The National Hospice and Palliative Care Organization

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The National Hospice and Palliative Care
Organization

• Navigating the New Medicare Hospice CoPs

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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?pageid54
  94

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Sec. 418.3 Definitions

• New in the final rule
• Comprehensive assessment
• Dietary counseling
• Initial assessment
• Physician designee

4
 418.52 Patients 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 patients/ representatives signature
  confirming receipt of copy of the notice of
  rights and responsibilities

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 418.52 Patients 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

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 418.52 Patients 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.

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 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 assessment of the patient/family
  immediate needs
• The purpose of the initial assessment is not to
  determine the patients eligibility for the
  hospice benefit, which is addressed in 418.22 and
  418.24, or to orient the patient to the hospice
  benefit and obtain the election statement.

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 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.

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 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

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 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

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 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

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 418.54 Initial and comprehensive assessment
of the patient

• (d) Standard Update of the comprehensive
  assessment.
• Updated by the IDG
• As frequently as the patients 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.

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 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 hospices QAPI
  program
• Data elements must be collected and documented in
  a consistent, systematic, and retrievable way.

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 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 patients and familys 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.

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 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.

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 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 patients and familys needs
• Measurable outcomes
• Drugs and treatments
• Medical supplies and appliances
• Documentation (in the clinical record) of the
  patients or representatives level of
  understanding, involvement and agreement with the
  plan of care

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 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 patients condition requires, but no less
  frequently than every 15 calendar days
• Completed by the IDG in collaboration with the
  attending physician (if any)

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 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

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 418.56 Interdisciplinary group, care
planning, and coordination of services

• (e) Standard Coordination of services (contd)
• 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.

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 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.

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 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 hospices governing body

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 418.58 Quality assessment and performance
improvement

• (c) Standard Program activities
• The hospices 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

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 418.58 Quality assessment and performance
improvement

• (c) Standard Program activities
• The hospices 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

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 418.58 Quality assessment and performance
improvement

• (d) Standard Performance improvement projects
• Hospice providers have until February 2, 2009 to
  demonstrate active performance improvement
  projects.
• The number and scope of projects conducted
  annually must reflect the scope, complexity and
  past performance of the hospices services and
  operations.
• Be prepared to show an operational QAPI program
  by December 2, 2008.

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Quality Partner Self-Assessments

• The self-assessments can help you decide where to
  start your Performance Improvement Projects.
• Provide a 3600 assessment of your hospice
  operations.
• Based on NHPCOs Standards of Practice for
  Hospice Programs (2006)
• Can be used by any provider member.

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 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.

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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

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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
  hospices QAPI and in-service training programs

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418.64 Core services

• Hospice must routinely provide substantially all
  core services directly by hospice employees.
• Nursing
• Medical Social Services
• Counseling
• May use contracted staff, if necessary, to
  supplement hospice employees in order to meet the
  needs of patients under extraordinary or other
  non-routine circumstances.

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418.64 Core services

• May also enter into a written arrangement with
  another Medicare certified hospice program for
  the provision of core services to supplement
  hospice employee/staff to meet the needs of
  patients.
• Circumstances under which a hospice may enter
  into a written arrangement for the provision of
  core services include
• Unanticipated periods of high patient loads
• Staffing shortages due to illness
• Other short-term temporary situations that
  interrupt patient care
• Temporary travel of a patient outside of the
  hospices service area.

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418.64 Core services

• (a) Standard Physician services
• Employee or contracted
• Responsible for the palliation and management of
  the terminal illness and related conditions
• Supervised by the hospice medical director
• Meets the medical needs of the patient when the
  attending physician is not available

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418.64 Core services

• (b) Standard Nursing services
• Role of the registered nurse
• 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
• Services to patient and family based on
  psychosocial assessment

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418.64 Core services

• (d) Standard Counseling services
• Bereavement counseling under the supervision of
  a qualified professional with experience or
  education in grief or loss counseling
• Available to family and other individuals,
  including residents of a SNF/NF or ICF/MR, when
  appropriate and identified in the bereavement
  plan of care
• Development of the bereavement plan of care
  starts before the patients death.

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418.64 Core services

• (d) Standard Counseling services (contd)
• 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
  patients spiritual needs.

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418.66 Nursing services Waiver

• Requirements to qualify for a waiver
• The location of the hospices central office is
  in a non- urbanized area as determined by the
  Bureau of the Census.
• There is evidence that a hospice was operational
  on or before January 1, 1983.
• Hospice made a good faith effort to hire nurses.
• Waiver request is deemed to be granted unless it
  is denied within 60 days after it is received.
• Waivers will remain effective for 1 year at a
  time from the date of the request.

