior to submitting claim • Certs/Recerts may be completed no more than 15 days prior to effective date of election or start of subsequent period

21. Section 418.22Certification of Terminal Illness – cont. (a) Timing – cont. • Face-to-Face encounter • Hospice Physician or NP must have F2F with each hospice patient whose total stay across all hospice is anticipated to reach the 3rd benefit period. • No more than 30 calendar days prior to recertification thereafter • To gather clinical findings to determine continued eligibility for hospice care (my emphasis) • Can occur on the first day of the 3rd benefit period (clarified in 2012)

22. Section 418.22Certification of Terminal Illness – cont. (b) Content • Based on the physician/medical director’s clinical judgment regarding the normal course of illness. • Cert must conform to the following: • Specify that the individual’s prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course • Clinical information that supports the medical prognosis must accompany certification • Initial certification requires two signatures – hospice medical director/physician AND attending. • Recertifications only require one signature

23. Section 418.22Certification of Terminal Illness – cont. (b) Content – cont. • Brief Narrative explanation of clinical findings that supports a life expectancy of 6 months or less • Can be on form or as an addendum • If part of form, narrative must be immediately prior to the physician’s signature • If addendum, physician must also sign immediately following the narrative. • Addendum creates need for two signatures – one with certification statement and one with brief narrative addendum

24. Section 418.22Certification of Terminal Illness – cont. (b) Content – cont. • Brief Narrative explanation of clinical findings that supports a life expectancy of 6 months or less • Narrative shall have statement directly above the signature attesting that physician composed narrative based upon his/her review of medical record or examination of patient. • Narrative must reflect the patient’s individual clinical circumstances and cannot contain check boxes or standard language used for all patients

25. Section 418.22Certification of Terminal Illness – cont. (b) Content – cont. • Face-to-Face Encounter if entering third benefit period • More than one physician can be involved. • MD or NP must attest in writing that he/she had a face to face encounter with the patient, including the date of that visit. • If different NP or MD performs F2F, they shall state the clinical findings were provided to MD for use in determining prognosis. • Attestation, signature, and date must be a separate and distinct section of addendum or form and must be clearly titled. • CMS change in position memo dated 25 Mar 2011

26. SUBPART C: PATIENT CARE • Conditions: • Patient Rights • Initial and Comprehensive Assessment • Interdisciplinary Group, Care Planning, and Coordination of Services • Quality Assessment and Performance • Infection Control • Licensed Professional Services • Core Services • Nursing Services Waiver

27. SUBPART C: PATIENT CARE – Cont. • Conditions, cont. • Furnishing of non-core services • PT, OT, Speech • Waiver of requirement – PT, OT, Speech, Dietary • Hospice Aide and Homemaker services • Volunteers

28. Subpart C – Patient Rights • SEC. 418.52: PATIENT RIGHTS • While not a new rule, it is new to Hospice rules • Determine how you will demonstrate compliance during a survey • Train staff on reviewing as part of assessment • Obtain a signature that acknowledged receipt of Notice • Look at P&P on communication barriers with persons of limited English proficiency • Family members should not be first choice

29. 418.52 Patient’s rights • (a) Standard: Notice of rights and responsibilities. • Verbally and in writing; • make all reasonable efforts to have written copies of the notice of rights available in the language(s) that are commonly spoken in the hospice’s service area. • In a language and manner that the patient understands; and • make all reasonable efforts to secure a professional, objective translator for hospice-patient communications, including those involving the notice of patient rights. • During the initial assessment visit in advance of furnishing care.

30. 418.52 Patient’s rights • Interpretive Guidelines (IG) • Pt refers to patient or patient representative • Family members can serve as interpreters only when an objective translator cannot be obtained or the patient requests it. • Procedures and Probes (PP) • Ask for copies of material • Ask patients if, who and when informed

31. 418.52 Patient’s rights • (a) Standard: Notice of rights and responsibilities. • Advance directives • ‘‘The hospice must obtain the patient’s or representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities.’’ • Interpretive Guidelines (IG) • Admission does not require an advance directive • Policies and Procedures • Procedures and Probes (PP) • Review clinical record for evidence

32. 418.52 Patient’s rights • (b) Standard: Exercise of rights and respect for property and person. • Patients have the right to: exercise their rights, be treated with respect, voice grievances, and be protected from discrimination or reprisal for exercising their rights • Process for dealing with alleged violations: • Report violations to hospice administrator • Investigate violations & complaints • Take corrective action if violation is verified • Report verified significant violations within 5 working days of becoming aware of incident

33. 418.52 Patient’s rights • Interpretive Guidelines (IG) • Definitions of various types of abuse • Procedures and Probes (PP) • Review admission information for instructions on making a compliant • Review prior 12 months documentation of complaints – how received, investigated, resolved • Ask patient if they know how to make a complaint and treatment • Determine if staff can ID various forms of abuse and if they know how to report

34. 418.52 Patient’s rights (c) Standard: Rights of the patient • Pain management and symptom control. • Interpretive Guidelines • Patients should not have to experience long waits for pain and symptom management, medication, interventions • Hospice should have methods to assure 24 hours/7 days response in all settings and where ever pt resides • Procedures and Probes • Ask to describe policies • Determine how hospice assures timely response • Ask patients how quickly hospice responds

35. 418.52 Patient’s rights (c) Standard: Rights of the patient • Be involved in developing plan of care. • Probes • Ask staff how they facilitate pt/family involvement • Ask patient/family if they are involved. • Refuse care or treatment. • Interpretive Guidelines • Probes further if particular trend is identified, i.e. a majority of patients is refusing a particular service, to assure that hospice is fully prepared to provide the service with qualified personnel.

