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The National Hospice & Palliative Care Organization. Navigating the New Medicare Hospice CoPs. Objectives. At the conclusion of the session, the participant will: Learn important highlights of the final Medicare hospice Conditions of Participation ( CoP)

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the national hospice palliative care organization

The National Hospice & Palliative Care Organization

Navigating the New Medicare Hospice CoPs

objectives
Objectives

At the conclusion of the session, the participant will:

  • Learn important highlights of the final Medicare
  • hospice Conditions of Participation (CoP)
  • requirements for Subpart C & D.
  • Know where to locate resources for implementation.
the new cops
The new CoPs
  • Focus of new CoPs
    • Patient centered
    • Emphasizes quality improvement and patient outcomes
  • The new CoPs are effective December 2, 2008.
  • Hospice providers are responsible to be compliant with the current regulations and its requirements until December 2, 2008.
    • 1983 CoPs with the updates to Subparts B, F, & G
      • Effective January 2006
      • Link to current version
        • http://www.nhpco.org/i4a/pages/index.cfm?pageid=5494
sec 418 3 definitions
Sec. 418.3: Definitions

Revised based on public comments received:

Bereavement counseling

Clinical note

Employee

Hospice care

Licensed professional

Multiple location

Restraint

Seclusion

  • No changes:
    • Attending physician
    • Cap period
  • Same as proposed rule
    • Hospice
    • Palliative care
    • Physician
    • Representative
    • Terminally ill
sec 418 3 definitions5
Sec. 418.3: Definitions
  • New in the final rule
    • Comprehensive assessment
    • Dietary counseling
    • Initial assessment
    • Physician designee
slide6

SUBPART C: PATIENT CARE

SEC. 418.52:

PATIENT RIGHTS

Replaces the existing CoP, Informed consent, at § 418.62.

418 52 patient s rights
§ 418.52 Patient’s rights
  • (a) Standard: Notice of rights and responsibilities.
    • Verbally and in writing;
    • In a language and manner that the patient understands; and
    • During the initial assessment visit in advance of furnishing care.
    • Advance directives
    • Must obtain patient’s/ representative’s signature confirming receipt of copy of the notice of rights and responsibilities
418 52 patient s rights8
§ 418.52 Patient’s rights
  • (b) Standard: Exercise of rights and respect for property and person.
    • Report violations to hospice administrator
    • Investigate violations & complaints
    • Take corrective action if violation is verified
    • Report verified significant violations to State/ local bodies within 5 days of incident
418 52 patient s rights9
§ 418.52 Patient’s rights
  • (c) Standard: Rights of the patient
    • Pain management and symptom control.
    • Be involved in developing plan of care.
    • Refuse care or treatment.
    • Choose attending physician.
    • Confidential clinical record/ HIPAA.
    • Be free of abuse.
    • Receive information about hospice benefit.
    • Receive information about scope and limitations of hospice services.
slide10

SUBPART C: PATIENT CARE

SEC. 418.54:

