Basic Hospice Agency Surveyor Training

Transcription

1 Basic Hospice, November 2008 Student Manual Basic Hospice Agency Surveyor Training November 18-20, 2008 Baltimore, Maryland Student Manual 1

2 Basic Hospice Lesson 1: Welcome and Introductions The (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 The (CMS) has awarded 2.1 CEUs to participants who successfully complete this program. 2

3 Basic Hospice Lesson 1: Welcome and Introductions Copyright Permission Training materials produced by the 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. 3

4 Basic Hospice Lesson 1: Welcome and Introductions 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 * Medical conditions and allergy information may be disclosed by the Training Coordinator to Emergency Medical Technicians or other medical personnel in the event that you are unable to provide this information yourself. 4

5 Basic Hospice Lesson 1: Welcome and Introductions 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 H. Completing Forms CMS-417, CMS-643, CMS-2567 and CMS-2567B 5

6 Basic Hospice Lesson 1: Welcome and Introductions Role of Accrediting Organizations and Deemed Status...9 Immediate Jeopardy Hospices that Provide Inpatient Services Directly 42 CFR & 42 CFR 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. 6

7 Basic Hospice Lesson 1: Welcome and Introductions 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 7

8 Basic Hospice Lesson 1: Welcome and Introductions 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, :00 Registration Patricia Payne Tab 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 4:30 Adjourn 8

9 Basic Hospice Lesson 1: Welcome and Introductions Wednesday, November 19, :00 Review and Preview Kim Roche Tab 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 4:30 Adjourn 9

10 Basic Hospice Lesson 1: Welcome and Introductions 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 CFR & 42 CFR :15 Course Summary Kim Roche 2:45 Final Questions and Answers Faculty 3:00 ADJOURN 10

11 Basic Hospice Lesson 1: Welcome and Introductions Mavis Connolly CMS Consultant Faculty List 2008 Basic Hospice Surveyor Training Faculty List Pat Frey, PHN Nurse Consultant Division of Survey & Certification 75 Hawthorne St., Suite 408 San Francisco, CA Katherine E. Lucas, PhD Mailstop: C Security Blvd. Baltimore, MD Melanie Merriman, PhD, MBA CMS Consultant Patricia Payne Survey & Certification Group/Training Staff Center for Medicaid and State Operations Mail Stop S Security Blvd. Baltimore, MD Kim Roche, MA, BSN, RNC, CCS-P Nurse Consultant Division of Continuing Care Providers Survey and Certification Group Mail Stop S Security Blvd. Baltimore, MD Joanne Rokosky, BSN, MN CMS/CMSO Region X 2201 Sixth Ave. Seattle, WA

12 Basic Hospice Lesson 1: Welcome and Introductions Mary Rossi-Coajou, MS, RN Health Program Evaluations Officer Commander, U.S. Public Health Service 7500 Security Blvd. Baltimore, MD Patricia Sevast, BSN, RN Nurse Consultant Division of Continuing Care Providers Survey and Certification Group Mail Stop S Security Blvd. Baltimore, MD Danielle Shearer Health Insurance Specialist Office of Clinical Standards and Quality Clinical Standards Group 7500 Security Blvd. Baltimore, MD Crystal Simpson, MD Medical Officer Division of Continuing Care Providers Survey and Certification Group Mail Stop S Security Blvd. Baltimore, MD Jan Tarantino, Director Division of Continuing Care Providers Survey and Certification Group Mail Stop S Security Blvd. Baltimore, MD Heather Wilson, PhD CMS Consultant Barbara Woodford, RN CMS Consultant Margo Zink, RN, BSN, MSN, Ed.D CMS Consultant 12

13 Basic Hospice Lesson 1: Welcome and Introductions Participant List 2008 Basic Hospice Agency Surveyor Training Provided by the CMS Training Coordinator. 13

14 Basic Hospice Lesson 1: Welcome and Introductions 14

15 Basic Hospice Lesson 1: Welcome and Introductions Lesson 1 Basic Hospice Agency Welcome and Introductions Basic Hospice 1-1 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 1-2 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 end of the course Basic Hospice

16 Basic Hospice Lesson 1: Welcome and Introductions Introductions Welcome to the Basic Hospice Agency Surveyor Training Course! Who are we? Basic Hospice 1-4 Why Do A Hospice Survey? Protect hospice patients Assure the hospice is meeting minimum health and safety requirements (CoPs) CoP = Condition of Participation Basic Hospice 1-5 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 surveys after this course? Basic Hospice

17 Basic Hospice Lesson 1: Welcome and Introductions 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 1-7 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 1-8 Resource Manual Separate manual Table of Contents Developed as surveyors tools for use during survey CMS Web address to access hospice information Select Regulations and Guidance Select Hospice Center Basic Hospice

18 Basic Hospice Lesson 1: Welcome and Introductions Course Agenda Day 1 Hospice Overview Hospice Conditions of Participation Pain and Symptom Management Quality Assessment and Performance Improvement (QAPI) Basic Hospice 1-10 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 Basic Hospice 1-11 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 Directly Basic Hospice

19 Basic Hospice Lesson 1: Welcome and Introductions 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! Basic Hospice 1-13 Lesson 1 Questions? Basic Hospice 1-14 Lesson 1 Pre-test Basic Hospice

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21 Basic Hospice, November 2008 Student Manual Lesson 2: Overview of Hospice Program Learning Objectives At 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). 1

22 Basic Hospice Lesson 2: Overview of Hospice Program 2

23 Basic Hospice Lesson 2: Overview of Hospice Program Lesson 2 Overview of Hospice Program Basic Hospice 2-1 Learning Objectives 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) Basic Hospice 2-2 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 2-3 3

24 Basic Hospice Lesson 2: Overview of Hospice Program 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: ) Basic Hospice 2-4 Medicare Options Care reasonable and necessary for: Diagnosis or treatment of illness or injury versus Palliation and management of a terminal condition Basic Hospice 2-5 Comfort Versus Cure Hospice professionals specially trained to focus on management and palliation of terminal illness not curative medical care Basic Hospice 2-6 4

25 Basic Hospice Lesson 2: Overview of Hospice Program Concepts in Hospice Care Provide pain and symptom control Provide interdisciplinary approach to care Support patient selfdetermination 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 2-7 Required Services in Hospice Care Nursing Social Work Counseling Physician Hospice Aide & Homemaker Therapies Volunteers Drugs, DME, Biologicals Short-term Inpatient Care Patient & Family Basic Hospice 2-8 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 Providing Care Directly Basic Hospice 2-9 5

26 Basic Hospice Lesson 2: Overview of Hospice Program Hospice Synergy IDG Pt/ Family Plan of Care Assessment QAPI Basic Hospice 2-10 Hospice Interdisciplinary Group Registered nurse Physician Social worker Counselor Basic Hospice 2-11 Hospice Core Services Physician services Nursing services Medical social services Counseling services (dietary, bereavement, spiritual) Basic Hospice

27 Basic Hospice Lesson 2: Overview of Hospice Program 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 2-13 Core Services: Exceptions & Waivers The hospice must: Maintain professional, financial and administrative responsibilities Assure staff are qualified and services meet requirements Basic Hospice Levels of Hospice Care Routine Home Care Continuous Care Respite Care General Inpatient Care Basic Hospice

28 Basic Hospice Lesson 2: Overview of Hospice Program Location of Routine & Continuous Hospice Care Apartment Private home Condo Hospice residence Assisted living Nursing home Family member ICF-MR Trailer Houseboat Patient s Home Basic Hospice 2-16 Location of Inpatient Care: General and Respite Hospice inpatient facility or unit Hospital Skilled nursing facility (SNF) Nursing facility (NF) (respite care only) Basic Hospice 2-17 Inpatient Care Hospice may provide Directly Under Arrangement Basic Hospice

29 Basic Hospice Lesson 2: Overview of Hospice Program Inpatient Care Provided Directly Arrangement Own facility Must meet Leased space Must meet Medicare hospital* Medicare SNF* Medicare hospice Space in a Medicare hospital or SNF/NF Must meet (b)&(e) *Must meet (b)&(e)) Basic Hospice 2-19 Under Arrangement Hospice must have a written agreement to provide services under arrangement See (e) Professional Management Responsibilities Basic Hospice 2-20 Lesson 2 Questions? Basic Hospice

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31 Basic Hospice, November 2008 Student Manual Lesson 3: Hospice Central Learning Objectives At 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. 1

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33 Basic Hospice Lesson 3: Hospice Central Hospice Central Hospice Medicare Benefit Highlights Certification of Terminal Illness, 42 CFR 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 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 and the Medicare Benefit Policy Manual (Chapter 9, section 10) For an individual who meets the eligibility requirement of 42 CFR : 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. 3

34 Basic Hospice Lesson 3: Hospice Central 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 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 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 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 Drugs and biologicals*, medical supplies and durable medical equipment related to the terminal illness and related conditions, 4

35 Basic Hospice Lesson 3: Hospice Central 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 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 Payment amounts are determined within each of the following level-of-care categories: Routine home care Continuous home care Inpatient respite care General short term inpatient care 5

36 Basic Hospice Lesson 3: Hospice Central Short-term Inpatient Care, 42 CFR ; Covered Services, 42 CFR ; and Payment Procedures for Hospice Care, 42 CFR 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 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 Core Services, 42 CFR (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 b; 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 ). 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 provide are not billable. 6

37 Basic Hospice Lesson 3: Hospice Central 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 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. 7

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39 Basic Hospice Lesson 3: Hospice Central Notes Page 9

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41 Basic Hospice Lesson 3: Hospice Central 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 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 property reported to the administrator 11

42 Basic Hospice Lesson 3: Hospice Central 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 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 The hospice must conduct and document a written patientspecific comprehensive assessment that identifies the patient s 12

43 Basic Hospice Lesson 3: Hospice Central need for hospice care and services including the 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 Interdisciplinary Group, Care Planning and Coordination of Services, 42 CFR 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 13

44 Basic Hospice Lesson 3: Hospice Central 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 o With other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. 14

45 Basic Hospice Lesson 3: Hospice Central Organization and Administrative Services, 42 CFR 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 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 15

46 Basic Hospice Lesson 3: Hospice Central 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 inservice 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 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 qualified licensed pharmacist. 16

47 Basic Hospice Lesson 3: Hospice Central 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 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 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. 17

48 Basic Hospice Lesson 3: Hospice Central 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 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 Medicare certified hospital or SNF that meets (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 Medicare certified hospital or SNF that meets (b) and (e) regarding 24 hour nursing services and patient areas Medicare or Medicaid certified nursing facility that also meets (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 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 Physician Services The hospice medical director, physician employees, and contracted physician(s) of the hospice, in conjunction with the 18

49 Basic Hospice Lesson 3: Hospice Central 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. 19

50 Basic Hospice Lesson 3: Hospice Central Notes Page 20

51 Basic Hospice Lesson 3: Hospice Central 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 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 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. 21

52 Basic Hospice Lesson 3: Hospice Central Either hard copy or electronic records must be readily available on request. Infection Control, 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 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 governing body must appoint a qualified administrator. 22

53 Basic Hospice Lesson 3: Hospice Central o The hospice administrator is responsible for the day-today 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 during the previous 12 months must be maintained. 23

54 Basic Hospice Lesson 3: Hospice Central Quality assessment and performance improvement, 42 CFR 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 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. The roles of the IDG include participation in the comprehensive assessments, plan of care development, 24

55 Basic Hospice Lesson 3: Hospice Central 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 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. 25

56 Basic Hospice Lesson 3: Hospice Central 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 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 (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. 26

57 Basic Hospice Lesson 3: Hospice Central Notes Page 27

58 Basic Hospice Lesson 3: Hospice Central 28

59 Basic Hospice, November 2008 Student Manual Lesson 4: Conditions of Participation Activity Learning Objective At the conclusion of this lesson, you will be able to: Demonstrate a working knowledge of the hospice Conditions of Participation (CoP). 1

60 Basic Hospice Lesson 4: Conditions of Participation Activity 2

61 Basic Hospice Lesson 4: Conditions of Participation Activity 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? What is the impact on service delivery? 3

62 Basic Hospice Lesson 4: Conditions of Participation Activity 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. 4

63 Basic Hospice Lesson 4: Conditions of Participation Activity 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. 5

64 Basic Hospice Lesson 4: Conditions of Participation Activity 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. As a table, decide: 1. To which condition of participation these findings pertain? List the L-tag, the CFR reference and the title. 6

65 Basic Hospice Lesson 4: Conditions of Participation 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. 7

66 Basic Hospice Lesson 4: Conditions of Participation Activity Scenario 3: Based on record review and staff interview, it was determined that the hospice failed to ensure completion of the initial assessment by the Registered Nurse (RN) within 48 hours after election of hospice care for one out of nine patients (Patient 2). Without a completed initial assessment, the patient was at risk for not having immediate needs for care and services met. Findings: Patient 2 was an 86-year-old female with end-stage congestive heart failure who elected hospice on 1/16/. Review of the patient's clinical record revealed a physician referral and order for hospice services dated 1/16/. The clinical record further documented that the first home visit, at which time the RN completed an initial assessment, was on 1/20/. On 4/2/ at 4:15 PM, the director of nurses was interviewed regarding the delay in initial assessment. She stated that the referral came on a Friday and, other than the on-call nurse, no RN staff were available to conduct the initial assessment. 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, and 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 8

