Basic Hospice Agency
Surveyor Training
November 18-20, 2008
Baltimore, Maryland
Student Manual
The Centers for Medicare & Medicaid Services (CMS) has been reviewed and approved as an Authorized Provider by the International Association for Continuing Education and Training (IACET), 1620 I Street, NW, Suite 615, Washington, DC 20006. The Centers for Medicare & Medicaid Services (CMS) has awarded 2.1 CEUs to participants who successfully complete this program.
Copyright Permission
Training materials produced by the Centers for Medicare & Medicaid Services are considered to be in the public domain, except where specific copyrighted works have been incorporated into the material with permission from the copyright holder. Such permission allows CMS to use the material only within the full context of the course. These materials may include audiovisual materials (photos, slides, films, videos, computer generated images, illustrations,
graphics, audio recordings) and text materials, such as direct quotes or entire reprints. With respect to such copyrighted works, reproducing them is prohibited without permission from the copyright holder.
Emergency Medical Information (Optional)
Please provide the information requested below. This form will be held by the CMS Training Coordinator and used only in the event that you require assistance in obtaining medical treatment while attending a training program. PLEASE NOTE: These forms are destroyed at the conclusion of the training program. Thank you.
Participant’s Last Name First Name Middle Initial
Name of person (family member or friend) to contact in case of emergency:
Phone number(s): Relationship:
Please list any medical conditions or diagnoses you have, such as diabetes, epilepsy, heart disease, history of heart attack, high blood pressure, asthma, glaucoma, etc.*
Please list your food allergies*:
If none, please write “none”
Please list your medication allergies (i.e., penicillin, sulfa drugs*):
If none, please write “none”
Name and phone number of your physician:
Name of your medical insurance company/plan: Identification number:
Your supervisor’s name and phone number:
Thank you! Training Staff
Center for Medicaid and State Operations Centers for Medicare & Medicaid Services
Table of Contents
Emergency Medical Form (optional) 4
Mission 6
Course Goals 6
How to Use This Manual 6
Materials and AV List 7
Course Agenda 8
Faculty List 11
Participant List 13
Lesson Tab
Welcome and Introductions ... 1
Table of Contents Course Agenda Faculty List IACET Statement Participant List Overview of Hospice Program ...2
Hospice Central ...3
Conditions of Participation Activity...4
Pain and Symptom Management in Hospice Care ...5
Quality Assessment and Performance Improvement (QAPI)...6
Hospice Care in the Nursing Home ...7
Outcome-Oriented Survey Process ...8 A. Pre-Survey Preparation
B. Entrance Interview C. Sample Selection D. Clinical Record Review E. Home Visit Procedures F. Information Analysis G. Exit Conference
Role of Accrediting Organizations and Deemed Status...9 Immediate Jeopardy ... 10 Hospices that Provide Inpatient Services Directly
42 CFR 418.110 & 42 CFR 418.106... 11
Mission
The mission of the course is to train Regional Office and State survey agency surveyors in how to conduct a Hospice Agency survey.
Course Goals
• Familiarize the surveyors with the hospice survey process
• Convey information on how to determine if a hospice is in compliance with the Medicare Conditions of Participation
• At the conclusion of this course, health facility surveyors will be able to conduct a hospice survey.
How to Use This Manual
This manual is to be used during classroom sessions. It contains instructional objectives and materials for each of the 11 lessons.
Each unit provides objectives and a reproduction of lecture slides and/or
instructional material intended to guide note taking. Any handouts, worksheets or materials needed for a unit will be provided following the slides of that unit.
Materials and AV List
You will need the following materials in order to properly teach this course:
Print Materials
• 1 Instructor Manual per instructor • 1 Student Manual per student
• 1 Resource Manual per instructor and student
• 5 laminated job-aids (Hospice Highlights; L-Tags; Outline of Hospice Survey Process; Principles of Documentation and IJ Decision Worksheet) per student and instructor
• 1 Pre-test, post-test per student and instructor • 1 Post-test key per instructor
AV Equipment
• Laptop computer (with PowerPoint) • DVD
• LCD projector • Screen
• Visualizer
• Microphones (Lavaliere, stationary & hand-held) Other
• Easel charts • Index cards • Comment cards • Markers:
o Dark pens for use on overheads o Thicker markers for easel chart use
Course Agenda
Hospice Surveyor Training
Prerequisite: Participants who attend this course must have read and be familiar with the hospice Conditions of Participation at 42 CFR 418 published June 5, 2008 and State Operations Manual, Appendix M and Interpretive Guidelines. Participants should have been taught the Principles of Documentation and the legal aspects of surveying. It is strongly recommended that participants observe a hospice survey prior to attending the training.
Tuesday, November 18, 2008
Tab
7:00 Registration Patricia Payne
8:00 Welcome and Introductions Patricia Payne 1
Kim Roche
8:30 Welcome Jan Tarantino
8:45 Overview of Hospice Program Kim Roche 2
History, Philosophy, Goals, Services
Hospice Central: Simulation of Telephone Contacts 3
9:15 Medicare Hospice Benefit Katherine Lucas & 3
Barbara Woodford
9:45 Family Member Contact Mary Rossi-Coajou & 3
Margo Zink
10:15 Break
10:30 Nurse Applicant Contact Pat Frey & Pat Sevast 3 11:00 Conditions of Participation Activity Joanne Rokosky 4 12:00 Lunch
1:15 Pain and Symptom Management in Hospice Care Dr. Crystal Simpson, MD 5 2:15 Break
2:30 QAPI Kim Roche 6
Heather Wilson
Melanie Merriman
Wednesday, November 19, 2008
Tab
8:00 Review and Preview Kim Roche
8:15 Hospice Care in the Nursing Home Kim Roche 7
Outcome-Oriented Survey Process 8
9:15 Pre-Survey Preparation Joanne Rokosky 8A
9:30 Break
9:45 Entrance Interview Barbara Woodford, 8B
Joanne Rokosky,
Mavis Connolly,
Pat Frey &
Margo Zink
10:30 Sample Selection Kim Roche 8C
10:50 Clinical Record Review Pat Frey 8D
11:10 Clinical Record Review Exercise Danielle Shearer &
Mary Rossi-Coajou
11:30 Lunch
12:45 Clinical Record Review (Individual) Danielle Shearer &
Mary Rossi-Coajou
1:30 Clinical Record Review (Group Exercise) Danielle Shearer &
Mary Rossi-Coajou
2:30 Home Visit Procedures Margo Zink 8E
2:45 Break
3:00 Home Visit Role Play Danielle Shearer,
Pat Sevast &
Mary Rossi-Coajou
4:00 Questions and Answers Barbara Woodford
Thursday, November 20, 2008
Tab
Outcome-Oriented Survey Process (cont.) 8
8:00 Review and Preview Kim Roche
8:15 Information Analysis Pat Frey, 8F
Joanne Rokosky,
Margo Zink, &
Barbara Woodford
9:00 Exit Conference Barbara Woodford, 8G
Joanne Rokosky,
Mavis Connolly,
Pat Frey &
Margo Zink
9:45 Completing Forms CMS-417, CMS-643, Joanne Rokosky 8H CMS-2567 and CMS-2567B
10:00 Break
10:15 Role of Accrediting Organizations and Pat Sevast 9 Deemed Status
10:45 Immediate Jeopardy Joanne Rokosky 10
11:45 Lunch
1:00 Hospices that Provide Inpatient Services Directly Pat Frey 11 42 CFR 418.110 & 42 CFR 418.106
2:15 Course Summary Kim Roche
2:45 Final Questions and Answers Faculty 3:00 ADJOURN
Faculty List
2008 Basic Hospice Surveyor Training Faculty List
Mavis Connolly
CMS Consultant
Pat Frey, PHN 415-744-3705
Nurse Consultant [email protected]
Division of Survey & Certification
Centers for Medicare & Medicaid Services 75 Hawthorne St., Suite 408
San Francisco, CA 94105
Katherine E. Lucas, PhD 410-786-7723
Centers for Medicare & Medicaid Services [email protected] Mailstop: C5-08-23
7500 Security Blvd. Baltimore, MD 21244
Melanie Merriman, PhD, MBA
CMS Consultant
Patricia Payne 410-786-3401
Survey & Certification Group/Training Staff [email protected] Center for Medicaid and State Operations