INITIAL AND COMPREHENSIVE ASSESSMENT OF THE PATIENT

418 54 initial and comprehensive assessment of the patient
§ 418.54 Initial and comprehensive assessment of the patient
  • 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.
  • Comprehensive assessment is about assessing WHAT the patient needs, not all about WHO completes the assessment.
418 54 initial and comprehensive assessment of the patient12
§ 418.54 Initial and comprehensive assessment of the patient
  • (a) Standard: Initial assessment.
    • Completed by RN
    • Must occur within 48 hours after election of hospice care
    • This is an initial overall assessment of the patient/family needs
      • Significant issues in one area, recommend that the specialty IDG member complete the comprehensive assessment
418 54 initial and comprehensive assessment of the patient13
§ 418.54 Initial and comprehensive assessment of the patient
  • (b) Standard: Time frame for completion of the comprehensive assessment.
    • Completed by the hospice IDG in consultation with the attending physician.
    • Completed within 5 calendar days after the patient elects hospice care.
    • CMS does not dictate how the comprehensive assessment is completed
418 54 initial and comprehensive assessment of the patient14
§ 418.54 Initial and comprehensive assessment of the patient
  • (b) Standard: Time frame for completion of the comprehensive assessment.
    • Completed by the hospice IDG in consultation with the attending physician.
    • Completed within 5 calendar days after the patient elects hospice care.
    • CMS does not dictate how the comprehensive assessment is completed
418 54 initial and comprehensive assessment of the patient15
§ 418.54 Initial and comprehensive assessment of the patient
  • (c) Standard: Content of the comprehensive assessment.
    • Physical, psychosocial, emotional, and spiritual needs related to the terminal illness and related conditions
418 54 initial and comprehensive assessment of the patient16
§ 418.54 Initial and comprehensive assessment of the patient
  • (c) Standard: Content of the comprehensive assessment.
    • Physical, psychosocial, emotional, and spiritual needs related to the terminal illness and related conditions
    • Nature and condition causing admission
    • Complications and risk factors
    • Functional status
    • Imminence of death
    • Symptom severity
    • Drug profile
      • Identify ineffective drug therapies- §418.54(c)(6)(i).
    • Bereavement
    • Referrals
418 54 initial and comprehensive assessment of the patient17
§ 418.54 Initial and comprehensive assessment of the patient
  • (d) Standard: Update of the comprehensive assessment.
    • Updated by the IDG
    • As frequently as the patient’s condition requires
    • At a minimum every 15 days
    • Update those sections of the comprehensive assessment that require updating.
    • Patient condition change - comprehensive assessment must be updated to reflect changes.
    • Hospices are free to choose the method that best suits their needs when documenting the comprehensive assessment and the updates to that assessment.
418 54 initial and comprehensive assessment of the patient18
§ 418.54 Initial and comprehensive assessment of the patient
  • (e) Standard: Patient outcome measures.
    • Patient level data elements must be included in each patient assessment
    • Data elements must be used in patient care planning and evaluation AND in the hospice’s QAPI program
    • Data elements must be collected and documented in a consistent, systematic, and retrievable way.
slide19

SUBPART C: PATIENT CARE

SEC. 418.56:

INTERDISCIPLINARY GROUP, CARE PLANNING, AND COORDINATION OF SERVICES

418 56 interdisciplinary group care planning and coordination of services
§ 418.56 Interdisciplinary group, care planning, and coordination of services

(a) Standard: Approach to service delivery

  • Hospice designates an IDG
  • Hospice designates an IDG RN to provide program coordination, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation and revision of the plan of care.
  • Hospice identifies a specifically designated IDG to establish day-to-day policies and procedures.
418 56 interdisciplinary group care planning and coordination of services21
§ 418.56 Interdisciplinary group, care planning, and coordination of services
  • (b) Plan of Care
    • The plan of care is one of the most important documents in hospice care.
    • IDG consults with the following to establish plan of care
      • Attending physician (if any);
      • Patient or representative; and
      • Primary caregiver
    • All services must follow a written plan of care.
    • Patient and primary caregiver(s) educated & trained related to their care responsibilities identified in the plan of care.
418 56 interdisciplinary group care planning and coordination of services22
§ 418.56 Interdisciplinary group, care planning, and coordination of services
  • (c) Standard: Content of the plan of care
    • Reflects patient and family goals
    • Includes interventions for problems identified throughout the assessment process
    • Includes all services necessary for palliation and management of terminal illness and related conditions
    • Detailed statement of the scope and frequency of services to meet the patient’s and family’s needs
    • Measurable outcomes
    • Drugs and treatments
    • Medical supplies and appliances
    • Documentation (in the clinical record) of the patient’s or representative’s level of understanding, involvement and agreement with the plan of care
418 56 interdisciplinary group care planning and coordination of services23
§ 418.56 Interdisciplinary group, care planning, and coordination of services
  • (d) Standard: Review of the plan of care
    • Revised plan of care includes:
      • Information from the updated comprehensive assessment
      • Information regarding the progress toward achieving specified outcomes and goals
    • Plan of care must be reviewed as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days
    • Completed by the IDG in collaboration with the attending physician (if any)
418 56 interdisciplinary group care planning and coordination of services24
§ 418.56 Interdisciplinary group, care planning, and coordination of services
  • (e) Standard: Coordination of services
    • Develop and maintain a system of communication and integration
    • Ensure the IDG maintains responsibility for directing, coordinating, and supervising the care and services provided
    • Care and services are provided in accordance with the plan of care
    • Care and services are based on assessments of the patient and family needs
418 56 interdisciplinary group care planning and coordination of services25
§ 418.56 Interdisciplinary group, care planning, and coordination of services
  • (e) Standard: Coordination of services (cont’d)
    • Sharing information between all disciplines providing care and services, in all settings, whether provided directly or under arrangement
    • Sharing information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions.
slide26