67 Basic Hospice Lesson 4: Conditions of Participation Activity 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. 9

68 Basic Hospice Lesson 4: Conditions of Participation Activity Scenario 4: Based on clinical record review and staff interview, it was determined the agency failed to ensure that written plans of care were developed which included individualized interventions for the problems identified in the comprehensive assessment for three of four patients (Patients 4, 9 and 14). Findings: 1. Patient 4 was a 73-year-old female whose start of care date was 4/1/. Diagnoses included end-stage chronic obstructive pulmonary disease and diabetes. Her initial psychosocial assessment, dated 4/3/, stated she is hesitant to be on hospice. She is fearful of dying and death. She doesn t want to talk about hospice. The plan of care, dated 4/5/, did not address psychosocial issues. A social work note, at 3:15 PM on 4/28/, stated the patient s daughter called to express her frustration with care giving responsibilities for her mom. She is overwhelmed with her job, flooded basement, and her mother s demands. Interdisciplinary Group (IDG) minutes for Patient 4, dated 5/3/_ stated, No new social service needs identified. The revised plan of care, dated 5/3/ did not include a plan for social services. The social worker, interviewed at 8:25 AM on 5/15/, confirmed there was no plan to address the patient s psychosocial issues. 2. Patient 9 was a 69-year-old female whose hospice start of care date was 3/20/. Diagnoses included cancer of the spine with metastasis. The initial assessment, dated 3/21/, indicated that she had an intrathecal pain pump through which she received morphine sulfate. The plan of care, dated 3/24/, did not address the pump and did not specifically address pain control for this patient. The plan had only checked the pre-printed items of Monitor levels of pain, Titrate medications and dosages per physician orders, and Instruct patient/caregiver on route, dose, and side effects. The lack of a specific plan for pain management was confirmed during an interview with the Director of Patient Care Services on 5/15/ at 2 PM. 3. Patient 14 was an 89-year-old male whose hospice start of care date was 1/27/. His diagnoses included debility and acute renal failure. The initial assessment, dated 1/27, stated he had pain of 7-8 on a scale of 10 when he needed to urinate. Pain was not assessed further and was not addressed on his plan of care. When interviewed on 5/15/ at 2 PM the Director of Patient Care Services confirmed the lack of a specific plan for pain management. 10

69 Basic Hospice Lesson 4: Conditions of Participation Activity 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. 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. 11

70 Basic Hospice Lesson 4: Conditions of Participation Activity Scenario 5: Based on documentation review and interview, it was determined that the plan of care for one of four patients (Patient 10) did not identify the patient s unique needs or include the specific interventions required, including the management of discomfort and symptom relief. Patient 10 may have sustained harm related to the agency's failure to ensure specific interventions for management of a urinary catheter. Findings: Patient 10 was admitted to hospice services on 12/9/. The patient's hospice diagnosis was bladder cancer. On the day of admission, the registered nurse (RN) had documented on a clinical note form that the patient had an indwelling Foley catheter that was draining "light red urine." The next day, 12/10/, the RN had documented that the patient had a Foley catheter that was draining "blood tinged urine." Neither the size of the catheter nor the size of the balloon was identified. The record contained a plan of care dated 12/9/. This document did not contain any treatments or interventions to address the needs of Patient 10, including his/her hematuria and the care of the Foley catheter. Further review of Patient 10's record revealed an entry by an RN in the clinical notes that described a "focused visit" to the patient on 1/1/ at This entry contained the following: "[Patient] had a Foley catheter in. There was frank blood and clots in the collection bag. [He/she] reported lower abdominal discomfort from being unable to void. I attempted to flush the catheter. I was able to remove some blood and a considerable number of clots before the catheter ceased being patent. I was able to instill fluid but not to withdraw fluid. I replaced the catheter but the new catheter clotted off immediately...i called [the physician] and...[he/she] felt that [the patient] should be taken to the ER [Emergency Department]." The record contained documentation that Patient 10 s plan of care had been reviewed by the interdisciplinary group during the case conferences held on 1/3/08, 1/28/08 and 2/20/08. None of the revised plans of care contained specific directives for Foley catheter care. No documentation could be located to indicate that Patient 10 s attending physician had been contacted to determine whether irrigation and/or replacement of this catheter by hospice staff would be safe and appropriate in view of the diagnosis of bladder cancer. 12

71 Basic Hospice Lesson 4: Conditions of Participation Activity Agency administrative and clinical staff were jointly interviewed on 3/14/ at 10 AM (Staff #1, 2, and 6). They acknowledged that Patient 10 s care plan was non-specific. They were unable to provide documentation of communication with the physician or physician orders for Foley catheter care for Patient #10. 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. 13

72 Basic Hospice Lesson 4: Conditions of Participation Activity Scenario 6: Based on record review, patient interview, and staff interview, it was determined that the hospice failed to investigate an allegation of theft reported by one of nine sample patients (Patient 5). By failing to investigate this allegation, the hospice could not ensure that patients would be protected from misappropriation of their property. Findings: Patient 5 was a 68-year-old male whose hospice start of care date was 1/14/. His diagnosis was small cell lung cancer with metastasis. The initial assessment, dated 1/15/, described the patient as forgetful and frequently confused. The plan of care, dated 1/17/ included skilled nursing visits two to three times per week and hospice aide visits two times per week. Review of the patient s clinical record revealed a home visit by the Registered Nurse (RN) on 1/22/. The home visit documentation contained the following entry, Patient claims that hospice aide stole $50 from his wallet during her visit yesterday. No other documentation was found regarding this allegation. There was no documentation that the allegation had been reported to the hospice administrator. A home visit to Patient 5 was made with the RN #2 on 1/25/. During the visit the patient responded to the RN s questions appropriately. RN #2 did not ask Patient 5 about his perception of the services he was receiving from the hospice aide. During the course of the visit she did not address the allegation of theft with the patient or with his wife. Following the visit RN #2 was questioned regarding the allegation of theft documented on 1/22/. She responded that the patient was confused and she did not think the allegation was valid. As a result, she had found no reason to report the allegation or pursue it further. 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. To which condition of participation these findings pertain? List the L-tag, the CFR reference and the title. 14

73 Basic Hospice Lesson 4: Conditions of Participation 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 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. 15

74 Basic Hospice Lesson 4: Conditions of Participation Activity Scenario 7: Based on clinical record review and staff interview, it was determined the agency failed to ensure that a written plan of care was established in consultation with skilled nursing facility staff for two of two hospice patients who resided in skilled nursing facilities (Patients 3 and 7). These patients were at risk for insufficient or inappropriate care due to the lack of coordination. Findings: 1. Patient 3, an 83-year-old skilled nursing facility (SNF) resident, was admitted to the hospice on 12/17/ with primary diagnoses of failure to thrive and senile dementia. Review of the skilled nursing facility's medical record for Patient 3 revealed documentation by the attending physician dated 12/4/. The patient was described as receiving Phenergan (promethazine hydrochloride), a sedative agent, for periodic episodes of nausea and having a long-standing colostomy. The patient was also identified as having Bipolar disease. Review of Patient 3's hospice medical record revealed a plan of care most recently revised 3/14/. This document included a problem list with associated goals/expected outcomes and interventions. The problem entitled, potential for constipation did not indicate that the patient had a colostomy. The problem entitled, eating and swallow included an order for prochlorperazine (Compazine), a medication similar to, but not identical to Phenergan. The care plan also listed general treatments such as indirect supervision of the hospice aide, ongoing assessment of patient safety and evaluation for depression and other factors that might influence patient safety or a need for mental health referral. No interventions specific to Patient 3's dementia and Bipolar disease, or the fact that she lived in a SNF were included. A problem entitled, medication management included interventions to instruct family caregivers in medications and the use of a medication box even though Patient 3 lived in a SNF and had medications administered by facility staff rather than by a family member. 2. Patient 7 was a 72-year-old female admitted to hospice services on 1/28/. Her diagnosis was breast cancer with metastasis. Review of the medical record revealed a plan of care dated 1/30/ and most recently updated 4/22/. Although nursing clinical notes reflected ongoing communication with staff of the SNF, no documentation was found to indicate a coordinated plan of care had been developed or that an agreement had been established with the SNF that specified who was responsible for what portions of the 16

75 Basic Hospice Lesson 4: Conditions of Participation Activity patient's care. The last problem in the hospice agency's pre-printed care plan related to impaired care giving. Interventions selected for Patient 7 included, "Assess who will be/or who is PCG (patient caregiver) and who else is able to contribute and to what extent. No documentation was found to indicate the patient's care would be coordinated with the SNF or provided in accordance with the plan of care. 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. 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. 17

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79 Basic Hospice, November 2008 Student Manual Lesson 5: Pain and Symptom Management in Hospice Care Learning Objectives At the conclusion of this lesson, you will be able to: Define pain. Describe the four components of pain. Identify two tools to assess pain. Describe the five components used in the history and physical to describe pain. Describe the basic treatments for the four components of pain. 1

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81 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care Basic Hospice 5-1 Learning Objectives To be able to define pain To describe the 4 components of pain To identify 2 tools to assess pain To describe the 5 components used in the history and physical to describe pain To describe the basic treatments for the 4 components of pain Basic Hospice 5-2 Definition of Pain An unpleasant sensory or emotional experience that can be acute, recurrent or persistent Highly subjective No biological makers Basic Hospice

82 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care 4 Components of Pain Physical Spiritual Total Pain Emotional Social Basic Hospice Basic Hospice 5-5 Pain Pathways Summary Pain receptors (nociceptors) originate signals Signals travel through peripheral nerves to spinal cord and brain Signals gather in dorsal (back) part of spinal cord Transmitted to thalamus and then to cerebral cortex, where pain is felt Basic Hospice 5-6 4

83 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care Fast Pathway Pain receptors sense injury and release chemical messengers Chemicals travel through very fast nerve pathways Signals directly to thalamus and cerebral cortex Brain identifies and sends message to react Slower Pathway Pain signals enter dorsal (back) part of the spinal cord Signals transfer back and forth between nerves that regulate pain message Signals go to cerebral cortex Entire nervous system may be reprogrammed Basic Hospice 5-7 May have both acute and chronic components Multiple simultaneous causes Some causes may be more modifiable than others May benefit from cause-specific and general interventions Requires skilled clinical assessment to differentiate Basic Hospice 5-8 COMMUNICATION Basic Hospice 5-9 5

84 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care What are your hopes (your expectations, your fears) for the future? What has been most difficult about this illness? How is treatment going for you (your family)? What makes life most worth living for you? Given the severity of your illness, what is most important for you to achieve? The answers can change as the illness progresses Basic Hospice 5-10 Ask patients about pain At scheduled assessments and whenever change in patient status noted Phrase as: Does it hurt anywhere? Do you have any aching or soreness? If patient cognitively impaired, also ask questions of family members, where feasible Basic Hospice 5-11 Observe patient for signs and symptoms that suggest pain Nonspecific symptoms Grimacing, agitated, restless, etc. May have other or multiple causes Pain Assessment Scales Basic Hospice

85 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care Pain Assessment Scales Partners against pain.com Visual Analog Scale Number Pain Intensity Scale Simple Descriptive Pain Intensity Scale Graphic Rating Scale Verbal Rating Scale Pain Faces Scale Numeric Pain and Pain Distress Scale Brief Pain Inventory Basic Hospice 5-13 P Q Position Quality R S T Radiation Severity Time Basic Hospice 5-14 Aggravating Alleviating Factors Dosage and Frequency of Pain Medications Basic Hospice

86 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care P Q R S T Epigastric, Right Upper Quadrant or Suprapubic Cramping, Burning, Gnawing Does the pain move anywhere or does it stay in one spot Constant or Intermittent Scale of 1 to 10; Worsening or Improving When did the pain start? How long does it last? Basic Hospice 5-16 Abdominal Pain (cont.) Aggravating What makes it worse? Alleviating Factors What makes it better? Dosage and Frequency of Pain Medications How often are you taking pain medications, if any? Natural remedies Hot water bottle Basic Hospice 5-17 A practitioner may need to evaluate patient to: Get details of symptoms Review existing diagnoses and conditions that may cause or contribute to pain Discuss with family members and other members of interdisciplinary team Basic Hospice

87 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care In end-of-life patients, try to identify most likely causes using clinical evaluation instead of diagnostic testing Often, careful review of symptom details and likely causes will best possible approach Review current medications as possible causes Basic Hospice 5-19 Summarize characteristics and causes of patient's pain Assess impact of pain on individual Basic Hospice 5-20 Depression Dyspnea Constipation Nausea Anxiety Delirium Anorexia/Cachexia Basic Hospice

