WORKSHOP ON COMPLIANCE REVISED HOSPICE CONDITIONS OF PARTICIPATION

1
WORKSHOP ON COMPLIANCEREVISED HOSPICECONDITIONS
OF PARTICIPATION

• Deborah Randall, Esq.
• law_at_deborahrandallconsulting.com

2
The Workshop Goals

• Understand the compliance background to the new
  COPs the times we work in
• Learn recent regulatory enforcement activities
  affecting Hospice brief overview
• Comprehend The Hospice COPs content, a timeline
  approach and a structural approach
• Analyse a case study

3
Compliance Reviewers

• State Survey and Certification Agencies CHAP
  JCAHO
• State Medicaid Fraud Control Units (MFUCUs)
  Medicaid Inspector Generals (IG)
• Federal Office of the Inspector General (OIG)
  Fiscal Intermediaries/MACs
• State Consumer Protection Agencies

4
The Numbers Game

• 18.7 1 yr. increase in Medicare costs
• 28 Residents in nursing homes receiving
  hospice care in 2005
• FY 2007, MFCUs recovered gt 1.1 billion in
  penalties obtained 1,205 convictions. More
  than 800 exclusions,based on referrals made to
  OIG by MFCUs.

5
Medicare Program Integrity

• Will use the Resubmission of the Form 885s Every
  3 years
• No Certainty providers will stay in system
• Resurveying possible

6
Failures in COPs affect Billing

• Government theory is that really poor care means
  a bill should not be sent
• If you bill a claim when you know or should know
  the quality was inadequate, this could be a
  False Claim. Federal and State false claims
  act FCA cases growing
• Billing a claim without documentation to prove
  care, level of care, or terminal status could
  also be a False Claim

7
Failures in COPs affect Billing

• Relationships with referral sources are
  inevitable in hospice (physicians, nursing homes,
  hospitals) must be free of fraudulent kickbacks
  or inducements. The new COPs require
  relationships and documentation
• Federal and State OIG say billing care that came
  from kickback False Claim
• OIG says billing false certifications FCA
• COPs suggest gt documentation at admission

8
Hospice Fraud and Abuse Cases

• Odyssey HealthCare paid the US 12.9 million to
  settle a qui tam false claims case. Records did
  not support terminality.
• Home Hospice of No.Texas paid ½
  millionmisinformed MDs of patient data
• Faith Hospice paid ½ million ineligible care.
  

9
Under-serving Medicare Patients

• Can be a compliance issue
• Could be suggested by care plans not followed or
  differences in care between nursing home based
  patients and private home based patients
• Can result in an action by OIG under the Civil
  Money Penalties Act, for money and to exclude you
  from the program

10
THE LESSON OF DME

• INDUSTRY OF SMALL COMPANIES
• A DECENTRALIZED, HOME BASED SERVICE
• PHYSICIANS ORDERING SERVICE THEY DID NOT MONITOR
  CLOSELY
• MAJOR INCREASE in Medicare Spending (Power
  Wheelchairs FL and TX)
• RESULT Proposed Competitive Bidding

11
Growth without Monitoring

• US v.Palavyanpaying for referrals So.CA
• People v.Gilles homecare worker sentenced to
  prison for false, undelivered services to
  disabled persons
• Aging Care HomeHealth kickbacks to MDs and
  patients contracting violations with physicians

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Brief Update on Hospice

• Reimbursement under review at MedPAC
• OIG WorkPlan continues examination of hospice
  care to nursing home patients
• Quality of Care initiatives and concerns
• Program Integrity initiatives line item of claim
  for specific professional services
• Hospice investigations
• CMSs PSC actions with hospices

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WHEW! WHAT NOW??

• Understand the new COPs as written
• Put the new COPs in a timeline for actual care
• See COPs as a structural improvement
• Understand that it is a Team Approach
• ASK CAN I DO IT?

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I CAN DO IT !

• Intake
• Communication and Coordination
• Assessment
• Nursing Facility patients
• Documentation Changes
• Outcomes by QAPI
• IDT/IDG Changes
• Training

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418.52 PATIENTS RIGHTS

• Patient Right to be informed
• Hospice Protect and promote
• Notice at assessment, before care
• Spoken and written understood in language
• Advanced directives/State law signed

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What are the Patients Rights?