SUBPART C: PATIENT CARE

SEC. § 418.58:

QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT

418 58 quality assessment and performance improvement
§ 418.58 Quality assessment and performance improvement
  • (a) Standard: Program scope
    • Show measurable improvement in indicators for which there is evidence that improvement in those indicators will improve palliative outcomes and end of life support services
    • Replaces the existing § 418.66, ‘‘Condition of participation-Quality assurance”.
418 58 quality assessment and performance improvement28
§ 418.58 Quality assessment and performance improvement
  • (b) Standard: Program data
    • Must utilize quality indicator data, including patient care, and other relevant data, in the design of its program
    • Must use data collected to monitor effectiveness and safety of services and quality of care and identify opportunities and priorities for improvement
    • Frequency and detail of the data collection must be specified by the hospice’s governing body
418 58 quality assessment and performance improvement29
§ 418.58 Quality assessment and performance improvement
  • (c) Standard: Program activities
    • The hospice’s performance improvement activities must:
      • Focus on high risk, high volume, problem prone areas
      • Consider evidence, prevalence, and severity of problems in those areas
      • Affect palliative outcomes, patient safety and quality of care
418 58 quality assessment and performance improvement30
§ 418.58 Quality assessment and performance improvement
  • (c) Standard: Program activities
    • The hospice’s performance improvement activities must:
      • Performance activities must track adverse patient events, analyze their causes and implement preventive actions and mechanisms that include feedback and learning throughout the hospice
      • Take action aimed at performance improvement
      • Measure success of action
      • Track performance of action to ensure that improvements are sustained
418 58 quality assessment and performance improvement31
§ 418.58 Quality assessment and performance improvement
  • (d) Standard: Performance improvement projects
    • Begins 240 days after publication date of final rule
      • Effective date: February 2, 2009
    • The number and scope of projects conducted annually must reflect the scope, complexity and past performance of the hospice’s services and operations
    • Document what quality improvement projects are being conducted, reasons for conducting the projects and measurable progress achieved on these projects
418 58 quality assessment and performance improvement32
§ 418.58 Quality assessment and performance improvement
  • (e) Standard: Executive responsibilities
    • Governing body ensures:
      • That an ongoing program for QI and patient safety is defined, implemented and maintained.
      • The QAPI efforts address quality of care and patient safety, and all improvement actions are evaluated for effectiveness.
      • That an individual(s) is designated to lead QAPI efforts.
slide33

SUBPART C: PATIENT CARE

§ 418.60 INFECTION CONTROL

§ 418.62 LICENSED PROFESSIONAL SERVICES

418 60 infection control
§ 418.60 Infection control
  • (a) Standard: Prevention
    • Follow accepted standards of practice, including standard precautions
  • (b) Standard: Control
    • Maintain a coordinated, agency-wide program for surveillance, identification, prevention, control, and investigation of infectious and communicable diseases
  • (c) Standard: Education
    • Infection control education provided to staff, patients, families, and other caregivers
418 62 licensed professional services
§ 418.62 Licensed professional services
  • (a) Services, whether provided directly or under arrangement, must be authorized, delivered, and supervised by qualified personnel
  • (b) Professionals must actively participate in coordinating patient care (includes: patient assessment; care planning and evaluation; and patient and family counseling and education)
  • (c) Professionals must participate in the hospice’s QAPI and in-service training programs
slide36