88 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care Symptoms (cont.) Symptom Assessment Treatment Depression Dyspnea NOT normal SIGECAPS Cause Pleural Effusion CHF Pneumonia Psychostimulants (e.g. Ritalin) SSRI (e.g. Paxil) NO TCAs (Elavil) Oxygen Removal of Fluid Diuretics Antibiotics Low does Opiod Basic Hospice 5-22 Symptoms (cont.) Symptom Assessment Treatment Nausea Medication Adjust Medications Delayed Gastric Emptying Bowel Obstruction Vertigo Medications Medications Medications Constipation Cause Medications Stool Softeners- (e.g. Colace) Stimulants (e.g. Lactulose) Basic Hospice 5-23 Symptoms (cont.) Symptom Assessment Treatment Anorexia or Cachexia Is it caused by the disease? Is it caused by other symptoms? Is patient troubled by it? Medications (e.g. dexamethasone, megestrol acetate) Medications Medications Anxiety Cause Counseling Short acting benzodiazepine Basic Hospice

89 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care Symptoms (cont.) Symptom Assessment Treatment Delirium Cause (e.g. Electrolytes, Medications, Infection) Treat Cause Frequent reorientation Avoid Benzodiazepines Basic Hospice 5-25 Oxygen dependency + dyspnea + history of chronic obstructive pulmonary disease (COPD) = impaired gas exchange Impaired gas exchange chest pain Antidepressant + antinausea medication +antisecretion medication + antianxiety agent = adverse drug reaction (ADR) ADR severe intestinal ileus Severe ileus abdominal pain Abdominal pain narcotic analgesic Narcotic analgesic more ileus More ileus more pain miserable death Basic Hospice 5-26 Questions What is prognosis? What are overall goals for this individual? How will specific treatments and services help achieve those goals? Goals should be: Specific for that individual Relevant to underlying causes and risk factors Otherwise, hardly better than guesswork! Basic Hospice

90 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care Discuss findings and develop treatment plan with physician, interdisciplinary team, patient and family Identify patient's preferences, wishes and goals Consider complementary (nonpharmacologic) treatments Prescribe appropriate medications Where relevant, address underlying causes Basic Hospice 5-28 Objective Develop or refine plan to address relevant issues and problems Based on recognition of causes and consequences Identify specific roles/responsibilities of various individuals and disciplines Care plan should be Specific for that individual Relevant to underlying causes and risk factors Otherwise, hardly better than guesswork! Basic Hospice 5-29 Relieve low back pain due to muscle spasms by repositioning more frequently and applying heat Reduce abdominal pain due to ileus by reducing medications affecting GI motility Relieve left shoulder pain due to osteoarthritis by giving acetaminophen and anti-inflammatory medication Basic Hospice

91 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care Relieve back pain by giving pain medications Treat abdominal pain by increasing MS-Contin, Haldol, Reglan, etc. Give Duragesic patch for left shoulder pain Basic Hospice 5-31 Important to incorporate both nonpharmacologic and pharmacologic Approaches Provide a comforting, supportive environment General comfort measures may reduce need for high analgesic doses Don t do harm while trying to do good evaluate the risks of benefits of all interventions Basic Hospice 5-32 Intervention Rehabilitation/physical therapy Massage Transcutaneous/ percutaneous nerve stimulation Acupuncture Details Can improve stretching, strengthening,& mobility Family members can be taught Many hospice programs have trained, certified massage therapists Evidence of support with persistent low back and knee pain Popular therapy for cancer and other end stage pain Studies showing benefits on COPD, dyspnea, asthma Basic Hospice

92 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care Patient s underlying diagnosis and co-existing conditions Past patient experience with therapy Availability of skilled, experienced providers Patient or advocate preferences Advance directives Basic Hospice 5-34 Non-Opioids Acetaminophen NSAIDs Topical analgesics Opioids Adjuvant Analgesics Disease Modifying Therapies Basic Hospice 5-35 Relieving symptoms more important than treating causes But cause-specific pain management may be more beneficial with fewer side effects Side effects don t matter But they often do May be as unpleasant or problematic as pain May prevent individual from spending quality time at end of life Pain management is desirable It is, but it s a means to an end Basic Hospice

93 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care WHO s Pain Relief Ladder Freedom from Cancer Pain Opioid for moderate to severe pain +/- Non-Opioid +/- Adjuvant 3 Pain persisting or increasing Opioid for mild to moderate pain +/- Non-Opioid +/- Adjuvant 2 Pain persisting or increasing Non-opioid +/- Adjuvant I Basic Hospice 5-37 Acetaminophen: 1 st choice in those without significant liver disease or ETOH intake Example: 500 or 650 mg q4h 8AM 8PM and q4h PRN 8PM 8AM Topical agents: possible additional relief for those with musculoskeletal, neuropathic pain Counterirritants (e.g., menthol, methylsalicylate, trolamine salicylate): Supplied as liniments, creams, ointments, sprays, gels or lotions Can cause skin injury, especially when used with heat or with an occlusive dressing Basic Hospice 5-38 Non-Steroidal Anti-Inflammatory drugs (NSAIDs)/ Cyclooxygenase-2 (COX-2) inhibitors Risk in frail elderly: GI bleeding and renal impairment Ceiling effect : point after which increasing dose offers no additional pain relief and may produce added side effects Frequency of more serious side effects Tramadol Centrally acting analgesic May be added to NSAIDs or acetaminophen Watch for drug-drug Interactions Basic Hospice

94 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care Combining smaller doses of drugs from different classes If maximizing acetaminophen dosage fails to achieve pain relief May reduce risk of side effects associated with higher doses of a single medication Add an opioid Basic Hospice 5-40 Discontinue/transition from a mixed opioid to a pure opioid Opioid analgesics gaining wider acceptance as an important component of comfort care Examples: Codeine, oxycodone, hydrocodone, morphine and fentanyl: commonly used opioids Basic Hospice 5-41 When starting patient on opioids, begin with immediaterelease preparation After establishing amount needed daily to control pain, convert daily dose to sustained-release preparation given routinely every 12 hours May still need doses of immediate-release drug for breakthrough pain About 10% of daily dose may be as often as every 1 to 2 hours PRN for breakthrough pain Transdermal patch another option for patients requiring around-the-clock pain control for moderate to severe pain Administer opioids at regular intervals rather than PRN Use bowel regimens to avoid constipation Basic Hospice

95 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care Opioids that should be avoided in the elderly: Meperidine Propoxyphene Mixed Opioid Antagonists For instance, Pentazocine Basic Hospice 5-43 Medications with a primary indication other than pain that have analgesic properties Examples: Anticonvulsants Antidepressants Corticosteroids Bisphosphonates Muscle relaxants Basic Hospice 5-44 Individualize administration of medications to meet patient needs Identify events or activities that may exacerbate pain Medication may be more effective if given before such activities Use regular not PRN (as needed) administration if Frequent PRN use for relief Pain persists with PRN approach Use least invasive route of administration first Basic Hospice

96 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care Begin with low dose Reassess and adjust dose frequently to optimize pain relief while monitoring and managing side effects Elderly, chronically ill more likely to have adverse drug reactions Identify treatment goals: decrease pain, improve functioning, mood, sleep, etc. Basic Hospice 5-46 Appropriate Nonpharamcologic Approaches Topical analgesics Acetaminophen NSAIDs (short-term, low-dose preferred) Tramadol (if patient or advocate wishes to avoid opioids) Opioids Basic Hospice 5-47 If related to diabetes, establish control of blood glucose levels Topical analgesics Anticonvulsant or antidepressant Acetaminophen NSAIDs Tramadol (if patient or advocate wishes to avoid opioids) Opioids Basic Hospice

97 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care Review and reassess regularly Frequency and intensity of pain Ability to perform activities of daily living Sleep pattern Mood, cognition and behavior Participation in usual activities Treatment plan and effectiveness of current medications and complementary treatments Side effects of analgesics Conditions/diagnoses associated with pain Basic Hospice 5-49 Constipation: a laxative should be started at the time of prescribing an opioid Sedation: Residents may experience drowsiness and should decrease in a couple of days Nausea with/without vomiting: Check for impaction! Usually subsides within 3-4 days Delirium: Opioids can precipitate or aggravate confusion, delusions and hallucinations. Also make sure to r/o other medical issues Respiratory Depression: rare in opioid tolerant, yet more in common in opioid naive Basic Hospice 5-50 Revise treatment plan as necessary Options for unresponsive pain after above measures referral to: Pain clinic Physician certified in palliative medicine or psychiatrist experienced in care of elderly patients Pain specialist Basic Hospice

98 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care 50 y.o. male with terminal cancer Admitted for hospice inpatient Out-of-control pain Family Son about to graduate from high school Patient to retire from the Navy Extended family lived in the Philippines Basic Hospice 5-52 What To Do Next? Reviewed pain medicines Patient at optimum (WHO) Patient taking the medicines appropriately Patient asked Given the severity of your illness what is most important for you to achieve? Basic Hospice 5-53 He wanted to say goodbye to his extended family He grieved not being able to attend his son s graduation His career was incomplete without a formal retirement ceremony Sacraments of his church Basic Hospice

99 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care Social Worker Arranged special visas for his family With his son s high school principal, they re-enacted his son s graduation 50 Navy colleagues joined the patient s commanding officer in a retirement ceremony in the hospice conference room Chaplain provided sacraments of anointing of the sick and communion Basic Hospice 5-55 What Happened to his Pain? WHO s Pain Relief Ladder Freedom from Cancer Pain Opioid for moderate to severe pain +/- Non-Opioid +/- Adjuvant 3 Pain persisting or increasing Opioid for mild to moderate pain +/- Non-Opioid +/- Adjuvant 2 Pain persisting or increasing Non-opioid +/- Adjuvant I Basic Hospice 5-56 Views about management of pain have changed Widespread concern about untreated pain and adequate pain management Pain can and should be addressed Cannot always be eliminated, given less-than-ideal options we have People should die as comfortably as possible Don t do harm while trying to do good Indiscriminate symptom-chasing can do harm Basic Hospice

100 Basic Hospice Lesson 5: Pain and Symptom Management in Hospice Care Summary (cont.) However, available treatments are only sometimes effective, often problematic May cause as many or more unpleasant effects as they relieve Pain in dying individuals should be treated as best as possible Basic Hospice 5-58 Questions? Basic Hospice

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105 Basic Hospice, November 2008 Student Manual Lesson 6: Quality Assessment and Performance Improvement (QAPI) Learning Objectives At the conclusion of this lesson, you will be able to: Define Quality Assessment and Performance Improvement (QAPI). State the goal of QAPI. Describe the key components of a QAPI program. Verbalize the survey expectations. 1

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107 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) Lesson 6 Quality Assessment & Performance Improvement (QAPI) Basic Hospice 6-1 Learning Objectives Define Quality Assessment & Performance Improvement (QAPI) State the goal of QAPI Describe the key components of a QAPI program Verbalize the survey expectations Basic Hospice 6-2 CMS Roadmap for Quality Vision: The right care for the every person every time Aims: Make care safe, effective, efficient, patient-centered, timely, equitable Basic Hospice 6-3 3

108 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) Quality Assurance Regulation More process/audit oriented Goal is to demonstrate compliance Focus is on doing the right things and doing them well Implicitly but not explicitly related to other regulations QA vs. QAPI QAPI Regulation More patient-focused and outcome oriented Goal is to monitor quality/performance, find opportunities for improvement, and improve Focus is on achieving desired outcomes Explicitly related to other regulations Basic Hospice 6-4 Desired Outcomes in Hospice vs. Other Health Care Setting Hospice Comfortable dying Safe dying Self-determined life closure Effective grieving Other health care settings Cure of illness Improved functionality (including ADLs) The goal of the professional palliative care team is to enable the dying person to live until he dies, at his own maximum potential, performing to the limit of his physical activity and mental capacity, with control and independence wherever possible. ---The Oxford Textbook of Palliative Medicine Basic Hospice 6-5 QAPI Regulation Condition of Participation (CoP) 42 CFR Standards more detail on what hospices must do Program scope Program data Program activities Performance improvement activities Executive responsibilities Basic Hospice 6-6 4

109 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) Key Points (QAPI in a Nutshell) QAPI operates on two levels Patient-level and hospice-level At both levels, hospices must Collect data to assess quality Use the data to identify opportunities for improvement Demonstrate performance improvement in one or more areas Data-driven decision-making In combination with clinical and managerial expertise and experience Achieving desired outcomes Clinical care Hospice operations Basic Hospice 6-7 The QAPI CoP says: The hospice must develop, implement and maintain an effective, ongoing, hospice-wide, data-driven QAPI program The hospice s governing body must ensure that the program: Reflects the complexity of its organization and services; Involves all hospice services (including those services furnished under contract or arrangement); Focuses on indicators related to palliative outcomes; and Takes actions to demonstrate improvement in hospice performance The hospice must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS Basic Hospice 6-8 The QAPI Standards Program Scope Measure, analyze and track indicators (including adverse events) to assess processes of care, hospice services and operations Show measurable improvement in indicators of palliative outcomes and hospice services Program Data Collect data (as approved by governing body) Timing and detail approved by governing body Use data Monitor effectiveness and safety of services and quality of care Identify opportunities and priorities for improvement Basic Hospice 6-9 5