Centers for Medicare & Medicaid Services Mail Stop S3-13-15
7500 Security Blvd.
Baltimore, MD 21244-1850
Kim Roche, MA, BSN, RNC, CCS-P 410-786-3524
Nurse Consultant [email protected]
Division of Continuing Care Providers Survey and Certification Group
Centers for Medicare & Medicaid Services Mail Stop S2-12-25 7500 Security Blvd. Baltimore, MD 21244-1850 Joanne Rokosky, BSN, MN 206-615-2091 CMS/CMSO [email protected] Region X 2201 Sixth Ave. Seattle, WA 98121
Mary Rossi-Coajou, MS, RN 410-786-6051
Health Program Evaluations Officer [email protected] Commander, U.S. Public Health Service
Centers for Medicare & Medicaid Services 7500 Security Blvd.
Baltimore, MD 21244-1850
Patricia Sevast, BSN, RN 410-786-8135
Nurse Consultant [email protected]
Division of Continuing Care Providers Survey and Certification Group
Centers for Medicare & Medicaid Services Mail Stop S2-12-25
7500 Security Blvd.
Baltimore, MD 21244-1850
Danielle Shearer 410-786-6617
Health Insurance Specialist [email protected] Office of Clinical Standards and Quality
Clinical Standards Group
Centers for Medicare & Medicaid Services 7500 Security Blvd.
Baltimore, MD 21244-1850
Crystal Simpson, MD 410-786-0245
Medical Officer [email protected]
Division of Continuing Care Providers Survey and Certification Group
Centers for Medicare & Medicaid Services Mail Stop S2-12-25
7500 Security Blvd.
Baltimore, MD 21244-1850
Jan Tarantino, Director 410-786-0905
Division of Continuing Care Providers [email protected] Survey and Certification Group
Centers for Medicare & Medicaid Services Mail Stop S2-12-25 7500 Security Blvd. Baltimore, MD 21244-1850 Heather Wilson, PhD CMS Consultant Barbara Woodford, RN CMS Consultant
Participant List
2008 Basic Hospice Agency Surveyor Training
1-1
Basic Hospice
Lesson 1
Basic Hospice Agency
Welcome and
Introductions
Basic Hospice 1-2
Course Logistics
Location of restrooms, telephones and
snacks during breaks
Class Time
Days 1–2 - 8:00 A.M. to 4:30 P.M. Day 3 – 8:00 A.M. to 3:00 P.M.
Lunch spots and other nearby attractions Please turn off cell phones, pagers,
blackberries & other electronic devices
Basic Hospice 1-3
Certificates
CMS is authorized by IACET to issue
CEUs. There are RULES. You must: Sign in every day
Attend all sessions and stay until the
conclusion of the course
Sign for receipt of your certificate at the
Basic Hospice 1-4
Introductions
Welcome to the Basic Hospice Agency Surveyor Training Course!
Who are we?
Basic Hospice 1-5
Why Do A Hospice Survey?
Protect hospice patients
Assure the hospice is meeting minimum
health and safety requirements (CoPs)
• CoP = Condition of Participation
Who Are You?
Who is here? (RNs, SWs, PTs, Supervisors,
AO, RO, others)
Have you ever performed a hospice
survey?
What do you hope to learn here?
Who will be assigned to perform hospice
Basic Hospice 1-7
Your Questions?
Your questions are important
There will be time for questions throughout the course
Index cards are on the tables
Put off-topic questions in the question box Use the microphone
Basic Hospice 1-8
Course Basics
Combination of lecture, discussion, case
studies and skits
Can be confusing at times, so please ask
questions
Tools:
Student Manual, laminated job-aids, Resource Manual, structured note-taking pages
Basic Hospice 1-9
Resource Manual
Separate manual
Table of Contents
Developed as surveyors’ tools for use
during survey
CMS Web address to access hospice
information
www.cms.hhs.gov
Select Regulations and Guidance Select Hospice Center
Basic Hospice 1-10
Course Agenda – Day 1
Hospice Overview
Hospice Conditions of Participation
Pain and Symptom Management
Quality Assessment and Performance
Improvement (QAPI)
Basic Hospice 1-11
Course Agenda – Day 2
Hospice Care in the Nursing Home
Outcome-Oriented Survey Process
Pre-Survey Preparation Entrance Interview Sample Selection Clinical Record Review Home Visits
Course Agenda – Day 3
Outcome-Oriented Survey Process (cont.)
Information Analysis Exit Conference
Completing forms
Role of Accrediting Organizations and
Deemed Status
Immediate Jeopardy
Hospices that Provide Inpatient Services
Basic Hospice 1-13
Course Evaluation/Feedback
Because we strive to improve, your
comments and suggestions are very important to us!
Complete one evaluation for each day Codes are located on the bottom of the agenda Make YOUR comments count!