SUBPART C: PATIENT CARE

§ 418.64 CORE SERVICES

§ 418.66 NURSING SERVICES – WAIVER

418 64 core services
§ 418.64 Core services
  • (a) Standard: Physician services
    • Employee or contracted
  • (b) Standard: Nursing services
    • Highly specialized nursing services maybe provided under contract
  • (c) Standard: Medical social services
    • Provided by a qualified social worker under the direction of a physician
  • (d) Standard: Counseling services
    • Bereavement counseling: under the supervision of a qualified professional with experience or education in grief or loss counseling
    • Development of the bereavement plan of care starts before the patient’s death.
418 64 core services38
§ 418.64 Core services
  • (d) Standard: Counseling services
    • Dietary counseling: preformed by a qualified individual such as dieticians and nurses
    • Spiritual counseling: Make all reasonable efforts to facilitate visits from local clergy, pastoral counselors, or other individuals who support the patient’s spiritual needs.
418 66 nursing services waiver
§ 418.66 Nursing services – Waiver
  • Unlimited 1 year extensions
  • Difference between nursing service waiver and nurse shortage waiver
    • § 418.66 –
      • Statutory
      • Short term relief
      • Addresses need in times of peak patient loads
    • Nursing shortage waiver –
      • Chronic lack of nurses in service area
      • Implemented in 2004, renewed in 2006
slide40

SUBPART C: PATIENT CARE

§ 418.70 NON-CORE SERVICES

§418.72 PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND SPEECH-LANGUAGE PATHOLOGY

§418.74 WAIVER OF REQUIREMENT- PT, OT, SLP, AND DIETARY COUNSELING

non core services
Non-core Services
  • § 418.70 Non-core services (Same)
  • §418.72 Physical therapy, occupational therapy, and speech-language pathology (Same)
  • §418.74 Waiver of requirement- PT, OT, SLP, and dietary counseling
      • Unlimited 1 year extensions
418 76 hospice aide and homemaker services
§ 418.76 Hospice aide and homemaker services
  • (a) Standard: Hospice aide qualifications
    • Completed hospice aide training and competency evaluation OR Competency evaluation, OR nurse aide training and competency evaluation, OR State licensure program
  • (e) Standards: Qualifications for instructors conducting classroom and supervised practical training
    • Training performed by RN, at least 2 years experience, with at least 1 year in homecare (home health or hospice)
418 76 hospice aide and homemaker services43
§ 418.76 Hospice aide and homemaker services