• Effective Pain management
• Involvement in Care Plan Development
• Information on coverage, scope, limitations
• Refusing care or treatment
• Choosing the attending
• Confidential patient record, access/release HIPAA
• Freedom from mistreatment, neglect, abuse,
  property misappropriation, injuries of unknown
  source

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418.52 PATIENTS RIGHTS

• Exercise Property Grievances about care or
  disrespect of property Non-discrimination
  Exercise by guardian or State-recognized patient
  representative
• Hospice must immediately investigate and resolve
  anyone furnishing services on behalf of
  hospice, with established procedures, report to
  authorities in 5 days

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Compliance Response

• Who owns this COP and what do they do?
• When is this COP applicable
• Where do the documents demonstrating compliance
  reside in the Company
• How do we assure this COP is compliant
• Training, audits, patient discussions,
  grievance process, other ideas??
• Why? What external impact from failure?

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418.54 Assessments of Patients

• Patient-specific
• Need for hospice care
• Need for physical, psychosocial, emotional and
  spiritual care
• All aspects of terminal illness-palliation and
  management
• Initial w/in 48 hrs or less of Notice of
  Election-Patients right to request sooner!

20
Assessments of Patients

• Comprehensive5 days of NOE q.15 days
• ?Signed and dated Election Importance
• Content the clinical presenting picture the
  functional status and patient participation in
  care risk factors in care planning imminence of
  death Drug Profiling bereavement needs
  Referral Needs.
• ?May be an amalgam of documentsmay collapse
  Initial and Comprehensive

21
Assessment of PatientsUpdate

• IDT and collaboration of the attending
• ?How do you document how do you prove
• Progress toward desired outcomes response to
  care did you ask patients?
• Uniform data outcomes measures across all
  patients
• Data systematic, retrievable for individual
  care planning and larger QAPI work

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Compliance Response

• Who owns this COP and what do they do?
• When is this COP applicable
• Where do the documents demonstrating compliance
  reside in the Company
• How do we assure this COP is compliant
• Training, audits, patient discussions,
  grievance process, other ideas??
• Why? What external impact from failure?

23
418.56 Interdisciplinary GroupIDG

• RN IDG member must coordinate care and ensure
  continuous assessment of patient and family
  needs
• IDG must work together, provide the care and
  meet the needs reassess every 15 days
• Must have a Super IDG to set policies on day to
  day care, if gt1 IDG in the hospice
• IDG must document patients understanding,
  involvement and agreement w care planning

24
418.56 Care Plan CP Content

• Assessment ?Needs Goals in CP
• Needs Goals?InterventionsServices
• ?Patient/Caregiver
  Education Training
• on their Role in
  CP
• Interventions ?Updated Assessment IDG
  review of CP sharing with non-hospice
  care providers

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THEME Coordination and Communication

• In 418.56(e)- System of Communication and
  Integration that
• IDG does its job
• Care provided is based on all needs and
  assessments
• Information is shared among hospice care
  providers and contractors
• Information shared w non-hospice care providers

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Compliance Response

• Who owns this COP and what do they do?
• When is this COP applicable
• Where do the documents demonstrating compliance
  reside in the Company
• How do we assure this COP is compliant
• Training, audits, patient discussions,
  grievance process, other ideas??
• Why? What external impact from failure?

27
The Right Services from the Right People

• Credentialing
• Training and competencies
• Supervision
• Core Services from Hospice Employees or
  Contractors when permitted
• Waivers of Required Services
• Role of Personal Care Workers and NF employees as
  Family-equivalents

28
Credentialing

• 418.2 Definitions Bereavement counselor, dietary
  counselor, physician, physician designee,
  licensed professional
• 418.56 RN IDG coordinator members of IDG
  teamPhysician does not include NP
• 418.62 Licensed Professional Services, persons
  must participate in QAPI and training
• 418.114 Specifics in disciplines MSW issue
• 418.112(f)NF staff must be oriented to hospice

29
Credentialing

• Hospice Aide training and supervision
  requirements 418.76
• IDG pharmacy specialist 418.106(a) confers on all
  drug planning in care plan-How realistic??
• Hospice doing or referring laboratory tests
• --if doing, must be licensed meet CLIA
• --if referring, the laboratory must be certified
  in specialties and subspecialities
• 418.116

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Linking Credentials to Services