1-14 Basic Hospice Lesson 1
Questions?
1-15 Basic Hospice Lesson 1Pre-test
Basic Hospice, November 2008 Student Manual
Lesson 2:
Overview of Hospice
Program
Learning ObjectivesAt the conclusion of this lesson, you will be able to:
•
Explain the general concepts and goals of hospice care.•
Name the services hospice must provide.•
List the core services.•
Identify the settings where hospice can be provided.•
Discuss the role of the Interdisciplinary Group (IDG).2-1 Basic Hospice
Overview of Hospice
Program
Lesson 2 Basic Hospice 2-2￭ Explain the general concepts and goals of hospice care
￭ Name the services hospice must provide
￭ List the core services
￭ Identify the settings where hospice can be provided
￭ Discuss the role of the Interdisciplinary Group (IDG)
Learning Objectives
Basic Hospice 2-3
Early Hospice Movement
You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but to live until you die.
written by Dame Cicely Saunders
“
Basic Hospice 2-4
Attributes of a Good Death
Patient:
￭ Is free from pain
￭ Is at peace with personal religious beliefs ￭ Is supported by family
￭ Is mentally aware
￭ Is able to choose treatment ￭ Feels life was meaningful
￭ Resolves conflicts and dies at home
(Source: JAMA 2000:284:2476-2482)
Basic Hospice 2-5
Medicare Options
Care reasonable and necessary for: ￭ Diagnosis or treatment of illness or injury
versus
￭ Palliation and management of a terminal
condition
Comfort Versus Cure
Hospice professionals specially trained to focus on management and palliation of terminal illness—notcurative medical care
Basic Hospice 2-7
Concepts in Hospice Care
￭ Provide pain and symptom control
￭ Provide interdisciplinary approach to care
￭ Support patient self-determination
￭ Allow patient to die at home or place of own choosing
￭ Treat patient with dignity and respect
￭ Address physical, psychosocial and spiritual needs
￭ Assist family with bereavement
￭ Focus on patient and family
Basic Hospice 2-8
Required Services in Hospice Care
Patient & Family
Nursing Social Work Counseling Physician Hospice Aide &
Homemaker Therapies Short-term Inpatient Care Drugs, DME, Biologicals Volunteers Basic Hospice 2-9
Hospice CoP Topics
￭ Patient's Rights
￭ Initial & Comprehensive Assessment
￭ IDG, Care Planning & Coordination of Services
￭ Quality Assessment Performance improvement (QAPI)
￭ Infection Control
￭ Core Services
￭ Hospice Aide & Homemaker Services
￭ Volunteers
￭ Medical Director
￭ Clinical Records
￭ Drugs, Biologicals & DME
￭ Short-term Inpatient Care
Basic Hospice 2-10
Hospice Synergy
Plan of Care Assessment IDG
Pt/ Family
QAPI
Basic Hospice 2-11
Hospice Interdisciplinary Group
￭ Registered nurse
￭ Physician
￭ Social worker
￭ Counselor
Hospice Core Services
￭ Physician services ￭ Nursing services ￭ Medical social services
￭ Counseling services (dietary, bereavement, spiritual)
Basic Hospice 2-13
Furnishing Core Services
￭ Hospice must ensure that substantially all core services are routinely provided directly by hospice employees ￭ CMS defines a direct employee by the W-2 Basic Hospice 2-14
Core Services: Exceptions & Waivers
￭ The hospice must:
￭ Maintain professional, financial and administrative responsibilities
￭ Assure staff are qualified and services meet requirements
Basic Hospice 2-15
4 Levels of Hospice Care
￭ Routine Home Care
￭ Continuous Care
￭ Respite Care
Basic Hospice 2-16
Location of Routine & Continuous Hospice Care
Apartment Private home Condo Hospice residence Assisted living Nursing home
Houseboat Trailer ICF-MR Family member Patient’s Home Basic Hospice 2-17
Location of Inpatient Care: General and Respite
￭ Hospice inpatient facility or unit ￭ Hospital
￭ Skilled nursing facility (SNF)
￭ Nursing facility (NF) (respite care only)
Inpatient Care
Hospice may provide
Directly Under
Basic Hospice 2-19
Inpatient Care Provided
￭ Own facility ￭ Must meet 418.110 ￭ Leased space ￭ Must meet 418.110 ￭ Space in a Medicare hospital or SNF/NF ￭ Must meet 418.110(b)&(e) ￭ Medicare hospital* ￭ Medicare SNF* ￭ Medicare hospice *Must meet 418.110(b)&(e)) Directly Arrangement Basic Hospice 2-20 Under Arrangement
Hospice must have a written agreement to provide services under arrangement See 418.100(e) Professional Management Responsibilities
2-21 Basic Hospice
Lesson 2
Basic Hospice, November 2008 Student Manual
Lesson 3:
Hospice Central
Learning ObjectivesAt the conclusion of this lesson, you will be able to:
•
Explain Medicare coverage for hospice services.•
Verbalize hospice care concepts and goals.•
Identify hospice Conditions of Participation (CoP).•
Discuss the relationship of CoPs to the survey process and hospice operations.Hospice Central
Hospice Medicare Benefit Highlights
Certification of Terminal Illness, 42 CFR 418.22
• Terminal illness is defined by statute to mean that the medical prognosis of life expectancy is six months or less if the terminal illness runs its normal course.
• Based on physician’s judgment.
• Certification of terminal illness must occur at the beginning of each election period.
• The initial election period requires written certification (the initial certification) of the patient’s terminal illness from the medical director of the hospice or the physician member of the interdisciplinary group (IDG) and patient’s attending physician (if the patient has one).
• Subsequent certifications require the signature of the medical director of the hospice or the physician member of the hospice IDG.
• The attending physician is identified by the patient at the time of election as the doctor or nurse practitioner who has the most significant role in determining and delivering care. A patient can identify a hospice physician or nurse practitioner as his or her attending physician. A nurse practitioner cannot certify the terminal illness.
Admission to Hospice Care, 42 CFR 418.25
• The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient’s attending physician (if any).
• The medical director must consider at least the following: o Diagnosis of the terminal condition.
o Other health conditions, whether related or unrelated to the terminal condition.
o Current clinically relevant information supporting the diagnosis.
Election of Hospice Care, 42 CFR 418.24 and the Medicare Benefit Policy Manual (Chapter 9, section 10)
• For an individual who meets the eligibility requirement of 42 CFR 418.20:
o The beneficiary (or his or her legal representative) must sign and file an election statement with the hospice he or she chooses to provide care.
o The individual or representative acknowledges that care will be palliative, not curative.
o Election of hospice care waives the patient’s right to any Medicare services that are related to the treatment of the terminal illness and related conditions for which hospice care was elected, except those provided by the designated hospice or under arrangement.
o Medicare benefits are still available for the treatment of conditions unrelated to the terminal illness.