110 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) The QAPI Standards (cont.) Program Activities Focus on high risk, high volume, problem prone areas affecting palliative outcomes, patient safety and quality of care (consider incidence, prevalence, severity) Track adverse events; analyze causes and develop processes and training to prevent them Take action to improve where and when necessary, AND measure (assess) to ensure that improvement is sustained Basic Hospice 6-10 The QAPI Standards (cont.) Performance Improvement Projects (PIP) Number and scope must be based on needs, and reflect scope, complexity and past performance of hospice Document what, why and how successful (measurable improvement) Executive Responsibilities must ensure: QAPI program is defined, implemented and maintained annual review Quality of care and patient safety priorities are identified and addressed effectively One or more individuals are designated to be responsible for operating the QAPI program Basic Hospice 6-11 Timeframe Data collection and internal reporting must begin by Dec 2, 2008 Performance improvement projects must begin by Feb 2, days to collect quality assessment data before beginning improvement projects Basic Hospice

111 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) Think About QAPI As A combination of two different but related processes: Quality Assessment (QA) Performance Improvement (PI) Basic Hospice 6-13 QAPI Functions Basic Hospice 6-14 QAPI Operates on Two Levels Hospice-level QAPI Patient-level QAPI Patient-level: Individual patients outcomes or events Hospice level: Overall hospice performance Clinical (all patients) Non-clinical operations Basic Hospice

112 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) Patient-Level QAPI Collect data on what happened for an individual patient Assessment/ Reassessment ( ) Care plan ( ) Clinical notes Use the data to improve quality of care and outcomes for that patient ( ) Basic Hospice 6-16 Patient-Level The Cycle of Care Basic Hospice 6-17 EXAMPLE: Use of patient-level data Symptom Management Collect symptom severity data on each assessment Collect patient goal Monitor severity over time and relative to the goal Adjust interventions to reach goal and/or assist patient in refining the goal Basic Hospice 6-18 Symptom 3/2/08 3/3/08 3/6/08 Anxiety Moderate Mild Mild Dyspnea Mild None Mild Patient Goal: 3 Admit Day 3 First week 3 3 Last week 8

113 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) Hospice-Level QAPI Clinically focused Aggregate (patient-level) data Collect satisfaction data HOSPICE Non-clinically focused Administrative data Marketing - referral source contact Outreach to community Profitability Fundraising Use the data to improve clinical operations and non-clinical operations Basic Hospice 6-19 Hospice-Level QAPI (cont.) Basic Hospice 6-20 Hospice-Level QAPI (cont.) (a) Program Scope The hospice must measure, analyze, and track quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services and operations (e) Patient outcome measures Assessment must Include data elements to be used for outcome measurement Data must be used in the aggregate for the hospice s QAPI program Basic Hospice

114 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) Aggregated Patient Data Percentage of patients uncomfortable on admission who were more comfortable within 2 days (Labels indicate # patients included) % of patients uncomfortable on admission 100% 80% 60% 40% 20% 0% National Average 82% Q2007 2Q2007 3Q2007 4Q2007 Basic Hospice 6-22 Administrative Data - HR st Qtr 2nd Qtr 3rd Qtr 4th Qtr %Reviews completed on time (target 95%) %Employee turnover (target 20% max) Basic Hospice 6-23 Not just Hospice by the numbers Quality assessment (QA) requires quantitative information Numbers OR Uniform variables (e.g. Yes/No; increased/decreased) that you can count Good patient care and PI require qualitative information Narrative data usually non-uniform Provides detail behind quantitative information Hospices should be using a mix of data sources and types Basic Hospice

115 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) Keys To Compliance A plan to collect a full complement of quality measures Clinical quality Service quality Patient and family outcomes Non-clinical operations Monitoring of quality/performance indicators at regular intervals (intervals may vary for different measures) Use of industry benchmarks and/or internal targets (and patient-identified goals at the patient-level) Implementation of performance improvement projects One or more individuals who have responsibility for operating the QAPI program Board involvement Evidence of improvement and achieving desired outcomes Basic Hospice 6-25 Visualize QAPI Hospice See Quality information/data Data elements on patient assessment/care plan forms PI data posted on bulletin boards or in reports Hear about Culture of quality Quality assessment is a core activity across the organization Positive questioning, not finger pointing Reliance on data for decision-making Performance improvement, not criticism or punishment, is the organizational response to errors and problems Basic Hospice 6-26 Visualize QAPI Hospice (cont.) Read Plans and reports QAPI plan PIP reports Governing body meeting agendas/minutes Observe Everybody participates All licensed professionals must participate (g) Hospice aides must report changes in patient needs as they relate to quality assessment and the plan of care Preamble involve all employees, paid and volunteer, including contracted staff Basic Hospice

116 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) Possible QAPI Participation Quality Idea Governing Body/senior managers/directors Appoints QAPI manager/team Selection of measures and PIPs Review quality assessment data Managers and staff Review quality assessment data relevant to their areas Identify strengths and weaknesses Contribute ideas for PIPs Participate in PIP teams Administrative staff Perform data entry Run programmed analyses Contribute ideas for PIPs Participate in PIP teams Basic Hospice 6-28 Case Study - Unwanted Hospitalization Data elements on comprehensive assessment Preference for hospitalization Interventions on the plan of care Reassessment review and update plan of care Update preferences Note any unwanted/unexpected hospitalizations Aggregate data for all closed charts quarterly Track percentage who did not want and did not get hospitalization Basic Hospice 6-29 Q & A Basic Hospice

117 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) Assessing the QAPI Program Questions for those who have responsibility for the QAPI program, and other managers and staff Observational evidence Documentary evidence Basic Hospice 6-31 Overarching Question Is the hospice using quality assessment and performance improvement to achieve desired palliative outcomes for patients/families and operational outcomes for the agency? Basic Hospice 6-32 Regulatory Requirements Condition of Participation (CoP) 42 CFR Standards Program scope Program data Program activities Performance improvement activities Executive responsibilities Basic Hospice

118 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) The QAPI CoP The hospice must develop, implement and maintain an effective, ongoing, hospice-wide, data-driven QAPI program The hospice s governing body must ensure that the program: Reflects the complexity of its organization and services; Involves all hospice services (including those services furnished under contract or arrangement); Focuses on indicators related to palliative outcomes; and Takes actions to demonstrate improvement in hospice performance The hospice must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS Basic Hospice 6-34 Evidence of QAPI Compliance (From the CMS Preamble to CoPs) QAPI plan and identified individual(s) responsible Meeting minutes development and operation Quality indicators Which ones; why; and how assure consistent data collection Use of measures in patient care How data are aggregated and analyzed PIPs How selected and implemented Evidence of improvement (PIP reports and patient charts) Evidence that QAPI is prevalent throughout operations Actual experience of patients and employees Basic Hospice 6-35 Standard (a): Program Scope 1) The program must at least be capable of showing measurable improvement in indicators related to improved palliative outcomes and hospice services 2) The hospice must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations Basic Hospice

119 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) Program Scope: What Might you Ask? Is the QAPI program hospice-wide, including patient outcomes, processes of care, hospice services and operations? What measures/indicators have been selected and why? How are adverse events and other indicators tracked over time and relative to benchmarks or targets? Is there evidence of improved patient care and/or operational outcomes? Basic Hospice 6-37 Program Scope: Possible Evidence QAPI Plan with descriptions of indicators and processes for tracking Reports or storyboards of performance improvement activities Minutes of QAPI meetings Adverse events policy/procedure Basic Hospice 6-38 Standard (b): Program Data 1) The program must use quality indicator data, including patient care, and other relevant data, in the design of its program 2) The hospice must use the data to do the following: i. Monitor the effectiveness and safety of services and quality of care ii. Identify opportunities and priorities for improvement 3) The frequency and detail of the data collection must be approved by the hospice s governing body Basic Hospice

120 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) Program Data: What Might you Ask? What kinds of patient care and other program data are included in the hospice s QAPI program? What systems are in place to collect, aggregate and monitor data for quality assessment? How does the hospice use the data to track outcomes of patient care and operational efficiency and effectiveness? Has the governing body approved what data is to be collected? Basic Hospice 6-40 Program Data: Possible Evidence QAPI Plan with information on the sources and types of data used in the QAPI program Policies, procedures or reports showing the collection and aggregation of data for quality assessment Governing body minutes documenting discussions and/or decisions related to QAPI data Basic Hospice 6-41 Standard (c): Program Activities 1) The hospice s performance improvement activities must: i. Focus on high risk, high volume, or problem-prone areas ii. Consider incidence, prevalence and severity of problems in those areas iii. Affect palliative outcomes, patient safety, and quality of care 2) Performance improvement activities must track adverse patient events, analyze their causes and implement preventive actions and mechanisms that include feedback and learning throughout the hospice 3) The hospice must take actions aimed at performance improvement. After implementing these actions, the hospice must measure its success and track performance to ensure that improvements are sustained Basic Hospice

121 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) Program Activities: What Might you Ask? In deciding what outcomes/indicators to track, does the hospice consider how many patients/families are affected and how severe the impact is? Does the hospice have adequate policies/ procedures for tracking, responding to and preventing adverse events? (e.g., Are staff aware of what constitutes an adverse event and their responsibilities for reporting and preventing?) What improvements have been made through the QAPI program? How does the hospice assure that outcome and/or performance improvements are sustained? Basic Hospice 6-43 Program Activities: Possible Evidence Data sources for information on adverse events (e.g., incident reports, complaint logs) Education records showing training on reporting and preventing adverse events PIP reports and/or QAPI meeting notes that document improvement in quality indicators that is sustained over time Basic Hospice 6-44 Standard (d): Performance Improvement Projects Beginning February 2, 2009, hospices must develop, implement and evaluate performance improvement projects 1) The number and scope of distinct performance improvement projects conducted annually, based on the needs of the hospice s population and internal organizational needs, must reflect the scope, complexity, and past performance of the hospice s services and operations 2) The hospice must document what performance improvement projects are being conducted, the reasons for conducting these projects, and the measureable progress achieved on these projects Basic Hospice

122 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) Performance Improvement Projects: What Might you Ask? How does the hospice decide how many PIPs to do and what issues to address through PIPs? Does the hospice conduct a reasonable number of PIPs annually given its size, the needs of the hospice population and the past performance? Does the hospice maintain adequate documentation of PIPs? Do the PIPs show that adequate progress was made and sustained? Basic Hospice 6-46 Performance Improvement Projects: Possible Evidence QAPI committee and/or board minutes documenting discussions about choosing issues for PIPs PIP reports, or a PIP log, that document the focus of each PIP, the reason(s) for conducting it and data (or other results) showing progress was made and sustained Basic Hospice 6-47 Standard (e): Executive Responsibilities The hospice s governing body is responsible for ensuring the following. 1) That an ongoing program for quality improvement and patient safety is defined, implemented and maintained and is evaluated annually 2) That the hospice-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness 3) That one or more individual(s) who are responsible for operating the quality assessment and performance improvement program are designated Basic Hospice

123 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) Executive Responsibilities: What Might you Ask? How is the governing body involved in the development and ongoing evaluation of the QAPI program? Has the hospice s governing body designated responsibility for operation of the QAPI program to one or more individuals? Has the governing body assured that adequate resources are available to operate an effective QAPI program? Basic Hospice 6-49 Executive Responsibilities: Possible Evidence A governing body resolution regarding QAPI Governing body meeting agendas showing discussions and decisions regarding the QAPI program, such as: Appointment of one more individuals to run the program Approval of data collection Reviews of program effectiveness; specifically whether progress/improvements are being made and sustained Basic Hospice 6-50 Questions Basic Hospice

124 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) QAPI Exercise 6-1 Each table will receive an assigned letter Find the question on the exercise handout assigned to your table s letter Take 10 min to discuss with your tablemates appropriate responses/evidence for each item note key points that should be covered; if you finish early, look at the other questions Report out to all participants 1 minute per table Basic Hospice

125 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) QAPI Case Study Unwanted Hospitalization At Hospice QE, the comprehensive assessment includes a question about whether the patient and family wish to avoid hospitalization if the patient s condition worsens. The answer is recorded on the assessment form and on the cover sheet for the patient s medical record in a specific shaded box provided for this information. If hospitalization is to be avoided, there are specific interventions added to the plan of care, such as (1) a sticker on the phones at the patient s home directing everyone to call the hospice s 24 hour number rather than 911 if the patient s condition worsens, (2) a note in the patient s electronic and paper record for on-call staff that indicates the preference to avoid hospitalization, and (3) other procedures to assure that calls from this patient and family receive priority response from a team member. At each reassessment, the patient and family preference regarding hospitalization is reviewed and updated. The information is also updated on the face sheet, and any unwanted and/or unexpected hospitalizations since the last review are also noted on the care plan and on the cover sheet (in the area provided for this information); then the team determines whether any interventions need to be changed. During the monthly review of all discharged patient charts, the medical records reviewer adds the information on unwanted hospitalization for each individual patient to the Excel spreadsheet created for aggregating the data. Quarterly, the QAPI manager runs a preprogrammed report from the Excel spreadsheet that tallies the number of patients who had data on this indicator, the number who at any time wanted to avoid hospitalization, and the number of those wanting to avoid hospitalization, but were still hospitalized. The percentage [i.e., those who wanted to avoid AND who were not hospitalized divided by the number who wanted to avoid X 100] is tracked for every month and reported quarterly as shown in the graph. If the percentage 21