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Nursing Shortage Exemption

• Allows hospices to contract for nursing staff in
  a chronic nurse shortage situation
• Extraordinary Circumstance Exemption
• Hospice must notify the State Survey Agency (SSA)
  responsible for licensing and certification that
  it intends to elect an exception under the
  "extraordinary circumstance" authority. (written
  notice)
• Must follow instructions in the letter include
  specified detail.
• Policy ends September 30, 2008.
• CMS SC-06-28 letter

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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)

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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

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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
  patients 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

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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

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 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

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 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)

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 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
  hospices patient care program
• Removed oversight for QAPI program

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 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

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 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
  patients 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

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 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

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 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 patients 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

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 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
• Family should be able to demonstrate the proper
  use of the equipment back to hospice staff
• May only contract for DME services with a
  supplier that meets the Medicare DMEPOS Supplier
  Quality and Accreditation Standards at 42 CFR
  424.57.
• CMS link to DMEPOS accreditation information
  http//www.cms.hhs.gov/MedicareProviderSupEnroll/0
  3_DeemedAccreditationOrganizations.asp

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DME Accreditation

• DME providers must be accredited per CMS by
  September 30, 2009
• Hospice CoPs require contract with accredited DME
  providers by December 2, 2008
• Disconnect in dates!
• Hospice contracted with a DME (that has a
  Medicare supplier number), must obtain a letter
  from the DME stating the DME has applied and is
  waiting for accreditation by the 9/09 date.
• Hospice contracted with a DME that only serves
  hospice, (no Medicare supplier number), the
  hospice will need to make sure the same type of
  letter from the DME is in place in their files.
•  If the hospice owns its own DME, then no
  accreditation is needed.

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 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

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 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

52
 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 patients clinical record

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 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 residents 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

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 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
• Bachelors in social work AND employed by hospice
  before the effective date of the final rule
  (December 2, 2008)

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 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

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418.114 Criminal Background Checks Hospice
Employees

• (d) Standard Criminal background checks
• Hospice employees
• All hospice employees who have direct patient
  contact
• All hospice employees who have access to patient
  records.
• New hires
• Obtain a criminal background check within three
  months of the date of employment
• From all states that the individual has lived or
  worked in for the past three years.
• If no State requirements, obtain criminal
  background checks within three months of the date
  of employment

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Criminal Background Checks

• Licensed Health Care Practitioners
• If the state has a requirement for background
  checks as a part of licensing for a specific
  discipline and the hospice complies with the
  State requirement for that discipline, then the
  hospice is in compliance with this Federal
  requirement.
• This means that an individual does not need a
  criminal background check if his or her license
  is current and the State licensure requires a
  background check and it is updated when the
  license is renewed.
• Contract Entities
• All contracted entities on contracted employees
  who have direct patient contact
• All contracted entities on contracted employees
  who have access to patient records.

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 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

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CoPs-Planning for Success!

• NHPCO campaign to assist hospices to implement
  the new regulations.
• Education
• Audio web seminars in June 2008
• Online education modules
• Downloadable tools, tips, and information
• Resources in the NHPCO Regulatory Compliance
  Center
• Audio web seminars online education module
  about the upcoming interpretive guidelines

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CoPs-Planning for Success!

• NHPCO campaign to assist hospices to implement
  the new regulations.
• Education
• Audio web seminars June 2008
• Online education modules
• Downloadable tools, tips, and information
• Resources in the NHPCO Regulatory Compliance
  Center
• Audio web seminars and online education modules
  when interpretive guidelines released

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More Resources

• NHPCO Regulatory Compliance Center
• Redesigned to be user friendly for members
• Topic area buttons give user information in 1-2
  clicks
• Quality Partners Self Assessments
• Self-assessments are a foundation for building or
  refining your quality improvement program to meet
  the new demands for quality (i.e., QAPI
  requirements). 
• We can Do This
• An easy how-to guide to implement a hospice QAPI
  program

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Connecting to Quality Partners

• Quality Partners is your resource for complying
  with QAPI
• Dont know where to start? Try the Self
  Assessment process
• Will help you identify areas to work on
• Will address both clinical and non-clinical
  projects
• Go to www.nhpco.org/quality to get started

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NHPCO Regulatory

• Judi Lund Person, MPH
• Vice President
• Regulatory State Leadership
• Jennifer Kennedy, MA,BSN, RN, CLNC
• Regulatory Compliance Specialist
• NHPCO Regulatory Assistance
• regulatory_at_nhcpo.org
• 703-647-8516

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Questions?