Benefit Election Periods, 42 CFR 418.21
Once a Medicare beneficiary elects hospice care, care is divided into the following benefit periods: an initial 90-day period, a subsequent 90-day period and an unlimited number of 60-day periods.
Medical Director, 42 CFR 418.102
• The medical director or physician designee reviews clinical information and provides written certification that the patient’s life expectancy is 6 months or less if the illness runs its normal course.
o The physician must consider the following when making this determination:
o The primary terminal condition; o Related diagnosis(es), if any;
o Current subjective and objective medical findings; o Current medication and treatment orders; and
o Information about the medical management of any of the patient’s conditions unrelated to the terminal illness. • Before the recertification period for each patient, the medical
director or physician designee must review the patient’s clinical information.
Revoking the Election of Hospice Care, 42 CFR 418.28
• An individual or their representative may revoke the individual’s election of hospice care at any time during an election period. • An individual may at any time elect to receive hospice coverage
for any other hospice election period that he or she is eligible to receive.
Drugs and Biologicals, Medical Supplies and Durable Medical Equipment, 42 CFR 418.106
identified in the plan of care, must be provided by the hospice while the patient is under hospice care.
*Biologicals is a general term applied to medicinal compounds that are prepared from living organisms and their products. Includes: serums, vaccines, antigens, and antitoxins.
• The hospice IDG must confer with an individual with education and training in drug management to ensure that drugs and biologicals meet each patients needs.
• The hospice must obtain drugs and biologicals from a community or institutional pharmacist or stock drugs and biologicals itself.
Organization and Administration of Services 42 CFR 418.100
• The hospice must organize, manage, and administer its
resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and
management of the terminal illness and related conditions.
• Optimize comfort and dignity; consistent with patient and family needs and goals.
• The hospice must provide nursing services, medical social services, physician services, counseling services (including spiritual, dietary and bereavement counseling), hospice aide, volunteers, homemaker services, physical therapy, occupational therapy, speech-language pathology, short-term inpatient
services and medical supplies (including drugs and biologicals) and medical appliances.
• Nursing services, physician services and drugs and biologicals must be routinely available of a 24-hour basis, 7 days per week. Patient co-pay may apply.
• Other covered services must be available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family.
Payment Procedures for Hospice Care, 42 CFR 418.302
• Payment amounts are determined within each of the following level-of-care categories:
– Routine home care – Continuous home care – Inpatient respite care
Short-term Inpatient Care, 42 CFR 418.108; Covered Services, 42 CFR 418.202; and Payment Procedures for Hospice Care, 42 CFR 418.302
• Inpatient care must be available for pain control, symptom management and respite purposes.
• Inpatient care must be provided in a participating Medicare or Medicaid facility.
• Short-term inpatient care meeting the covered services
standards in 42 CFR 418.202 must conform to the written plan of care and may be required for procedures necessary for pain control or acute or chronic symptom management.
• Inpatient care may also be furnished as a means of providing respite.
• Payment for inpatient care is to be made at the rate appropriate to the level of care as specified in 42 CFR 418.302.
Core Services, 42 CFR 418.64(b), Nursing Services
• The hospice must provide nursing care and services by or under the supervision of a registered nurse.
• If State law permits a registered nurse, including a nurse
practitioner or advanced practice nurse, to see, treat and write orders, then they may perform this function while providing nursing services to hospice patients.
Medicare Benefit Policy Manual, Chapter 9, Coverage of Hospice Services (Section 40.1.3b; Nurse Practitioners as Attending Physicians)
• A nurse practitioner is defined as a registered nurse who is permitted to perform such services as legally authorized to perform (in the state in which the services are performed) in accordance with State law (or State regulatory mechanism provided by State law) and who meets specific training, education and experience requirements (described in 42 CFR 410.75).
• Services provided by a nurse practitioner that are medical in nature must be reasonable and necessary, be included in the plan of care and must be services that, in the absence of a nurse practitioner, would be performed by a physician. If the services performed by a nurse practitioner are such that a registered nurse could perform them in the absence of a
physician, they are not considered attending physician services. Services that are duplicative of what the hospice nurse would
• Nurse practitioners cannot certify a terminal diagnosis or the prognosis of six months or less, if the illness or disease runs its normal course, or re-certify terminal diagnosis or prognosis. In the event that a beneficiary’s attending physician is a nurse practitioner, the hospice medical director and/or physician designee may certify or re-certify the terminal illness.
Discharge from Hospice Care, 42 CFR 418.26 and SOM 2082
• A hospice may discharge a patient if:
o Patient moves out the hospice’s service area or transfers to another hospice.
o The patient is no longer terminally ill.
o The patient’s (or other persons in the patient’s home) behavior is disruptive, abusive or uncooperative to the extent that delivery of care to the patient, or the ability of the hospice to operate effectively, is seriously impaired. This is discharge for cause.
• The hospice must do the following before it seeks to discharge a patient for cause:
o Advise the patient that a discharge for cause is being considered;
o Make a serious effort to resolve the problem(s) presented by the patient’s (or other persons in the patient’s home) behavior or situation;
o Ascertain that the patient’s proposed discharge is not due to the patient’s use of necessary hospice services; and o Document in the clinical record, the problem(s) and efforts
made to resolve the problem(s).
• Prior to discharging a patient, for any reason, the hospice must obtain a written physician’s discharge order from the hospice medical director. The attending physician should be consulted, and his/her view and decision should be included in the
discharge note.
• The hospice must have a process for discharge planning in place. • The hospice must notify their Medicare administrative contractor
(MAC) and State agency (SA) of the circumstances surrounding the impending discharge.
• Referrals to other appropriate and/or relevant state/community agencies or health care facilities must be considered before discharge.
These highlights provide a general overview of the hospice benefit. Please see 42 CFR Part 418 for more complete details.
Hospice Central
Family Contact Highlights
Philosophy of Hospice
• Hospice provides care to individuals who have been diagnosed with a terminal illness and have six months or less to live if the disease runs its normal course.
• Hospice provides palliative rather than curative care, with a focus on pain management and symptom control.
• Hospice care is aimed at helping people live as comfortably as possible.
• Hospice cannot add days to a patient’s life, but it can add quality to their days.
Terminal Status
• Hospice provides care to individuals who have been diagnosed with a terminal illness and have six months or less to live if the disease runs its normal course.