126 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) drops below 95 percent more than once in a quarter, the hospice will conduct a performance improvement study to understand why patients are receiving unwanted hospitalization and to determine whether and how the hospice can improve. 22

127 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) Quality Assessment and Performance Improvement (QAPI) Exercise 6-1 A. How do quality assessment and performance improvement work together? B. What is the key goal/purpose for the hospice s QAPI program? C. How might a hospice show that the QAPI program hospice-wide, including patient outcomes, processes of care, hospice services and operations? D. Name three documents that you might review to learn about operation of the QAPI program. E. What should be included in the QAPI Plan? (Name at least three items/topics.) F. How would a hospice demonstrate improved patient care and/or operational outcomes? G. What kinds of patient care and other program data might be included in the hospice s QAPI program? H. Where would you expect to find data elements used to track operational outcomes? (Name at least three data sources.) I. Briefly describe how QAPI plays out at the level of an individual patient. J. What do we mean by hospice-level QAPI? K. What should the hospice consider when deciding what outcomes/indicators to track? L. List two items you might look for on governing body meeting agendas showing discussions and decisions regarding the QAPI program. M. How will you know if the hospice has an effective QAPI program? 23

128 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) N. Name two possible data sources for information on adverse events. O. When interviewing interdisciplinary team members about their role in QAPI, what are two questions you might ask? P. When interviewing senior managers about their role in QAPI, what are two questions you might ask? Q. How should the hospice decide how many performance improvement projects (PIP) to do and what issues to address through PIPs? R. When reviewing PIP reports, name two things to look for. S. How should the governing body be involved in the development and ongoing evaluation of the QAPI program? T. Who should have day to day operational responsibility for operation of the QAPI program? 24

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131 Basic Hospice Lesson 6: Quality Assessment and Performance Improvement (QAPI) Notes Page 27

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133 Basic Hospice, November 2008 Student Manual Lesson 7: Hospice Care in the Nursing Home Learning Objectives At the conclusion of this lesson, you will be able to: Explain Hospice Professional Management responsibilities for nursing home (NH) residents. Discuss the requirements for the written agreement between the hospice and the NH. Discuss the goals of a coordinated plan of care in the NH setting. Review the coordination of services requirement. Describe orientation and training of staff in the NH. 1

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135 Basic Hospice Lesson 7: Hospice Care in the Nursing Home Lesson 7 Hospice Care in the Nursing Home Basic Hospice 7-1 Learning Objectives Explain Hospice Professional Management responsibilities for nursing home (NH) residents Discuss the requirements for the written agreement between the hospice and the NH Discuss the goals of a coordinated plan of care in the NH setting Review the coordination of services requirement Describe orientation and training of staff in the NH Basic Hospice Condition of Participation: Hospices that Provide Hospice Care to Residents of a SNF/NF or ICF/MR Must meet all of the Conditions of Participation at through Basic Hospice 7-3 3

136 Basic Hospice Lesson 7: Hospice Care in the Nursing Home (a) Standard-Resident Eligibility, Election and Duration of Benefits Medicare patients receiving hospice services and residing in a SNF, NF or ICF/MR are subject to the Medicare eligibility criteria that includes: Eligibility Election Duration of benefits Basic Hospice (b) - Standard Professional Management Hospice assumes responsibility for professional management of the resident s hospice services provided, in accordance with the plan of care and hospice CoPs Arrange for hospice-related inpatient care in a participating Medicare/Medicaid facility Basic Hospice (c) - Standard Written Agreement The hospice must have a written agreement with the facility that specifies the provision of hospice services in the facility The agreement must be signed by authorized representatives of the hospice and facility before the provision of hospice services. Basic Hospice 7-6 4

137 Basic Hospice Lesson 7: Hospice Care in the Nursing Home Written Agreement (cont.) Includes communication methods and documentation of same to ensure that the needs of the patients are addressed and met 24 hours a day Basic Hospice 7-7 Written Agreement (cont.) A provision that the facility immediately notifies the hospice if any of the following occur: Significant change in condition Clinical complications Need to transfer from the facility Patient dies Basic Hospice 7-8 Written Agreement (cont.) A provision that the hospice assumes responsibility for determining the course of hospice care including the determination to change the level of services provided Basic Hospice 7-9 5

138 Basic Hospice Lesson 7: Hospice Care in the Nursing Home Written Agreement (cont.) The facility is responsible to continue to furnish room and board care, meeting the personal care and nursing needs that would have been provided by the primary caregiver at home at the same level of care provided before hospice care was elected Basic Hospice 7-10 Written Agreement (cont.) The hospice will provide services at the same level to the same extent if the patient was in his/her own home Basic Hospice 7-11 Written Agreement Delineation of Hospice s Responsibilities Medical direction & management Nursing Counseling (including spiritual, dietary and bereavement) Social work Medical supplies DME and drugs necessary for palliation of pain & symptoms associated with terminal illness and related conditions All other hospice services necessary for care of terminal illness and related conditions Basic Hospice

139 Basic Hospice Lesson 7: Hospice Care in the Nursing Home Written Agreement Delineation of Hospice s Responsibilities (cont.) Hospice may use the facility nursing personnel where permitted by State law and as specified by the facility to assist in the administration of prescribed therapies included in the plan of care only to the extent that the hospice would routinely use the services of a hospice patient s family in implementing the plan of care Basic Hospice 7-13 Written Agreement (cont.) Alleged Violations A provision that the hospice must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual and physical abuse, including injuries of unknown source and misappropriation of patient property by anyone unrelated to the hospice to the facility administrator within 24 hours of the hospice becoming aware of the alleged violation Basic Hospice 7-14 Written Agreement (cont.) Bereavement Services The written agreement should include a provision regarding the responsibility of the hospice for providing bereavement services to the SNF/NF or ICF/MR Basic Hospice

140 Basic Hospice Lesson 7: Hospice Care in the Nursing Home (d) Standard - Hospice Plan of Care Established and maintained in consultation with facility Care provided must be in accordance with plan Identification of care and services, and who is responsible Reflects participation of hospice, facility and patient/family Changes discussed and approved Basic Hospice (e) Coordination of Services The hospice must designate an IDG member responsible for: Overall coordination of hospice care Communication with facility and other health care providers participating in the provision of care to ensure quality of care Basic Hospice 7-17 Coordination of Services (cont.) Ensure that the hospice IDG communicates with the facility medical director, patient s attending physician and other physicians participating in the provision of care so that the medical care and the hospice care can compliment and enhance the outcomes of the patient Basic Hospice

141 Basic Hospice Lesson 7: Hospice Care in the Nursing Home Coordination of Care Provide facility with patient-specific information: Most recent plan of care Election form Advance directives (if any) Certification and recertifications Hospice contact information Access to 24 hour on call system Medication information/physician orders Basic Hospice (f) Orientation and Training of Staff Furnishing Care Hospice philosophy Hospice P & P s Pain control Symptom management Principles about Death & Dying Individual responses to death Patient Rights Appropriate forms Record keeping requirements Basic Hospice 7-20 Nursing Home Responsibilities Assess resident Maintain MDS/RAI Provide personal care Coordinate plan with hospice Provide activities Meet all NH regulations Give medications Orient hospice staff Clean room Activities of daily living Notify hospice of any change in condition Basic Hospice

142 Basic Hospice Lesson 7: Hospice Care in the Nursing Home Hospice Responsibilities Assess resident Financial responsibility terminal illness & related conditions Orient & Train NH staff Coordinate PoC with NH Professional management Determine level of care Interdisciplinary Group (IDG) Provide hospice care & services Monitor care review & update QAPI Meet all hospice CoPs Basic Hospice 7-22 Medicare + Medicaid Eligible Hospice & NH must have written agreement Hospice assumes professional management of the individual's hospice care Facility provides room & board Basic Hospice 7-23 Medicare & Medicaid Payments for Hospice Patients Residing in NH State Medicaid Agency Medicare Administrative Contractor Hospice Nursing Home Basic Hospice

143 Basic Hospice Lesson 7: Hospice Care in the Nursing Home Lesson 7 Questions? Basic Hospice

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145 Basic Hospice, November 2008 Student Manual Lesson 8A: Pre-Survey Preparation Learning Objective At the conclusion of this lesson, you will be able to: Identify requirements a hospice must meet to be eligible for an initial survey. Identify requirement for a surveyor to fully participate on a hospice survey. Prepare for a hospice survey. 1

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147 Basic Hospice Lesson 8A: Pre-Survey Preparation Lesson 8A Pre-Survey Preparation Basic Hospice 8A-1 Learning Objectives At the conclusion of this lesson, you will be able to: Identify requirements a hospice must meet to be eligible for an initial survey Identify requirement for a surveyor to fully participate on a hospice survey Prepare for a hospice survey Basic Hospice 8A-2 Survey Tasks Pre-survey preparation Entrance interview Information gathering Information analysis Exit conference Formation of statement of deficiencies Basic Hospice 8A-3 3

148 Basic Hospice Lesson 8A: Pre-Survey Preparation Survey Task Information State Operations Manual (SOM): Appendix M Revision (2008) Basic Hospice 8A-4 Hospice Outcome-Oriented Survey Process Emphasis on patient outcomes and implementation of requirements Initial focus on provision of services then on the underlying structure and processes All CoPs reviewed at initial or recertification survey Basic Hospice 8A-5 Pre-Survey Tasks Review of hospice file (SOM Section 2704) Existence of multiple location(s) Prior survey history Current and prior complaint history Disclosure of Ownership Information (855a) Media reports/publically available information Basic Hospice 8A-6 4

149 Basic Hospice Lesson 8A: Pre-Survey Preparation Plan Survey Identify key issues/focus Determine location for survey entrance and subsequent activities including home visits Establish survey team Review the hospice regulations Bring your regulations and required hospice survey forms Basic Hospice 8A-7 Initial Certification Survey Currently a Tier 4 priority for State survey agencies Prospective hospice providers can apply to accrediting organization (AO) for deemed status and request initial certification survey from AO Survey is unannounced Basic Hospice 8A-8 Initial Certification Survey (cont.) Prior to scheduling survey, confirm that facility: Is operational Has completed CMS-855A and been reviewed by MAC Has accepted patients Minimum of 5 3 receiving care at time of survey Is providing all hospice core services and other needed services Has demonstrated operational capability Has arrangements for inpatient care Basic Hospice 8A-9 5

150 Basic Hospice Lesson 8A: Pre-Survey Preparation Recertification Survey Unannounced Verify compliance with all hospice regulations 42 CFR CFR Can be conducted at a multiple location Ideally visit all locations Deficiencies at any multiple location apply to entire hospice Basic Hospice 8A-10 Complaint and Revisit Surveys Always unannounced Focused survey Determine compliance with applicable regulations only If CoP out of compliance, all CoPs reviewed For hospice with deemed status through an accrediting organization, SA receives authorization for survey from RO Basic Hospice 8A-11 Lesson 8A Questions? Basic Hospice 8A-12 6

151 Basic Hospice Lesson 8A: Pre-Survey Preparation Notes Page 7

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153 Basic Hospice, November 2008 Student Manual Lesson 8B: Entrance Interview Learning Objectives At the conclusion of this lesson, you will be able to: State the purpose of the entrance interview. Describe the key components to conducting the entrance interview. Conduct an entrance interview. 1

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155 Basic Hospice Lesson 8B: Entrance Interview Lesson 8B Entrance Interview Basic Hospice 8B-1 Learning Objectives At the conclusion of this lesson, you will be able to: State the purpose of the entrance interview Describe the key components to conducting the entrance interview Conduct an entrance interview Basic Hospice 8B-2 Entrance Interview Sets the tone for entire survey Surveyor: Presents identification Introduces other team members Asks to meet with administrator, director or supervisor Basic Hospice 8B-3 3

156 Basic Hospice Lesson 8B: Entrance Interview Entrance Interview Tasks Explain: Purpose of survey Process used Home visits Record reviews Estimated time schedule for completion Basic Hospice 8B-4 Entrance Interview Tasks (cont.) Be professional, courteous & well organized Ask pertinent questions to learn how hospice requirements are implemented Request needed documents Basic Hospice 8B-5 Entrance Interview Tasks (cont.) Ask for: Place to work Key person as point of contact to assist the team Basic Hospice 8B-6 4

157 Basic Hospice Lesson 8B: Entrance Interview Role Play Entrance Interview Basic Hospice 8B-7 Lesson 8B Questions? Basic Hospice 8B-8 5

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159 Basic Hospice Lesson 8B: Entrance Interview Notes Page 7

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161 Basic Hospice, November 2008 Student Manual Lesson 8C: Sample Selection Learning Objective At the conclusion of this lesson, you will be able to: Select appropriate samples for record reviews and home visits. 1