• Licensed professionals both direct other workers
  and are supervised. How?
• If they are under arrangements how will
  performance and quality be accounted for?
• Must do the authorizing of services How is
  this authority established?
• Must participate actively under current
  professional standards and practice

31
Training

• Who and by whom
• How do we document
• What indicators
• Who owns this process
• How do we centralize training and the evidence of
  training

32
Medical Social Services

• COPs continue to require the service to be
  supervised by a physician
• Changes in level of social worker who can work
  without supervision and who can be a supervisor
  418.114
• Significant issue for staff availability
• Grandfathering very limited

33
Hospice Aide Supervision

• In-person by an RN in the home every 14 days
• In-person to observe the aide perform services
  with a patient, 1 time per year
• No therapist and no LPN can satisfy the
  supervision requirement
• What mechanisms to ensure compliance through what
  RN observes of patient?

34
Background Checks

• You are not credentialed if your behavior or
  background do not meet standards
• 418.114(d) criminal background checks on all who
  do patient care or affect the patient
  record/billing. State law as guidance.
• Affirmative obligation to come forward?
• OIG and GAO exclusions list more than criminal
  activities all claims unbillable
• Uncredentialed below quality ?FCA

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Compliance Response

• Who owns these COPs what do they do?
• When are these COP applicable
• Where do the documents demonstrating compliance
  reside in the Company
• How do we assure COPs are compliant
• Training, audits, patient discussions,
  grievance process, other ideas??
• Why? What external impact from failure?

36
What are Hospice Core Services

• ???
• Who can provide a hospice core service?
• Answer W-2 employee
• Physician under contract
• Specialized nursing or
  infrequently used specialty under contract
• Peak service demands if rural, under
  contract if not routine
• Can you go without core services? Others?

37
The Role of the Hospice Physician in the COPs

• Medical Director designee by Hospice
• IDG physician
• Nurse practitioner
• Physician consultant
• Attending physician
• Nursing facility physician counterpart for
  hospice patient residing in NF
• Physician in hospice controlled in-patient unit

38
Hospice Medical Director

• If there is only one physician connected to the
  hospice,this physician is expected to provide
  direct patient care to each patient.
• Medical Director MDir provides overall medical
  leadership in the hospice
• Allowing numerous physicians to fulfill the MDir
  role would likely result in inconsistent care
  and decreased accountability.

39
Physician

• 418.2 definition (Medicare Act,) and 410.20
  employee or contractor 418.64(a) core service
• on IDG-helps create care plan, IDG
  reassessments responsible for management and
  palliation of condition if attending
  unavailable, must meet medical needs of patient
• supervised by the Medical Director MDir is
  responsible for the overall medical care provided
  by the hospice
• can be NP but not in IDG/care plan creation
• must assess physical restraints order drugs

40
Attending Physician AP

• Hospice cannot control this function YET
• Hospice must collaborate with AP
• Hospice must communicate and coordinate with AP
• Hospice must obtain AP certification for Medicare
  entitlement and coverage
• Hospice must provide information to AP about the
  condition of the patient

41
Compliance Response

• Who owns these COPs what do they do?
• When are these COP applicable
• Where do the documents demonstrating compliance
  reside in the Company
• How do we assure COPs are compliant
• Training, audits, physician discussions,
  grievance process, other ideas??
• Why? What external impact from failure?

42
Drugs,Biologicals,DME

• 418.106 contains many revised standards for
  Hospice and the IDG

43
Special Requirements Patients Residing in
Nursing FacilitiesNF

• How is this different from Hospice Patients
  receiving in-patient level of care under Hospice
  Benefit Compliance plan policy
• How are SNFs different from NFsor are they? Is
  Assisted Living NF residency?
• What is the role of the NF staff member?
• How do we measure quality care in the NF setting
  where we dont control everything?