Patient’s Rights, 42 CFR 418.52
• Patient rights and responsibilities information must be provided verbally (meaning spoken) and written in a language and
manner the patient understands in advance of providing care. • The patient or his/her legal representative must sign that they
have received information on patient rights and responsibilities. • Patients and/or their legal representatives have the right to be
informed about the care and services that may be provided. • Hospice programs are required to furnish advance directive
information to patients at the time of admission to hospice. o Advance directives are written instructions recognized
under State law, such as a living will or durable power of attorney for health care, relating to the provision of health care when an individual is incapacitated.
• Patients have the right to:
o Have their property and person treated with respect o Have a person designated by the court or the person in
accordance with State law exercise the patient’s rights o Voice grievances and not be subject to discrimination or
reprisal
o Have alleged violations involving mistreatment, neglect, or verbal, mental, sexual or physical abuse, including injuries of unknown source, and misappropriation of patient
o Have all alleged violations investigated
o If alleged violations are verified, the hospice must take appropriate corrective action. The hospice has five
working days to investigate any alleged violations and, if the alleged violation is verified, it must report the verified violation to the State and local bodies having jurisdiction within those five days.
o Effective pain management and symptom control o Be involved in development of his/her care plan o Refuse care and treatment
o Choose their attending physician o Confidential clinical record
o Be free from mistreatment, neglect or verbal, mental, sexual and physical abuse, injuries of unknown source and misappropriation of property
o Receive information about the services covered under the hospice benefit; and
o The scope of services that the hospice will provide and specific limitations on those services.
• In summary, the patient has the right to be informed of these rights and the hospice must protect and promote the exercise of these rights.
Medical Director, 42 CFR 418.102
The medical director:
• Must be a Medical Doctor (MD) or Doctor of Osteopathy (DO). • Assumes overall responsibility for the medical component of the
hospice patient’s care.
• With the attending physician (if any), initially certifies that all individuals admitted to the hospice have a terminal illness. Terminally ill is defined by statute to mean that the medical prognosis of life expectancy is six months or less if the illness runs its normal course.
• (Or physician member of the interdisciplinary group) assumes the responsibility for recertifying the patient’s eligibility for hospice services.
• The hospice may contract for a physician to be the medical director of a hospice.
Initial and Comprehensive assessment of the patient, 42 CFR 418.54
patient-need for hospice care and services including the patient-need for physical, psychosocial, emotional, and spiritual care.
• A registered nurse must complete an initial assessment within 48 hours of the election of hospice care unless the physician, patient or representative requests it be done sooner.
• The hospice interdisciplinary group (IDG) in consultation with the attending physician (if any) must complete the
comprehensive assessment no later than 5 calendar days following the election of hospice care.
• The comprehensive assessment must identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness and related conditions to promote the patient’s well-being, comfort and dignity throughout the dying process. • The comprehensive assessment must consider:
o Nature and condition causing admission
o Complications and risk factors effecting care planning o Functional status, including ability to understand and
participate in own care o Imminence of death o Severity of symptoms
o Drug profile and review, and
o An initial bereavement assessment
• The comprehensive assessment must be updated by the IDG, in collaboration with the attending physician (if any), no less
frequently than every 15 calendar days or as the patients condition requires.
• The comprehensive assessment must include data elements that allow for measurement of outcomes. The data elements must be used for individualized care planning, coordination of services and in aggregate for the hospice’s quality assessment and
performance improvement program (QAPI).
Interdisciplinary Group, Care Planning and Coordination of Services, 42 CFR 418.56
Interdisciplinary Group, Care Planning and Coordination of Services, 42 CFR 418.56
• The hospice must establish and maintain an individualized written plan of care for each individual admitted to the hospice. • The patient’s attending physician, the hospice medical director
and the interdisciplinary group must establish the written plan of care for each patient.
• The interdisciplinary group must include, but is not limited to, individuals who are qualified and competent to practice in the
roles of physician, registered nurse, social worker and pastoral or other counselor (dietary or bereavement).
• The plan of care must include the patient and family goals and the interventions necessary to meet the patient and family
needs identified through the initial, comprehensive, and updated assessment as those needs relate to the terminal illness and related conditions.
• A registered nurse (who is a member of the IDG) will be
designated to provide coordination of care and to ensure there are continuous assessments of each patient and family’s needs and implementation of the interdisciplinary plan of care.
• The plan of care must include:
o Interventions to manage pain and other symptoms
o Detailed statement of the scope and frequency of services needed to meet the patient’s and family’s needs.
o Measurable outcomes anticipated from implementing and coordinating the plan of care.
o Drugs, treatments, medical supplies and appliances necessary to meet the patient’s needs.
o The IDG’s documentation of the patient’s or representative’s understanding, involvement and agreement with the plan of care.
• All plans of care are reviewed and revised as often as the patient’s condition requires, but no less frequently than every 15 calendar days.
• The revised plan of care must include information from the updated comprehensive assessments and note any progress toward outcomes and goals.
• The patient and primary caregivers must receive education and training as appropriate to their responsibilities for the care and services identified in the plan of care.
• The hospice must develop and maintain a system of communication to ensure that:
o The IDG maintains the responsibility to direct, coordinate and supervise the care and service being provided to patients;
o Care and services are provided in accordance with the plan of care and based on patient assessments;
o There is an ongoing sharing of information between all disciplines providing care and services in all hospice settings; and
Organization and Administrative Services, 42 CFR 418.100
• In order to receive Medicare reimbursement for services, a hospice program must be Medicare certified and provide care in accordance with Medicare regulations and acceptable standards of practice.
• Hospices must provide care and services to patients, caregivers and families for the palliation and management of the terminal illness and related conditions.
• The care provided must optimize comfort and dignity consistent with the patient and family needs and goals.
• The hospice must provide nursing services, medical social services, physician services, counseling services (including spiritual, dietary and bereavement counseling), hospice aide, volunteers, homemaker services, physical therapy, occupational therapy, speech-language pathology, short-term inpatient
services and medical supplies (including drugs and biologicals) and medical appliances.
• Nursing services, physician services and drugs and biologicals must be routinely available of a 24-hour basis, 7 days per week. Patient co-pay may apply.
• Other covered services must be available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family.
• A hospice may not discontinue or diminish care provided to a Medicare beneficiary because of the beneficiary’s inability to pay for the services.