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163 Basic Hospice Lesson 8C: Sample Selection Lesson 8C Sample Selection Basic Hospice 8C-1 Learning Objective At the conclusion of this lesson, you will be able to: Select appropriate samples for record reviews and home visits Basic Hospice 8C-2 Sample Selection Number of unduplicated admissions during a recent 12-month period determines: Number of record reviews (RR) without home visits (HV) Number of RR with HV Basic Hospice 8C-3 3

164 Basic Hospice Lesson 8C: Sample Selection Minimum Number of Record Reviews Unduplicated Admissions Min # of RR Without HV Min # of RR With HV Total Record Reviews Less than or more Basic Hospice 8C-4 Sample Selection (cont.) Patients from different levels of care: Routine home care Inpatient care Respite care Continuous care Basic Hospice 8C-5 Sample Selection (cont.) Select: Active & closed records Patients with different terminal diagnoses Patients in different settings Bereavement cases (2-3) Basic Hospice 8C-6 4

165 Basic Hospice Lesson 8C: Sample Selection Sample Selection (cont.) Remember, you can always increase the number of record reviews with or without home visits Basic Hospice 8C-7 Lesson 8C Questions? Basic Hospice 8C-8 5

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167 Basic Hospice Lesson 8C: Sample Selection Notes Page 7

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169 Basic Hospice, November 2008 Student Manual Lesson 8D: Clinical Record Review Learning Objectives At the conclusion of this lesson, you will be able to: Identify practical investigative techniques for a clinical record review. Apply a systematic process for reviewing clinical records for a scenario-based situation. 1

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171 Basic Hospice Lesson 8D: Clinical Record Review Lesson 8D Clinical Record Review Basic Hospice 8D-1 Learning Objectives At the conclusion of this lesson, you will be able to: Identify practical, investigative techniques for a clinical record review Apply a systematic process for reviewing clinical records for a scenario-based situation Basic Hospice 8D-2 Clinical Record Review Written/documented evidence of: Patient/representative signature confirming receipt of patient rights & responsibilities Hospice election statement Physician certification and recertification of terminal illness Advance directives (if any) Physician orders Basic Hospice 8D-3 3

172 Basic Hospice Lesson 8D: Clinical Record Review Clinical Record Review (cont.) Initial and comprehensive assessments timely: Initial assessment by registered nurse (RN) within 48 hours of election Comprehensive assessment by interdisciplinary group (IDG) within 5 calendar days of election Assessments that accurately reflect patient/family status/needs Basic Hospice 8D-4 Clinical Record Review (cont.) Individualized plan of care: Based on assessments Reflects participation of entire IDG Identifies patient s current status & family/caregiver s needs Involves patient/family participation (as desired) Contains outcome measure data elements Clinical notations by all personnel providing services Basic Hospice 8D-5 Clinical Record Review (cont.) Assessment of patient care: Care furnished according to plan Visit frequency supports assessment findings Pain managed & other symptoms controlled Core services are provided by hospice employees All covered services available as necessary to meet needs of patient Drugs, medical supplies & durable medical equipment (DME) are provided as needed for palliation & management of terminal illness & related conditions Plan of care communicated to patient/caregiver in a comprehensible way Basic Hospice 8D-6 4

173 Basic Hospice Lesson 8D: Clinical Record Review Clinical Record Review (cont.) The clinical record documentation supports: Protection/promotion of patient rights Interdisciplinary approach to care Coordination/continuity of care Education to patient/family Activities of disciplines providing care Arrangements made for provision of all necessary covered hospice services Arrangements for inpatient care when needed Basic Hospice 8D-7 Clinical Record Review (cont.) Hospice aide services: Adequate in frequency to meet needs of patient Written patient care instructions prepared by RN Changes in patient condition/need reported to RN Documentation reflects patient status Assessed & supervised by RN Basic Hospice 8D-8 Clinical Record Review (cont.) Hospice aide supervision: Conducted by RN Onsite visits to patient s residence No less frequently than every 14 days Aide does not have to be present Assess quality of care, services & relationships As needed & annual onsite visits Basic Hospice 8D-9 5

174 Basic Hospice Lesson 8D: Clinical Record Review Practical Investigative Techniques Work with agency staff to capture appropriate sample (settings/diagnoses) Ask agency staff to provide overview of record format before beginning review If possible, review record before home visits At least review plan of care, medications, etc. Document observations, interviews & findings Basic Hospice 8D-10 Practical Investigative Techniques (cont.) Review clinical notes: Initial & comprehensive assessments timely & accurate? Plan of care developed by IDG & attending physician? Patient/family participation (as desired)? Plan of care followed? Coordination of services maintained? Patient status changes? Confirm: Physician notified IDG involvement/comprehensive assessment updates Plan of care updated Basic Hospice 8D-11 Practical Investigative Techniques (cont.) Appropriate patient/caregiver education? Clinical notes for all personnel providing services? Hospice aide ordered? Confirm: Followed assignment? Supervision? Appropriate communication of changes? Qualified personnel? Basic Hospice 8D-12 6

175 Basic Hospice Lesson 8D: Clinical Record Review Practical Investigative Techniques (cont.) Keep master list of findings List of questions for validation Possible deficiencies with patient identifiers Maintain ongoing, open dialogue with hospice personnel Share findings as appropriate Basic Hospice 8D-13 Lesson 8D Questions? Basic Hospice 8D-14 7

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177 Basic Hospice Lesson 8D: Clinical Record Review Clinical Record Review Exercise Guide General Directions: This exercise is to simulate the clinical record review part of the survey. Each table will receive two clinical records one record is primary and one record is secondary for your table. Half of the class will focus on Record 1 and the other half will focus on Record 2. Read both records so you will be familiar with the patients who will be discussed. Review your primary record and focus on compliance with the specific condition of participation (CoP) that your table is assigned. Discuss your concerns/questions about your primary record with your table. Each Table Is to Appoint a Facilitator/Recorder: This person is responsible for: 1. Assuring that all individuals have the opportunity to discuss their concerns and questions. 2. Drafting three home visit questions developed by your table. Directions to Facilitator/Recorder: 1. Write your table number on the index card found on your table. 2. Write three questions your group would like to pursue on a home visit. 3. Submit your questions to the faculty when asked. Directions to the Table: 1. Read both clinical records. 2. Discuss your assigned primary record and CoP with your table. 3. Discuss your table s findings/concerns related to the assigned clinical record and CoP. 4. Develop three questions for a home visit based on the review of your assigned clinical record. These questions should focus on your assigned CoP. The questions should be phrased as though you are on survey interviewing the patient. 9

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179 Basic Hospice Lesson 8D: Clinical Record Review Notes Page 11

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181 Basic Hospice, November 2008 Student Manual Lesson 8E: Home Visit Procedures Learning Objectives At the conclusion of this lesson, you will be able to: State the purpose of a home visit. Describe the criteria for conducting home visits. Conduct a home visit. 1

182 Basic Hospice Lesson 8E: Home Visit Procedures 2

183 Basic Hospice Lesson 8E: Home Visit Procedures Lesson 8E Home Visit Procedures Basic Hospice 8E-1 Learning Objectives At the conclusion of this lesson, you will be able to: State the purpose of home visits Describe the criteria for conducting home visits Conduct a home visit Basic Hospice 8E-2 Home Visit Requirements Home visits must be made to a sample of hospice patients as follows: Number of unduplicated patients admitted during recent 12 month period Less than or more Minimum number of home visits with record reviews Basic Hospice 8E-3 3

184 Basic Hospice Lesson 8E: Home Visit Procedures Home Visit Requirements (cont.) All payment sources Different diagnoses Different settings Basic Hospice 8E-4 Home Visit Purpose Home visits made to evaluate: Patient rights Assessments Plan of Care Coordination of care Use of volunteers/aides Infection control Patient satisfaction Basic Hospice 8E-5 Home Visit Consent Patient s consent Verbal Written (Exhibit 128) Basic Hospice 8E-6 4

185 Basic Hospice Lesson 8E: Home Visit Procedures Home Visit Procedures Develop home visit schedule Request copy of most recent plan of care Conduct home visit Explain purpose Observe hospice staff providing services Interview patient/family/caregivers Basic Hospice 8E-7 Home Visit Procedures (cont.) Reasons to discontinue visit Patient issues Safety issues Basic Hospice 8E-8 Lesson 8E Questions? Basic Hospice 8E-9 5

186 Basic Hospice Lesson 8E: Home Visit Procedures 6

187 Basic Hospice Lesson 8E: Home Visit Procedures Notes Page 7

188 Basic Hospice Lesson 8E: Home Visit Procedures 8

189 Basic Hospice, November 2008 Student Manual Lesson 8F: Information Analysis Learning Objectives At the conclusion of this lesson, you will be able to: List information sources used to perform the information analysis survey task. Discuss practical investigative techniques for making compliance decisions. Determine if the Conditions of Participation (CoP) are met/not met for scenario-based situations. 1

190 Basic Hospice Lesson 8F: Information Analysis 2

191 Basic Hospice Lesson 8F: Information Analysis Lesson 8F Information Analysis Basic Hospice 8F-1 Learning Objectives At the conclusion of this lesson, you will be able to: List information sources used to perform the information analysis survey task Discuss practical investigative techniques for making compliance decisions Determine if the Conditions of Participation (CoP) are met/not met for scenario-based situations Basic Hospice 8F-2 Sources of Information Home visit observations Patient/family interviews Staff interviews: Core services/idg members Medical Director Aides, therapy, volunteers, etc. Clinical record reviews Interdisciplinary group (IDG) meetings Review of care provided in all settings Basic Hospice 8F-3 3

192 Basic Hospice Lesson 8F: Information Analysis Sources of Information (cont.) QAPI Personnel files Disclosure of ownership Administrative records Governing body records Policy/procedures Basic Hospice 8F-4 Practical Investigative Techniques Maintain open and ongoing dialogue with hospice personnel Share observations Collect and evaluate all necessary information to determine compliance Review alternative explanations provided by the hospice prior to making compliance decisions Basic Hospice 8F-5 Practical Investigative Techniques (cont.) Confirm the following: Are patient rights provided/protected/promoted? Do patient and family participate in care planning? Were initial and comprehensive assessments done accurately and timely? Is care provided in accordance with the patient s individualized IDG plan of care? Do plans of care reflect patient s current status? Is care directed at pain management and control of symptoms? Basic Hospice 8F-6 4

193 Basic Hospice Lesson 8F: Information Analysis Practical Investigative Techniques (cont.) Were care plans updated as needed? Did patient/caregiver receive appropriate education & training? Is there evidence of coordination of care between all disciplines in all settings? Were all covered services provided as needed? Basic Hospice 8F-7 Practical Investigative Techniques (cont.) Does the hospice have a hospice-wide, data-driven QAPI program? Is there an effective infection control program? Basic Hospice 8F-8 Practical Investigative Techniques (cont.) Analyze findings relative to each requirement: Effect or potential effect on the patient or patients, Degree/potential degree of severity, Frequency of occurrence, and Impact on service delivery Use professional judgment Basic Hospice 8F-9 5

194 Basic Hospice Lesson 8F: Information Analysis Practical Investigative Techniques (cont.) Base deficiency on the statute or regulations Not on interpretive guidelines Basic Hospice 8F-10 Practical Investigative Techniques (cont.) Standard-level deficiency Provider submits a plan of correction Condition-level deficiency Provider submits a plan of correction Hospice on a termination tract Basic Hospice 8F-11 Information Analysis Role Play Basic Hospice 8F-12 6

195 Basic Hospice Lesson 8F: Information Analysis Lesson 8F Questions? Basic Hospice 8F-13 7

196 Basic Hospice Lesson 8F: Information Analysis 8

197 Basic Hospice Lesson 8F: Information Analysis Notes Page 9

198 Basic Hospice Lesson 8F: Information Analysis 10

199 Basic Hospice, November 2008 Student Manual Lesson 8G: Exit Conference Learning Objective At the conclusion of this lesson, you will be able to: Conduct an exit conference. 1

200 Basic Hospice Lesson 8G: Exit Conference 2

201 Basic Hospice Lesson 8G: Exit Conference Lesson 8G Exit Conference Basic Hospice 8G-1 Learning Objective At the conclusion of this lesson, you will be able to: Conduct an exit conference Basic Hospice 8G-2 Exit Conference Preparation There should be no surprises to entity at exit conference Survey team: Consolidates findings Decides how to present findings Determines whether entity wishes to audiotape or videotape Basic Hospice 8G-3 3

202 Basic Hospice Lesson 8G: Exit Conference Unusual Occurrences Surveyors may refuse to conduct or continue an exit conference if: Provider creates environment that is overtly hostile, intimidating Provider is represented by counsel Lawyer tries to turn exit conference into evidentiary hearing Basic Hospice 8G-4 Purpose of Exit Conference To informally communicate preliminary survey team findings; and Provide an opportunity for exchange of information, especially if there are differences of opinion Basic Hospice 8G-5 Exit Conference Format 1. Introductory remarks 2. Ground rules 3. Presentation of preliminary findings 4. Closure Basic Hospice 8G-6 4