(h) Standard: Supervision of hospice aides

  • RN onsite visit to assess the quality of care and services provided by the hospice aide (hospice aide does not have to be present during this visit)
    • Every 14 days
  • If concerns related to care and services provided by the hospice aide are noted by the supervising RN, the hospice must make an on-site visit to the location where the patient receives care
  • If concerns are verified the aide must complete a competency evaluation
  • The RN must make an annual onsite visit to observe and assess each aide while performing care
  • Aide must be supervised one time annually
418 76 hospice aide and homemaker services44
§ 418.76 Hospice aide and homemaker services
  • (i) Standard: Individuals furnishing Medicaid personal care aide-only services under a Medicaid personal care benefit
    • Medicaid personal care benefit services are used to the extent that the hospice would use the patient’s family in delivering care
    • Coordinate hospice aide services with Medicaid personal care benefit
  • (j) Standard: Homemaker qualifications (Reformatted)
  • (k) Standard: Homemaker supervision and duties
    • Homemaker services must be coordinated and supervised by a member of the IDG
418 78 volunteers
§ 418.78 Volunteers
  • (a) Standard: Training
  • (b) Standard: Role
  • (c) Standard: Recruiting and retaining
  • (d) Standard: Cost savings
  • (e) Standard: Level of activity
    • Hospices may count volunteer driving hours in the 5% calculation as long as they count staff driving hours
418 100 organization and administration of services
§ 418.100 Organization and administration of services
  • (a) Standard: Serving the patient and family
  • (b) Standard: Governing body and administrator
    • Administrator appointed by the governing body
  • (e) Standard: Professional management responsibility
418 100 organization and administration of services48
§ 418.100 Organization and administration of services
  • (f) Standard: Multiple locations
    • Medicare approval before providing services to Medicare patients
    • The multiple location must share administration, supervision, and services with the hospice issued the certification number
    • Lines or authority and control must be clearly delineated
    • Initial determination (appeals)
418 102 medical director
§ 418.102 Medical Director
  • (a) Standard: Medical director contract
    • A hospice may contract with a self-employed physician OR a physician employed by a professional entity or physicians group.
  • (b) Standard: Initial certification of terminal illness
  • (c) Standard: Recertification of the terminal illness- Review clinical information before recertifying
  • (d) Standard: Medical director responsibility- Responsible for medical component of the hospice’s patient care program
  • Removed: oversight for QAPI program
418 104 clinical records
§ 418.104 Clinical records
  • May be maintained electronically
  • (a) Standard: Content
  • (b) Standard: Authentication
  • (c) Standard: Protection of information
  • (d) Standard: Retention of records
    • 6 years after death or discharge unless State law says longer
  • (e) Standard: Discharge or transfer of care
    • Another Medicare/Medicaid facility- Forward discharge summary (always) and record (if requested)
    • Revoke election or discharge- Copy of discharge summary to attending physician (always) and record (if requested)
    • Discharge summary includes summary of treatments, symptoms, and pain management; current plan of care; recent physician orders; other documentation
418 106 drugs and biologicals medical supplies and durable medical equipment
§ 418.106 Drugs and biologicals, medical supplies, and durable medical equipment
  • (a) Standard: Managing drugs and biologicals
    • Ensure that IDG confers with individual with education and training in drug management to ensure that drugs and biologicals meet each patient’s needs.
    • Inpatient care directly: Pharmacy services under direction of licensed pharmacist
  • (b) Standard: Ordering of drugs
    • Ordered by physician or NP
    • Verbal or electronic orders given only to licensed nurse, pharmacist, or physician and must be recorded and signed in accordance with all regulations
  • (c) Standard: Dispensing of drugs and biologicals
418 106 drugs and biologicals medical supplies and durable medical equipment52
§ 418.106 Drugs and biologicals, medical supplies, and durable medical equipment
  • (c) Standard: Dispensing of drugs and biologicals
    • Obtain drugs from community or institutional pharmacists or stock itself
    • Inpatient care directly: Written policy to promote dispensing accuracy; accurate records
  • (d) Standard: Administration of drugs and biologicals
      • IDG must determine patient/family ability to safely administer drugs
  • (e) Standard: Labeling, disposing, and storing of drugs and biologicals
      • Labeled in accordance with accepted standards, including appropriate instructions and expiration date
418 106 drugs and biologicals medical supplies and durable medical equipment53
§ 418.106 Drugs and biologicals, medical supplies, and durable medical equipment
  • (e) Standard: Labeling, disposing, and storing of drugs and biologicals
    • Written policies and procedures for managing and disposing of drugs in patient’s home, discussed with patient and family at the time when controlled drugs are first ordered, document discussion in clinical record
    • Inpatient care directly- Dispose in compliance with hospice policy and Federal and State requirements, maintain current and accurate records
    • Inpatient care directly: Investigate discrepancies and report to appropriate State authority, document investigation and make available to appropriate authorities as required