Hospice Aide and Homemaker Services, 42 CFR 418.76
• Hospice aide services are available if the patient needs
assistance with personal hygiene, grooming, transferring, range of motion, etc. (these are considered activities of daily living or ADLs)
• A hospice aide is a person who has successfully competed the following;
o A training program AND competency evaluation; o A competency evaluation program;
o A nurse aide training and training program approved by the State which meets the Federal requirements; or o A State licensure program that meets the classroom,
supervised practical training and competency requirements.
• It is the responsibility of the hospice to ensure that hospice aides used by the hospice are proficient and remain proficient to
carry out their patient care assignments in a safe, effective, and efficient manner.
• All hospice aides must receive and the hospice must maintain documentation that each aide has received 12 hours of in-service during each 12 month period
• Hospice aides need to be assigned to a specific patient and provided with individualized written instructions for patient care prepared by a registered nurse, who is a member of the IDG. • Hospice aide services must be:
o Ordered by the IDG
o Included in the plan of care
o Permitted to be performed under State law by the aide; and
o Consistent with the hospice aide training.
• A registered nurse must make a supervisory visit to the home site at least every 14 days to access the quality of care and services provided by the aide. The aide does not need to be present during this visit.
• The supervisory visit must include an assessment of aide services.
• If concerns are identified during the supervisory visit, an on-site visit must be made when the aide is present to observe and assess them performing care.
• If area of concern is verified during the on-site visit, the hospice must conduct additional training and the aide must complete a competency evaluation.
• Annually, a registered nurse must make an on-site visit to the location where a patient is receiving services to observe and assess each aide while they are performing care.
Drugs and Biologicals, Medical Supplies and Durable Medical Equipment, 42 CFR 418.106
• Drugs and biologicals, medical supplies and durable medical equipment related to the terminal illness and related conditions, identified in the plan of care, must be provided by the hospice while the patient is under hospice care.
• The hospice IDG must confer with an individual with education and training in drug management to ensure that drugs and biologicals meet each patients needs.
• A hospice that provides inpatient care directly in its own facility must provide pharmacy services under the direction of a
• The hospice must obtain drugs and biologicals from a community or institutional pharmacist or stock drugs and biologicals itself.
• Drugs and biologicals should be available on a 24-hour basis. Patient copay may apply.
• The IDG must determine the patient and/or family ability to safely self-administer drugs in the patients’ home.
• Medications must be labeled according to accepted professional practices and include appropriate usage, cautionary instructions and expiration date.
• The hospice must have policies and procedures for the
management and disposal of controlled drugs that may be used for an individuals care. At the time when controlled drugs are first ordered, the hospice must provide the patient, patient’s representative or family member with a written copy of their policies and procedures.
• Medical supplies, appliances and durable medical equipment, as identified in the written plan of care, must be provided by the hospice while under hospice care.
o The hospice must ensure manufacturer recommendations for routine and preventive maintenance of medical
equipment are followed.
o Ensure that the patient (when appropriate) as well as the family and other caregivers receive instructions in the safe use of durable medical equipment and supplies.
Volunteers, 42 CFR 418.78
• Volunteers can be used in direct patient care roles to offer support in a patient’s home and provide caregivers a short respite from daily responsibilities.
• The hospice must provide volunteers with appropriate orientation and training that are consistent with acceptable standards of hospice practice.
Medicare Benefit Policy Manual, Chapter 9, Coverage of Hospice Services
Section 40.2.1 - Continuous Home Care
• Continuous home care may be provided only during a period of crisis.
• A period of crisis is a period in which a patient requires continuous care for as much as 24 hours, which is predominantly nursing care, to achieve palliation or management of acute medical symptoms.
• If a patient’s caregiver has been providing a skilled level of care for the patient and the caregiver is unwilling or unable to
continue providing care, this may precipitate a period of crisis because the skills of a nurse may be needed to replace the services that had been provided by the caregiver.
Short-Term Inpatient Care, 42 CFR 418.108
• Short term inpatient services must be available for pain control, symptom management and respite purposes.
• Inpatient services can be provided either directly by the hospice or at Medicare-/Medicaid-certified facilities.
o Inpatient care for pain management and symptom control must be provided in a:
￭ Medicare certified hospice that meets 418.110 ￭ Medicare certified hospital or SNF that meets
418.110(b) and (e) regarding 24 hour nursing services and patient areas
o Inpatient care for respite purposes provided in a:
￭ Medicare certified hospice that meets 418.110
￭ Medicare certified hospital or SNF that meets 418.110(b) and (e) regarding 24 hour nursing services and patient areas
￭ Medicare or Medicaid certified nursing facility that also meets 418.110(e) regarding patient areas. • The hospice is to inform the patient at admission of the facilities
used for short term inpatient services.
Hospices that provide hospice care to residents of a SNF/NF or ICF/MR, 42 CFR 418.112
• Medicare beneficiaries can receive hospice services while residing in a skilled nursing facility.
• The hospice would have a written agreement with the facility and maintain professional management responsibility for the hospice services provided.
• The services must be provided in accordance with the hospice plan of care.
• The hospice would coordinate care with the facility. • The facility would be providing the room and board
Core Services, 42 CFR 418.64 Physician Services
patient’s attending physician, are responsible for the palliation and management of the terminal illness and related conditions. • If the attending physician is unavailable, the hospice medical
director, hospice contracted physician, and/or hospice physician employee is responsible for meeting the medical needs of the patient.
Bereavement Counseling
• Bereavement counseling is an organized program under the direction of a qualified professional.
• The IDG plan of care should reflect the family and other individuals’ initial bereavement needs.
• Bereavement services must be made available to the family and other individuals up to 1 year following the death of the patient. • The bereavement plan of care must delineate the kind and
frequency of bereavement services to be offered.
These highlights provide a general overview. Please see 42 CFR Part 418 for more complete details.
Hospice Central
Nurse Applicant Contact Highlights
Compliance with Federal, State and local laws and regulations related to the health and safety of patients, 42 CFR 418.116
• The hospice and its staff must operate and furnish services in compliance with all applicable Federal, State, and local laws and regulations related to the health and safety of patients.
• If State or local law provides for licensing of hospices, the hospice must be licensed.
• In order to receive Medicare reimbursement, hospice providers must be in compliance with the Medicare hospice Conditions of Participation.
• If the hospice provides services at multiple locations each location must be approved by Medicare and licensed in accordance with State laws.
• If the hospice engages in specific laboratory testing or assisting patients with self-administration of tests (such as glucose
monitoring), they must have a CLIA certificate for the level of testing being performed.
Clinical Records, 42 CFR 418.104
• A clinical record must be maintained for every hospice patient. • The record must contain correct information and be available to
the attending physician and hospice staff.
• All entries must be clear, complete and appropriately authenticated and dated.