203 Basic Hospice Lesson 8G: Exit Conference General Principles Be polite, professional, organized & articulate Practice your presentation beforehand Be clear, concise & speak only to findings as they relate directly to noncompliance with regulations Basic Hospice 8G-7 Introductory Remarks Introduce self & team Restate why survey was conducted Thank provider organization Explain purpose of exit conference Explain that official findings are presented in writing Basic Hospice 8G-8 Ground Rules Explain how exit conference will be conducted & how survey team s findings will be presented: Disagreements Provision of additional information Basic Hospice 8G-9 5

204 Basic Hospice Lesson 8G: Exit Conference Presentation of Preliminary Findings Avoid reading findings or referring to them by data tag numbers Explain why findings are in violation of Medicare requirements Do not make general statements Stick to facts Do not rank requirements: Treat requirements as equal Cite problems that clearly violate regulatory requirements Basic Hospice 8G-10 Closure Explain process: Receipt of written statement of deficiencies (SOD) Due date for submitting Plan of Correction (POC) Immediate & serious threat Only compliance stops adverse action Initial survey results: Notification by Regional Office (RO) Recertification results: Notification by State Basic Hospice 8G-11 Cautions Never be too casual or informal It is never dress-down day on survey Maintain objectivity Basic Hospice 8G-12 6

205 Basic Hospice Lesson 8G: Exit Conference Exit Conference Role Play Basic Hospice 8G-13 Lesson 8G Questions? Basic Hospice 8G-14 7

206 Basic Hospice Lesson 8G: Exit Conference 8

207 Basic Hospice Lesson 8G: Exit Conference Notes Page 9

208 Basic Hospice Lesson 8G: Exit Conference 10

209 Basic Hospice, November 2008 Student Manual Lesson 8H: Completing Forms CMS-417, CMS-643, CMS-2567 and CMS-2567B Learning Objectives At the conclusion of this lesson, you will be able to: Complete Form CMS-417, Hospice Request for Certification in the Medicare Program. Complete Form CMS-643, Hospice Survey and Deficiencies Report. Complete Form CMS-2567, Statement of Deficiencies and Plan of Correction. Complete Form CMS-2567B, Post- Certification Revisit Report. 1

210 Basic Hospice Lesson 8H: Completing Forms CMS-417, CMS-643, CMS-2567 and CMS-2567B 2

211 Basic Hospice Lesson 8H: Completing Forms CMS-417, CMS-643, CMS-2567 and CMS-2567B Notes Page 3

212 Basic Hospice Lesson 8H: Completing Forms CMS-417, CMS-643, CMS-2567 and CMS-2567B 4

213 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB No INSTRUCTIONS FOR COMPLETING HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM STATEMENT CONCERNING INFORMATION COLLECTION REQUIREMENTS AND USES This form is required to obtain or retain Medicare benefits. It serves two purposes. First, it provides basic information about the Hospice which is necessary for the State to properly schedule a survey. Second, it provides a data-base necessary for responding to questions frequently asked by Congress, Federal agencies, and interested members of the public. Submission of this form will initiate the process of obtaining a decision as to whether the Conditions are met. Item IV If a service is provided directly by the facility place a 1 the appropriate block. If a service is provided through an outside source (i.e., by contract/arrangement), place a 2 in the appropriate block. Answer all questions as of the current date. Return the original and first two copies to the State Agency; retain the last copy for your files. If a return envelope is not provided, the name and address of the State Agency may be obtained from the nearest Social Security Office. Detailed instructions are given for questions other than those considered self-explanatory. Item I Request to establish eligibility in - current Hospice Benefits are available only through the Medicare program. Medicare certification number - insert the facility s six digit Medicare Certification Number. Leave blank on initial requests for certification. State/County and State/Region Codes Leave blank. The Centers for Medicare & Medicaid Services Regional Office will complete. Related certification number If Hospice is affiliated with any other type Medicare provider, insert the related facility s six digit Medicare Certification Number. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland

214 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB No HOSPICE REQUEST FOR CERTIFICATION IN THE MEDICARE PROGRAM (Read Instructions and Information Collection Statement On Cover Sheet of Form Prior to Completion) I. Identifying Information Name of Hospice Street Address II. Type of Hospice (Check One) III. Type of Control (Check One) IV. Services Provided: By staff, place a 1 in the block(s) If under arrangement, place a 2 in the block(s) V. Number of Employees/ Volunteers Full-time Equivalent (Top section of professional category reflects total number of FTE (i.e., PH 11 through PH 18)) PH7 PH8 PH9 Request to Establish Eligibility In 1. Medicare Medicare/Certification Number PH2 1. Hospital 2. Skilled Nursing Facility 3. Intermediate Care Facility 4. Home Health Agency 5. Freestanding Hospice State/County PH1 State/Region A. B. A. B. A. B. A. B. A. B. Whoever knowingly or willfully makes or causes to be made a false statement or representation on this form may be prosecuted under applicable Federal or State laws. In addition, knowingly and willfully failing to fully and accurately disclose the information requested may result in denial of a request to participate, or where the entity already participates, a termination of its agreement or contract with the State agency or the Secretary as appropriate. PH3 City, County and State PH4 Telephone Number (include area code) For Hospitals Only (Check One) A. The Joint Commission Accredited B. AOA Accredited C. Both The Joint Commission and AOA Accredited D. Non-Accredited PH5 Zip Code Related Certification Number Fiscal Year Ending Date Non-Profit Proprietary Government 1. Church 4. Individual 8. State 12. Combination 2. Private 5. Partnership 9. County Government and 3. Other 6. Corporation 10. City Nonprofit 7. Other 11. City-County 13. Other Core: 1. Physician Services 2. Nursing Services 3. Medical Social Services 4. Counseling Services Name and Address of Contractee 5. Physical Therapy 6. Occupational Therapy 7. Speech-Language Pathology 8. Hospice Aide 9. Homemaker 10. Medical Supplies 11. Short Term lnpatient Care PH1O A. Acute 12. Other(Specify) B. Respite Physicians PH11 Registered Professional Licensed Practical Nurses/ Employees Volunteers Nurses PH12 Licensed Vocational Nurses P Employees Volunteers Employees Volunteers A. B. A. B. A. B. Homemakers PH15 Hospice Aide PH16 Counselors PH17 Employees Volunteers Employees Volunteers Employees Volunteers Medicare Certification/Supplier Number Name of Authorized Representative and Title (Typed) Signature Date PH6 Medical Social Total Number Workers PH14 Employees A. Volunteers B. PH19 Others PH18 Employees Volunteers Employees Volunteers Form CMS-417 (06/08) PH20

215 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No Hospice Survey and Deficiencies Report Page of Certification Number Name of Facility Survey Date 1. Was this hospice surveyed for compliance with 42 CFR ? L50 Yes No 2. If this hospice provides inpatient care directly, is the inpatient care provided on the premises? L51 Yes No 3. Has a waiver of core nursing services been granted? L52 4. If Yes indicate date Yes No L53 5. Indicate type of setting(s) in which the hospice provides routine home care. L54 Private residence SNF NF Other (specify) 6. Number of hospice patients residing in a SNF, NF or other residential facility who receive routine home care from the hospice. L55 7. Number of hospice patients admitted during recent 12 month period. L56 8. Number of records reviewed during survey. L57 9. Number of home visits conducted to patients in a private residence. L Number of home visits conducted to patients in residential facilities. L Does this hospice operate under the same certification L If Yes enter L61 number at more than one location? number of locations. Yes No 13. Does this hospice operate as part of another entity that participates L If Yes enter the Medicare L63 certification number of the entity. in the Medicare program? Yes No Surveyor Signature Title Date According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is The time required to complete this information collection is estimated to average 2.5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland CMS-643 (06/08)

216 Deficiencies Hospice Survey and Deficiencies Report Page of Data Tag Number CoP/Stnd. No. Comments I certify that I have reviewed each hospice Condition of Participation and related standards and except as indicated on this form the facility was found to be in compliance with the standards and/or the Conditions of Participation. Surveyor Signature Title Date Surveyor Signature Title Date CMS-643 (06/08)

217 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO NAME OF FACILITY STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: STREET ADDRESS, CITY, STATE, ZIP CODE (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERRED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete EF 11/2004 If continuation sheet Page of

218 INSTRUCTIONS FOR COMPLETION OF THE STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (CMS-2567) I. PURPOSE V. II. This document contains a listing of deficiencies cited by the surveying State Agency (SA) or Regional Office (RO) as requiring correction. The Summary Statement of Deficiencies is based on the surveyors' professional knowledge and interpretation of Medicare and/or Medicaid or Clinical Laboratory Improvement Amendments requirements. FORM COMPLETION Name and Address of Facility Indicate the name and address of the facility identified on the official certification record. When surveying multiple sites under one identification number, identify the site where a deficiency exists in the text of the deficiency under the Summary Statement of Deficiencies column. Prefix Identification Tag Each cited deficiency and corrective action should be preceded by the prefix identification tag (as shown to the left of the regulation in the State Operations Manual or survey report form). For example, a deficiency in Patient Test Management ( ) would be preceded by the appropriate D-Tag in the 3000 series. A deficiency cited in the Life Safety Code provision 2-1 (construction) would be preceded by K8. Place this appropriate identification tag in the column labeled ID Prefix Tag. VI. VII. Waivers Waivers of other than Life Safety Code deficiencies in hospitals are by regulations specifically restricted to the RN waiver as provided in section 1861(e)(5) of the Social Security Act. The long term care regulations provide for waiver of the regulations for nursing, patient room size and number of beds per room. The regulations provide for variance of the number of beds per room for intermediate care facilities for the mentally retarded. Any other deficiency must be covered by an acceptable plan of correction. The waiver principle cannot be invoked in any other area than specified by regulation. Waiver Asterisk(*) The footnote pertaining to the marking by asterisk of recommended waivers presumes an understanding that the use of waivers is specifically restricted to the regulatory items. In any event, when the asterisk is used after a deficiency statement, the CMS Regional Office should indicate in the right hand column opposite the deficiency whether or not the recommended waiver has been accepted. Signature This form should be signed and dated by the provider or supplier representative or the laboratory director. The original, with the facility's proposed corrective action, must be returned to the appropriate surveying agency (SA or RO) within 10 days of receipt. Please maintain a copy for your records. III. Summary Statement of Deficiencies Each cited deficiency should be followed by full identifying information, e.g., (a). Each Life Safety Code deficiency should be followed by the referenced citation from the Life Safety Code and the provision number shown on the survey report form. IV. Plan of Correction In the column Plan of Correction, the statements should reflect the facility's plan for corrective action and the anticipated time of correction (an explicit date must be shown). If the action has been completed when the form is returned, the plan should indicate the date completed. The date indicated for completion of the corrective action must be appropriate to the level of the deficiency(ies). According to the Paperwork Reduction Act of 1995, no persons are required to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information is The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland

219 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No xxxx POST-CERTIFICATION REVISIT REPORT PROVIDER/SUPPLIER/CLIA/IDENTIFICATION NUMBER MULTIPLE CONSTRUCTION DATE OF REVISIT A. Building Y1 B. Wing Y2 Y3 NAME OF FACILITY STREET ADDRESS, CITY, STATE, ZIP CODE This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction, that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on the survey report form). ITEM DATE ITEM DATE ITEM DATE Y4 Y5 Y4 Y5 Y4 Y5 ID Prefix Correction ID Prefix Correction ID Prefix Correction Reg. # Completed Reg. # Completed Reg. # Completed LSC / / LSC / / LSC / / ID Prefix Correction ID Prefix Correction ID Prefix Correction Reg. # Completed Reg. # Completed Reg. # Completed LSC / / LSC / / LSC / / ID Prefix Correction ID Prefix Correction ID Prefix Correction Reg. # Completed Reg. # Completed Reg. # Completed LSC / / LSC / / LSC / / ID Prefix Correction ID Prefix Correction ID Prefix Correction Reg. # Completed Reg. # Completed Reg. # Completed LSC / / LSC / / LSC / / ID Prefix Correction ID Prefix Correction ID Prefix Correction Reg. # Completed Reg. # Completed Reg. # Completed LSC / / LSC / / LSC / / REVIEWED BY REVIEWED BY DATE SIGNATURE OF SURVEYOR DATE STATE AGENCY (INITIALS) REVIEWED BY REVIEWED BY DATE TITLE CMS RO (INITIALS) FOLLOWUP TO SURVEY COMPLETED ON CHECK ( ) FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACULTY? YES NO Form CMS-2567B (09/92) EF (11/06)

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221 Basic Hospice, November 2008 Student Manual Lesson 9: Role of Accrediting Organizations and Deemed Status Learning Objectives At the conclusion of this lesson, you will be able to: Define deemed status. Describe the statutory and regulatory basis of deemed status. Explain the major deeming functions and CMS oversight activities. Describe what impact deeming has on you as a State or Regional Office (RO) surveyor. 1

222 Basic Hospice Lesson 9: Role of Accrediting Organizations and Deemed Status 2

223 Basic Hospice Lesson 9: Role of Accrediting Organizations and Deemed Status Lesson 9 Role of Accrediting Organizations & Deemed Status Basic Hospice 9-1 Learning Objectives Define deemed status Describe the statutory & regulatory basis of deemed status Explain the major deeming functions & CMS oversight activities Describe what impact deeming has on you as a State or Regional Office (RO) surveyor Basic Hospice 9-2 Definition of Deeming Authority Authority granted by CMS to private, national accrediting organizations to determine, on CMS behalf, whether a provider evaluated by the accrediting organization is in compliance with corresponding CMS regulations Basic Hospice 9-3 3