418 106 drugs and biologicals medical supplies and durable medical equipment54
§ 418.106 Drugs and biologicals, medical supplies, and durable medical equipment
  • (f) Standard: Use and maintenance of equipment and supplies
    • Follow manufacturer recommendations for DME maintenance
    • Ensure policies developed in absence of manufacturer recommendations
    • DME must be safe and must work as intended
    • Instruct patient and family in proper use of DME and supplies
    • May contract for all DME services; must only contract with supplier meeting Medicare DMEPOS Standards
418 108 short term inpatient care
§ 418.108 Short-term inpatient care
  • (a) Standard: Inpatient care for symptom management and pain control
    • Provided in a Medicare-certified facility.
  • (b) Standard: Inpatient care for respite purposes
      • Removed 24 hour RN requirement; not effective until December 2, 2008
  • (c) Standard: Inpatient care provided under arrangements
    • Plan of care to facility
    • Assure facility staff are trained in hospice care
    • Inpatient clinical record must document all inpatient services and events;
    • a copy of the inpatient clinical record must be available to the hospice at discharge; and a copy of the discharge summary is provided to the hospice at discharge
418 110 hospices that provide inpatient care directly
§ 418.110 Hospices that provide inpatient care directly
  • (a) Standard: Staffing
  • (b) Twenty-four hour nursing
    • 24 hour nursing services to meet patient needs
    • Each shift must include a RN who provides direct patient care for GIP
  • (c) Standard: Physical environment
    • Maintain a safe environment
    • Written disaster preparedness plan
  • (f) Standard: Patient rooms- No more than 2 patients per room with a waiver available if there is an unreasonable hardship.
  • (l) Standard: Meal service and menu planning
    • Less prescriptive
418 110 hospices that provide inpatient care directly58
§ 418.110 Hospices that provide inpatient care directly
  • (m) Standard: Restraint or seclusion
    • Patient right to be free of restraint
    • Restraints are the last resort
    • Discontinued at the earliest possible time
    • Implemented by specific physician order; no standing orders
    • No more than 24 hours total; renewed every 4
    • Monitored by trained staff
      • Staff trained/ competent
      • Training addresses all relevant areas
      • Training documentation in personnel records
  • (o) Standard: Death reporting requirements
    • Report deaths within 1 week of use
    • Report by phone to CMS no later than the close of the next business day after death; document reporting in patient’s clinical record
418 112 hospices that provide hospice care to residents of a snf nf or icf mr
§ 418.112 Hospices that provide hospice care to residents of a SNF/NF or ICF/MR
  • (a) Standard: Resident eligibility, election, and duration of benefits
  • (b) Standard: Professional management
    • Hospice assumes responsibility for professional management of resident’s hospice care
  • (c) Standard: Written agreement
  • (d) Standard: Hospice plan of care
  • (e) Standard: Coordination of services
    • Hospice designates IDG member to coordinate implementation of plan of care with facility representatives
    • Provide specific documentation to facility
  • (f) Standard: Orientation and training of staff
    • Hospice assures orientation facility staff in hospice
418 114 personnel qualifications
§ 418.114 Personnel qualifications
  • (a) Standard: General qualification requirements
  • (b) Standard: Personnel qualifications for certain disciplines
    • Social worker-
      • MSW with 1 year experience; or
      • Bachelors in social work, psychology, sociology, or other related field AND 1 year experience AND supervised by MSW; or
      • Bachelor’s in social work AND employed by hospice before the effective date of the final rule (December 2, 2008)
418 114 personnel qualifications61
§ 418.114 Personnel qualifications
  • (b) Standard: Personnel qualifications for certain disciplines
  • (c) Personnel qualifications when no State licensing, certification or registration requirements exist
  • (d) Standard: Criminal background checks
    • All employees with direct patient contact or access to patient records (hospice staff & contracted staff)
    • Hospice contracts must require contracted entities to obtain employee background checks
    • Obtained in accordance with State requirements
    • If no State requirements, must be obtained within 3 months of date of employment for all states where the individual has lived or worked in the past 3 years
slide62
§ 418.116 Compliance with Federal, State, and local laws and regulations related to the health and safety of patients
  • In compliance with all laws and regulations.
  • Hospice licensed if required by State
  • (a) Standard: Multiple locations
    • Disclosure of ownership
    • Approved by Medicare and licensed by the State
  • (b) Standard: Laboratory services
    • Lab testing (self or contracted) in accordance with CLIA requirements
cops planning for success
“CoPs-Planning for Success”!
  • NHPCO campaign to assist hospices to implement the new regulations.
  • Education:
    • Podcasts
    • Audio web seminars in June 2008
    • Online education modules
    • Downloadable tools, tips, and information
    • Resources in the NHPCO “Regulatory & Compliance Center”
nhpco regulatory
NHPCO Regulatory

Judi Lund Person, MPH

Vice President

Regulatory & State Leadership

Jennifer Kennedy, MA,BSN, RN, CLNC

Regulatory & Compliance Specialist

NHPCO Regulatory Assistance

regulatory@nhcpo.org

703-647-8516