• Each patient’s record must contain:
o Past and current findings, initial assessment,
comprehensive assessments, updated assessments, plan of care, updated plans of care, clinical notes, responses to medications, symptom management, treatments,
services, and physician orders.
o Signed copies of the notice of patient rights and election statement, outcome measure data elements, physician certification and recertification, and advance directives. • The records should be safeguarded against loss or unauthorized
use.
• Records must be retained for six years after the death or discharge of the patient, unless State law stipulates longer. • If care of the patient is transferred to another
Medicare/Medicaid facility a discharge summary must be sent or a copy of the clinical record, if requested.
• Either hard copy or electronic records must be readily available on request.
Infection Control, 418.60
• The hospice must maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases.
• The hospice infection control program must identify risks for the acquisition and transmission of infectious agents in all settings where the patient resides.
• There needs to be a system to communicate with all hospice personnel, patients, families and visitors about infection
prevention and control issues including their role in preventing the spread of infections and communicable diseases through daily activities.
• The hospice must follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions.
• The hospice must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice's quality assessment and
performance improvement program; and • The infection control program must include:
o A method of identifying infectious and communicable disease problems; and
o A plan for implementing the appropriate actions that are expected to result in improvement and disease
prevention.
• The hospice must provide infection control education to
employees, contracted providers, patients, and family members and other caregivers.
Organization and administration of services, 42 CFR 418.100
• Governing body and administrator
o Governing body assumes full legal authority and responsibilities for the management of the hospice services and all facets of the program including fiscal operations and continuous quality assessment and performance improvement.
o The hospice administrator is responsible for the day-to-day operations of the hospice and reports to the
governing body.
o The administrator must be a hospice employee and possess education and experience required by the governing body.
• Professional Management Responsibility
o The hospice must have a written agreement with another agency, individual, or organization to furnish services under arrangement.
o The hospice must retain administrative, financial management and staff oversight.
o All services must be:
• Authorized by the hospice
• Furnished in a safe and efficient manner by qualified personnel and
• Delivered in accordance with the patient’s plan of care.
• Multiple locations
o If the hospice operations multiple locations, each
location must be Medicare approved before hospice care and services are provided to Medicare beneficiaries. o Multiple locations must be part of the hospice and
share administration, supervision and services with the hospice issued the certification number (parent).
o Lines of authority and professional and administrative control must be clearly delineated in the organizational structure and practice, and traced back to the parent. o The hospice must continually monitor and manage all
services provided at multiple locations. • Training
o Hospices must provide orientation to all employees and contracted staff that have contact with patients and families about the hospice philosophy.
o Initial orientation must be provided to each employee that addresses their specific job duties.
o The hospice must assess the skills and competence of all individuals furnishing care. This includes volunteers. o In-service training and education programs must be
provided when required.
o The hospice must maintain policies and procedures describing its method(s) of assessment of competency. o A written description of in-service training provided
Quality assessment and performance improvement, 42 CFR 418.58
• Hospices are required to develop, implement and maintain their own quality assessment and performance improvement (QAPI) program to meet their specific program needs. The methods used by the hospice for self-assessment are flexible and may include a review of current documentation (e.g., review of clinical records, incident reports, complaints, patient satisfaction surveys, etc.); patient care, direct observation of clinical performance, operating systems and interviews with patients and/or staff. The information
gathered by the hospice should be based on criteria and/or measures generated by the medical and
professional/technical staffs and reflect hospice best practice patterns, staff performance, and patient outcomes.
• The hospice’s governing body must oversee the QAPI program.
• Hospices are required to assess quality in all areas of
operations. There is a specific requirement to track adverse events (as they are defined in hospice policy) and reduce their occurrence where possible. They must be able to show (using quantitative data or other means) that they can
improve quality, as measured by their own indicators or measures.
• Hospices must not limit their QAPI data collection efforts to the data collected during patient assessments.
• The hospice’s governing body is responsible for ensuring that the ongoing program is defined, implemented, maintained, and evaluated.
Interdisciplinary Group (IDG), Care planning and coordination of services, 42 CFR 418.56
• Designated by the hospice, the IDG is composed of
individuals who provide the care and services, and the group in its entirety, must supervise the care and services offered by the hospice.
• The IDG must include the following individuals: doctor, registered nurse (RN), social worker (SW) and a pastoral or other counselor.
• Documentation must be evident verifying the full
participation of all IDG members into each patient-specific individualized written plan of care.
provision or supervision of hospice care and services, periodic review and updating of the assessments and care plan for each individual receiving hospice care and services, and establishment of policies governing the day-to-day provision of hospice care and services.
• If a hospice has more than one IDG, it must identify a
specifically designated IDG to establish policies governing the day-to-day provisions of hospice care and services.
• The hospice must designate an RN to coordinate the implementation of the plan of care for each patient.
Core Services, 42 CFR 418.64
Nursing Services
• The hospice must provide nursing care and services by or under the supervision of an RN.
• Nursing services must be directed and staffed to assure that the nursing needs of patients are met as identified in the
patient’s initial assessment, comprehensive assessment and updated assessments.
• If a registered nurse, including a nurse practitioner,
advanced practice nurse, etc., is permitted by State law and regulation to see, treat, and write orders, then they may perform this function while providing nursing services for hospice patients. Hospices are free to use the services of all types of advanced practice nurses within their respective scopes of practice to enhance the nursing care furnished to patients. Services provided by a nurse practitioner (NP) who is not the patient’s attending physician, are included under nursing care.
• Highly specialized nursing services that are provided so infrequently that the provision of such services by direct hospice employees would be impracticable and prohibitively expensive, may be provided under contract.
o Highly specialized nursing services, such as complex wound care and infusion specialties, are determined by the nature of the service and the nursing skill level required to be proficient in the service. For example, a hospice may need to contract with a pediatric nurse because of the very infrequent pediatric patients the hospice cares for and that to employ a pediatric nurse would be impracticable and expensive.
o Continuous care is not a highly specialized service, because while time intensive, it does not require highly specialized nursing skills.
• Patient care responsibilities of nursing personnel must be specified.
• Recognized standards of practice for service must be followed.
Initial and Comprehensive assessment of the patient, 42 CFR 418.54
• A registered nurse must complete an initial assessment within 48 hours of the election of hospice care unless the physician, patient or representative requests it be done sooner.
• The hospice interdisciplinary group (IDG), which includes the registered nurse, in consultation with the attending physician (if any) must complete the comprehensive assessment no later than 5 calendar days following the election of hospice care. • The comprehensive assessment must be updated by the IDG,
which includes the registered nurse, in collaboration with the attending physician (if any), no less frequently than every 15 calendar days or as the patients condition requires.