44
418.112 Patients Residing in Nursing Facilities

• Written arrangement now necessary
• Designated liaison for both providers
• Primacy of the hospice in care decisionsfull
  responsibility
• Mandated strong communication and coordinationin
  written terms 112(e)(3)
• Absent revised SNF regulations, however,
  uncertain how to make this work

45
Special Requirements Patients Residing in
Nursing Facilities

• NFs responsibility to continue to provide
  services as before /roomboardsupport
• Core services remain the hospice
  employee/physician contractor directly
• Use of the NF personnel
• Plan of Care planning, sharing, identification to
  each provider, consistency
• Specific IDG member deals w NF coordn

46
Nursing Facility Contracts

• Offer to provide bereavement services to
  facility staff goes in contract 418.112(c)

47
Special Requirements Patients Residing in
Nursing Facilities

• Who drafts and presents the contract?
• Who minds the contract to ensure compliance
  with its terms?
• How are conflicts resolved and accountability
  ensured?
• Dialogue between Hospice MDir and NF MDir or
  other attending-like NF physician
• One contract or individual patient-specific?

48
Special Requirements Hospice-Run In-Patient Unit
IPU 418.110

• Staffing
• Rooming
• Pain management and pharmacist role
• Restraints
• Take care to distinguish the respite situation
  from the acute medical situation

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The Medical Record

• What does it consist of 418.104
• Where is it kept
• Who can enter it or change/alter notes
• How is it kept confidential and secure
• Can patient/family review it
• What about after death?
• What signatures can be electronic

50
Staffing between IPU and Respite

• The 24 hour nursing rule is now changed
• The nursing level depends upon the patient acuity
  level 418.108(b)
• This could result in needs fluctuations within a
  single facility
• Compliance capability must exist to track and
  maintain the right staffing level

51
Authentication of Records

• CMS now leaves this to the Hospice to design
• Uniform system, teaching for employees, and
  compliance maintenance audits are all necessary

52
QAPI as a Condition 418.58

• Driving, not responding to, quality concerns.
  Baselinegtactiongtmeasures
• Data from intake onward from professional
  organization sources
• Standards for care/quality
• Hospice chooses Quality Indicators and
  mechanisms for data analysis patient adverse
  eventsharm collected as data
• Available measures, not reinventing.

53
QAPI as a Condition

• Program activities that are high risk, high
  volume or problem prone. Prioritized.
• Number and scope of improvement projects scalable
  to the Company
• Governing Body central to entire process and
  bearing the brunt of the responsibility to ensure
  safe, effective, high quality care is being
  provided to patients 418.100(b)

54
QAPI as a Condition

• If you improve the indicators, do you improve the
  outcome?
• CMS points to transitions between care sites as
  important area for agreements, coordination,
  sharing of protocols, communication systems
• Outcome measures data must go in patient records
• CMS says look to past problems include

55
QAPI as a Condition

• CMS acknowledges more effort and time needed to
  develop national parameters, but cites a half
  dozen standards. BIG question is how well did
  CMS review and understand these named standards.
• Aggregation of data based on individual hospices
  policies procedures small hospices might
  aggregate several months
• Costs!! Surveyor understanding!!

56
Surveyors QAPI

• Will access aggregated data and analysis
• Will access QAPI plan, minutes and notes
• Will access individuals responsible
• Will match data w actual experiences of employees
  and patients to see if QAPI is Prevalent
  throughout and positively influencing patient
  care
• Why quality measures chosen, how data consistent,
  used in care planning

57
Surveyors QAPI - 2

• How data relates to performance improvement
  projects
• How projects implemented
• How data used to show if projects are effective
• State Operations Manual Interpretive Guidelines
  will be revised

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Compliance Response

• Who owns this COP and what do they do?
• When is this COP applicable
• Where do the documents demonstrating compliance
  reside in the Company
• How do we assure this COP is compliant
• Training, audits, patient discussions,
  grievance process, other ideas??
• Why? What external impact from failure?

59
Breakout to Work on Your QAPI

• What is status
• Who is in charge
• Discussion of process and progress
• Next steps
• ?

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Fundamentals of Hospice Organization

• Largely unchanged
• Governing Body Directly Involved
• Room for modern health delivery systems such as
  electronic medical records and signatures
• The Organization wraps around the clinical
  timetable
• Individualization is expected

61
Breakout COPs as a Timeline

• Can we fit the COPs to a timeline from first
  contact by referral source to discharge from care
  due to death, revocation, discharge or transfer?
• Can a Case Study aid in this exercise?
• I CAN DO IT as a tool?

62
I CAN DO IT !

• Intake
• Communication and Coordination
• Assessment
• Nursing Facility patients
• Documentation Changes
• Outcomes by QAPI, begin at the Start!
• IDT/IDG Changes
• Training, including Credentialing