36. 418.52 Patient’s rights (c) Standard: Rights of the patient • Choose attending physician. • Interpretive Guidelines • Pts have right to choose physician and have this person involved in their medical care in all settings • Probes • Is there evidence that the hospice does not allow the patient to choose their physician?

37. 418.52 Patient’s rights (c) Standard: Rights of the patient • Confidential clinical record/ HIPAA. • Interpretive Guidelines • Safeguarding content, paper and electronic, from unauthorized disclosure without consent • Observe whether staff shows evidence of protecting confidentiality • Is patient information posted in public places • Are clinical records accessible for reading or removing?

38. 418.52 Patient’s rights (c) Standard: Rights of the patient • Be free of abuse, neglect, mistreatment • Interpretive Guidelines • If issue identified during survey, investigate and report • Ensure that the hospice addresses the incident immediately

39. 418.52 Patient’s rights (c) Standard: Rights of the patient • Receive information about hospice benefit. • Interpretive Guidelines • Fully inform on covered services (Medicare and non-Medicare) • Procedures and Probes • Is pt/family aware of all covered services? • Has hospice described any services for which pt might have to pay? • Consider pts ability to understand and retain information

40. 418.52 Patient’s rights (c) Standard: Rights of the patient • Receive information about scope and limitations of hospice services. • Procedures and Probes • Ask pt/family what services they are receiving • Are they aware of any limitations to those services • Hospices are required to provide all services necessary for palliation and management of terminal illness and should not accept a patient if they cannot provide all services.

41. 418.54 Initial/Comprehensive assessment • Conduct and document in writing patient-specific comprehensive assessment and pts need for physical, psychosocial, emotional and spiritual care • The comprehensive assessment is not a single static document, a symptom and severity checklist, or a set of generic questions that all patients are asked. • It is a dynamic process that needs to be documented in an accurate and consistent manner for all patients. • Hospice P&Ps will serve to guide decisions about who assesses patient/family needs and how

42. 418.54 Initial/Comprehensive assessment (a) Standard: Initial assessment. • Completed by RN • Election can be another IDG member • Must occur within 48 hours after election of hospice care • Need staffing to address needs that require a shorter than 48 hours assessment and weekends/holidays • This is an initial overall assessment of the patient/family needs • If there are significant issues in one area, then it is recommended that the specialty IDG member complete the comprehensive assessment

43. 418.54 Initial/Comprehensive assessment (a) Standard: Initial assessment – cont. • Initial contact cannot be substituted for initial assessment • Cannot wait until comprehensive assessment is complete to formulate Plan of Care and provide services • Initial assessment guides decisions about who comprehensively assesses patient/family needs • Document the IDG formulation of the POC based upon initial assessment

44. 418.54 Initial/Comprehensive assessment (a) Standard: Initial assessment – cont. • Interpretive Guidelines • Purpose is to gather critical information necessary to treat immediate care needs • In the location where the hospice services are being delivered • Not a ‘meet and greet’ visit • RN must conduct, other IDTS can be involved • Procedures and Probes • Determine through interview, observation and record review if immediate care needs met • Did RN complete initial assessment?

45. 418.54 Initial/Comprehensive assessment (b) Standard: Time frame for completion of the comprehensive assessment. • Completed by the hospice IDG in consultation with the attending physician. • Attending not required to sign, but they do need to be involved – how to document • Completed within 5 calendar days after the patient elects hospice care, based upon patient needs. – IN TOP 10 DEFIENCIES FOR THE LAST 3 YEARS • Ensure imminently dying patients receive appropriate and timely assessments despite their short length of stay

46. 418.54 Initial/Comprehensive assessment b) Standard: Time frame for completion of the comprehensive assessment. • All members of the IDG do not necessarily need to visit the patient/family to complete the comprehensive assessment. • Comprehensive assessment is about assessing WHAT the patient needs, not all about WHO completes the assessment. • CMS does not dictate how the comprehensive assessment is completed

47. 418.54 Initial/Comprehensive assessment b) Standard: Time frame for completion of the comprehensive assessment. • Interpretive Guidelines • If no attending, hospice physician must assume role • If attending, must be consulted • Consultation occurs through phone calls, fax, emails, text messages, etc.) • Attending often has history and family dynamics • Election may be signed with a later date, but not earlier • May be completed earlier than 5 days

48. 418.54 Initial/Comprehensive assessment

49. 418.54 Initial/Comprehensive assessment c) Standard: Content of the comprehensive assessment. • Physical, Psychosocial, Emotional, Spiritual needs related to the terminal illness and related conditions • Ensure that assessment and POC address actual as well as potential problems • Interpretive Guidelines • Identifies minimum symptoms to be assessed • Pain, dyspnea, N&V, constipation, restlessness, anxiety, sleep disorders, skin integrity, confusion, emotional distress, spiritual needs, support systems, need for counseling/education • Identifies components of comprehensive pain assessment • History, characteristics, physical exam, current meds, goals

50. 418.54 Initial/Comprehensive assessment c) Standard: Content of the comprehensive assessment • Must take into consideration the following 8 factors: • 1) Nature and condition causing admission • 2) Complications and risk factors that affect care planning • 3) Functional Status including the patient’s ability to understand and participate in his/her own care (structure, function, activity) • 4) Imminence of death as evidenced by….