Personnel qualifications, 42 CFR 418.114(d), Criminal background checks
• The hospice must obtain a criminal background check on all hospice employees who have direct patient contact or access to patient records.
• Criminal background checks must be obtained in accordance with State requirements. If there are no state requirements, criminal background checks must be obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years.
Pain Management and Symptom Control
• Major focus of hospice care.
These highlights provide a general overview. Please see 42 CFR Part 418 for more complete details.
Basic Hospice, November 2008 Student Manual
Lesson 4:
Conditions of
Participation Activity
Learning ObjectiveAt the conclusion of this lesson, you will be able to:
•
Demonstrate a working knowledge of the hospice Conditions of Participation (CoP).Hospice Conditions of Participation
Compliance Decisions
Activity 4-1 Student Manual
I. MAKING THE HARD DECISION: STANDARD versus
CONDITION
Remember: Condition of Participation (CoP)-level deficiency:
• Highest level of non-compliance • Initiates the termination process
• If not corrected → termination of provider agreement
Standard-level deficiency:
• Subset requirement of a condition
• Continued certification with acceptable plan of correction
Considerations When Making the Decision:
• What is the degree and manner of the deficient practice?
• Is the issue entirely one of “paper,” no matter how broadly you consider the issue?
• Is there any potential or actual negative clinical outcome? • How significant is the potential or actual negative clinical
outcome?
• What is the frequency of occurrence and degree of severity? • What is the effect or potential effect on patient(s)?
• Is there a broken system that led or contributed to the deficient practice?
• Is control and supervision of clinical activities appropriate, sufficient and functioning?
• Is this agency functioning as a hospice according to the requirements in both the statute and the regulations?
• Is there immediate jeopardy? (automatic CoP-level deficiency)
II. Practice Making Compliance Decisions
Instructions:
Read the scenario assigned to your table and discuss with your tablemates. You have 15 minutes to complete this activity. As a table, decide:
1. Which condition of participation do these findings pertain to? List the L-tag, the CFR reference and the title.
2. Do these findings support deficient practice?
• If yes, list the L-tag(s) and specific findings that support deficient practice.
• If no, explain why not, then stop.
3. Does the deficient practice support a standard-level or a condition-level deficiency?
• Why or why not?
• What else do you need to know in order to make this decision?
Once you have completed the above three steps, appoint a
spokesperson for your table. Several tables will be assigned to each scenario. The spokespersons for each scenario should decide among themselves how they will briefly summarize the scenario, present the conclusions and any areas of differing conclusions. While the
spokespersons are meeting, the other tablemates should read the remainder of the scenarios.
Scenario 1:
Based on personnel record reviews and staff interview, it was determined that the hospice failed to maintain documentation that one of one hospice aides (Employee #1), met the skill requirements as specified in this regulation. As a result, Employee #1 was not available to provide hospice aide services to patients.
Findings:
Employee #1, a certified nursing assistant (CNA) was hired on
12/15/__ to provide hospice aide services. Employee #1, the only aide employed by the agency, had been scheduled for a competency
evaluation on 12/18/__. Review of the Employee #1’s personnel record on 1/15/__ revealed the absence of a documented competency evaluation. When interviewed on 1/15/__ at 2:00 PM, the hospice director stated that the competency evaluation had been completed but could not be located. She was unable to provide documentation of the completed competency evaluation by the time of the survey exit.
Instructions:
Read the scenario and discuss with your tablemates. You have 15 minutes to complete this activity.
As a table, decide:
1. To which condition of participation these findings pertain? List the L-tag, the CFR reference and the title.
2. Do these findings support deficient practice?
• If yes, list the L-tag(s) and specific findings that support deficient practice.
• If no, explain why not, then stop.
3. Does the deficient practice support a standard-level or a condition-level deficiency?
• Why or why not?
• What else do you need to know in order to make this decision?
Once you have completed the above three steps, appoint a
spokesperson for your table. Several tables will be assigned to each scenario. The spokespersons for each scenario should decide among themselves how they will briefly summarize the scenario, present the conclusions and any areas where there were different conclusions. While the spokespersons are meeting, the other tablemates should read the remainder of the scenarios.
Scenario 2:
Based on review of clinical records and verified in interviews with the director of nurses and the patient care coordinator, the agency failed to ensure that hospice aide services were provided in accordance with the plan of care for two of eight sample patients (Patients 3 and 5). Failure to meet this requirement may place patients at risk of not receiving services that are necessary for maintaining optimal comfort and function.
Findings:
1. Patient 5 was admitted on 2/17/__. The plan of care updated 3/2/__ contained a plan for hospice aide services four times per week to assist the patient with personal care, range of motion exercises, activities of daily living and housekeeping. The record contained documentation of two visits during the week of 3/9/__ - 3/15/__, no visits the week of 3/16/__ - 3/22/__, and two visits the week of 3/23/__ - 3/29/__. Review of hospice aide visit notes dated 3/6/__, 3/10/__, and 3/25/__ revealed no documentation that assistance with range of motion exercises or housekeeping had been provided or offered. Further review of the hospice clinical record revealed no evidence of RN supervisory visits.
2. Patient 3 was admitted on 12/28/__. The plan of care updated 1/22/__ indicates home health aide services three times per week for assistance with personal care and activities of daily living. The record contained documentation of one visit the week of 1/26/__- 2/1/__ and 1 visit the week of 2/2 - 2/8/__.
3. The missed visits and failure to follow the hospice plan of care were discussed with the director of nurses and the patient care coordinator at 3 PM on 4/2/__. Both concurred that the expectation was for the hospice aide to follow the plan of care or communicate with the supervising Registered Nurse if the plan needed to be
revised. They were unable to produce documentation for the missed visits, documentation of supervisory visits, or evidence that the hospice aide had communicated with the Registered Nurse. Instructions:
Read the scenario and discuss with your tablemates. You have 15 minutes to complete this activity.
2. Do these findings support deficient practice?
• If yes, list the L-tag(s) and specific findings that support deficient practice.
• If no, explain why not, then stop.
3. Does the deficient practice support a standard-level or a condition-level deficiency?
• Why or why not?
• What else do you need to know in order to make a decision?
Once you have completed the above three steps, appoint a
spokesperson for your table. Several tables will be assigned to each scenario. The spokespersons for each scenario should decide among themselves how they will briefly summarize the scenario, present the conclusions and any areas where there were differing conclusions. While the spokespersons are meeting, the other tablemates should read the remainder of the scenarios.