224 Basic Hospice Lesson 9: Role of Accrediting Organizations and Deemed Status Voluntary Accreditation Accreditation is not required for Medicare approval Hospices may choose the deemed status option accreditation surveys by The Joint Commission (JC) and/or Community Health Accreditation Program (CHAP) Basic Hospice 9-4 Accreditation & Medicare Approval Hospices may be accredited & not Medicareapproved Hospices may lose deemed status (CoP out) Hospices chose accreditation but not the deemed status survey Example: accredited as part of a hospital Basic Hospice 9-5 Definition of Deemed Status Designation that a provider or supplier accredited by a CMS-approved national accrediting organization (AO) meets CMS Conditions of Participation in the Medicare program These providers or suppliers are referred to as deemed status providers or suppliers Basic Hospice 9-6 4

225 Basic Hospice Lesson 9: Role of Accrediting Organizations and Deemed Status Approved National AOs For hospice: Community Health Accreditation Program (CHAP) The Joint Commission (JC) Basic Hospice 9-7 Validation Surveys Surveys conducted by State to validate AO s accreditation process Random selection of hospices Unannounced survey may be conducted between 60 days to 6 months following the AO survey Basic Hospice 9-8 Validation Surveys (cont.) Surveys are: Conducted in accordance with survey protocol for Hospices Comprehensive & address all Medicare conditions Basic Hospice 9-9 5

226 Basic Hospice Lesson 9: Role of Accrediting Organizations and Deemed Status Hospice Validation Process Process requires collaboration between Central Office (CO), Regional Office (RO), State Agency (SA) & the AOs CMS CO requires timely submission of survey data: Form CMS-2567 Online Survey Certification & Reporting System (OSCAR) Electronic data exchange Basic Hospice 9-10 Electronic Data Exchange Submission of quarterly data by the AOs to CMS: Determines top 10 deficiencies cited Used as validation by CMS & AO to assess current trends & develop areas of focus for hospice surveys Basic Hospice 9-11 Hospices with Deemed Status Are exempt from routine surveys by the SA With RO approval: May receive a validation survey by the SA May receive a complaint survey by the SA Will lose deemed status with a CoP out or loss of accreditation Have approval letter from AO indicating deemed status Basic Hospice

227 Basic Hospice Lesson 9: Role of Accrediting Organizations and Deemed Status Summary Providers may be deemed able to participate in the Medicare program by approved national AOs It is important that CMS have oversight of accreditation & deeming activities to make certain that AOs standards are at least as high as CMS Your role in conducting the validation surveys is vital in the validation process Basic Hospice 9-13 Lesson 9 Questions? Basic Hospice

228 Basic Hospice Lesson 9: Role of Accrediting Organizations and Deemed Status 8

229 Basic Hospice Lesson 9: Role of Accrediting Organizations and Deemed Status Accrediting Organizations and Deemed Status Highlights CMS-approved national accreditation organizations for hospice: Community Health Accreditation Program (CHAP) The Joint Commission (TJC) Definition of deemed status: Hospice agencies may seek accreditation from a CMS-approved national accreditation organization (AO). In addition to accreditation, a hospice agency may seek to receive deemed status from AOs. Deemed status means that the hospice agency is considered to meet the hospice Medicare Conditions of Participation. Authority for deeming found in Social Security Act, Section 1865(b). Hospice agencies with deemed status: Are exempt from routine surveys by the State survey agency (SA). May receive a validation or complaint survey by the SA. Deemed status is lost with a Condition of Participation out or loss of accreditation. Surveys by an AO: Can conduct an initial Medicare certification survey of a hospice agency. AO standards provide reasonable assurance that the Medicare Conditions are met. Process ensures home visits and record reviews look at patient outcomes. Must meet survey cycle requirements. Accreditation notification from AOs should reflect deemed status. AO supplies the Regional Offices with a list of deemed agencies. Validation surveys: Surveys conducted by the SA to validate the AO s accreditation process. Hospice agencies are selected randomly for a validation survey. Unannounced survey conducted 60 days to 6 months following AO survey. RO notifies SA using Form CMS-2802B. 9

230 Basic Hospice Lesson 9: Role of Accrediting Organizations and Deemed Status Surveys are: o Conducted in accordance with the hospice survey protocol o Comprehensive and address all Medicare Conditions CMS oversight of accreditation and deeming activities: Processes applications for deeming authority and renewals. Based on their previous approval, an approved AO must apply for continued approval of deemed authority. Hospice agency validation program. Electronic data exchange between CMS and AO (data submitted quarterly). Used to assess current trends and develop areas of focus for surveys. 10

231 Basic Hospice Lesson 9: Role of Accrediting Organizations and Deemed Status Hospice Accreditation Versus Deemed Status National Accreditation Organizations (AOs) approved by CMS to grant hospice deemed status: The Joint Commission (JC) Community Health Accreditation Program (CHAP) Medicare Survey Responsibilities Accreditation Only Accreditation and Deemed Status State Agency AO State Agency with CMS Regional Office Prior Authorization AO Initial Certification Accreditation Complaint Initial Certification Recertification Validation Recertification Complaint Complaint 11

232 Basic Hospice Lesson 9: Role of Accrediting Organizations and Deemed Status 12

233 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES REQUEST FOR VALIDATION OF ACCREDITATION SURVEY FOR HOSPICE 1. NAME AND ADDRESS OF STATE AGENCY 2. NAME AND ADDRESS OF hospice certification number 3. hospice accredited by o Joint Commission o CHAP o OTHER 4. please request completion of x CMS o x PLEASE DO NOT NOTIFY THE HOSPICE IN ADVANCE OF YOUR SURVEY. 6. o THIS VALIDATION IS BASED ON A SAMPLE SELECTION. THE DATE OF LAST ACCREDITATION SURVEY WAS. PLEASE CONDUCT A FULL VALIDATION SURVEY BETWEEN 60 DAYS AND 6 MONTHS FROM THE DATE OF THE AO SURVEY. o THIS VALIDATION IS BASED ON ALLEGATIONS OF SIGNIFICANT DEFICIENCIES WHICH COULD AFFECT THE HEALTH AND SAFETY OF PATIENTS IN THIS HOSPICE. PLEASE CONDUCT A SURVEY WITHIN 45 DAYS AFTER THIS REQUEST, FOR THE PURPOSE OF ASCERTAINING WHETHER THE HOSPICE MEETS THE CONDITIONS CHECKED. Survey all applicable conditions and standards, including life safety code. 7. Areas to be surveyed (Check all applicable Conditions; enter all applicable Standards) Condition(s) Standards Patient s Rights (418.52) Initial/Comprehensive Assessment of Patient (418.54) Interdisciplinary Group, Care Planning, & Coordination (418.56) Quality Assessment Performance Improvement (418.58) Infection Control (418.60) Licensed Professional Services (418.62) Core Services (418.64) Nursing Services-Waiver (418.66) Furnishing of Non-Core Services (418.70) Therapy Services (418.72) Therapy & Dietary Waiver (418.74) Hospice Aide & Homemaker Services (418.76) Volunteers (418.78) Organization & Administration of Services ( ) Medical Director ( ) Clinical Records ( ) Drugs, Biologicals, Medical Supplies & DME ( ) Short-term Inpatient Care ( ) Provide Inpatient Care Directly ( ) Provide Care SNF/NF or ICF/MR ( ) Personnel Qualifications ( ) Compliance with Laws & Regulations ( ) A COPY OF THE ALLEGATION IS ENCLOSED. A COPY OF THE ALLEGATION WAS PREVIOUSLY FORWARDED TO THE ACCREDITING AGENCY. THE NAME OF THE COMPLAINANT SHOULD NOT BE DISCLOSED UNLESS THERE IS SPECIFIC AUTHORIZATION. 8. SIGNATURE OF REGIONAL REPRESENTATIVE 9. REGION 10. DATE Form CMS-2802B (09/08) ORIGINAL TO: STATE SURVEY AGENCY COPIES TO: CMS Accreditation Staff Accreditation Organization

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235 Basic Hospice, November 2008 Student Manual Lesson 10: Immediate Jeopardy Learning Objectives At the conclusion of this lesson, you will be able to: Define Immediate Jeopardy (IJ). Describe survey procedures when IJ is suspected. List the 3 components required for a decision of IJ. Identify IJ triggers. 1

236 Basic Hospice Lesson 10: Immediate Jeopardy 2

237 Basic Hospice Lesson 10: Immediate Jeopardy Lesson 10 Immediate Jeopardy Basic Hospice 10-1 Learning Objectives Define Immediate Jeopardy (IJ) Describe survey procedures when IJ is suspected List the 3 components required for a decision of IJ Identify IJ triggers Basic Hospice 10-2 Definition CFR Immediate Jeopardy A situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Basic Hospice

238 Basic Hospice Lesson 10: Immediate Jeopardy Intent Ensure that crisis situations putting the health and safety of individuals at risk are accurately identified, thoroughly investigated & resolved as quickly as possible Applies to all providers & suppliers Basic Hospice 10-4 Principles in Appendix Q Harm does not have to occur before considering Immediate Jeopardy Only one individual needs to be at risk Basic Hospice 10-5 Principles (cont.) Serious harm can result from abuse or neglect Serious psychological harm is considered as significant as serious physical harm Basic Hospice

239 Basic Hospice Lesson 10: Immediate Jeopardy Principles (cont.) Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish Neglect: Failure to provide goods and services necessary to avoid harm, mental anguish or mental illness Basic Hospice 10-7 Principles: The Provider Knows or should have known about the situation Created the situation or allowed the situation to continue Had an opportunity to implement corrective measures Basic Hospice 10-8 Identifying Jeopardy Conditions Study Appendix Q Review triggers Know the 3 required components of Immediate Jeopardy Learn procedures Basic Hospice

240 Basic Hospice Lesson 10: Immediate Jeopardy Appendix Q Issues & triggers for suspecting Immediate Jeopardy Basic Hospice Possible Hospice Issues & Triggers Issue: Failure to protect from abuse Possible triggers: Unexplained serious injuries that have not been investigated Bruises around the breast or genital areas; black eyes, cigarette burns, rope marks etc. Basic Hospice Possible Hospice Issues & Triggers (cont.) Issue: Failure to protect from undue adverse medication consequences Trigger: Lack of monitoring and identification of potential serious drug interaction, side effects, & adverse reactions Basic Hospice

241 Basic Hospice Lesson 10: Immediate Jeopardy Suspicion of Immediate Jeopardy Notify the team leader immediately Stop the survey Immediate Jeopardy becomes the first priority of the team Must determine whether or not an IJ exists before proceeding with survey Basic Hospice Investigate the Situation Who is involved? What harm has occurred, is occurring, or is likely to occur in the very near future? When did the situation first occur? Where did the situation first occur? Why did the potential/actual harm occur? Basic Hospice Investigation Process Must proceed until one of two results is found: Immediate Jeopardy is confirmed Immediate Jeopardy is ruled out Basic Hospice

242 Basic Hospice Lesson 10: Immediate Jeopardy Components of Immediate Jeopardy Three factors must be present: 1. Harm Actual Potential 2. Immediacy 3. Culpability Basic Hospice Lesson 10 Case Study Activity 10-1 Basic Hospice Case Study What did the hospice fail to do? Basic Hospice

243 Basic Hospice Lesson 10: Immediate Jeopardy Harm: Actual Was there an outcome of harm? Does the harm meet the definition of Immediate Jeopardy? Has the provider s noncompliance caused serious injury, harm, impairment or death to an individual? Basic Hospice Harm: Potential Is there likelihood of potential harm? Does the potential harm meet the definition of Immediate Jeopardy? Is the provider s noncompliance likely to cause serious injury, harm, impairment or death to an individual? Basic Hospice Immediacy Is the harm or potential harm likely to occur in the very near future to this individual or others in the Provider (Hospice), if immediate action is not taken? Basic Hospice

244 Basic Hospice Lesson 10: Immediate Jeopardy Culpability Did the provider know about the situation? Should the provider have known? Did the provider thoroughly investigate? Did the provider implement corrective measures? Has the provider re-evaluated to ensure correction? Basic Hospice Team Makes Decision Decides if there is enough information to make a decision Clarifies any inconsistencies or contradictions Gathers additional information as needed Basic Hospice Team Consensus Identify most appropriate Federal regulation Contact State Agency (SA) per SA protocol Determine whether other agencies need to be notified (e.g., law enforcement) Basic Hospice

245 Basic Hospice Lesson 10: Immediate Jeopardy Implementation Team gives verbal notice to administration Include specific details Encourage immediate corrective actions Team must provide written notice of Immediate Jeopardy no later than 2 working days after date of survey Basic Hospice Citations: All Entities Only onsite confirmation of corrective action justifies a determination that the Immediate Jeopardy has been removed Basic Hospice Citations: Non-LTC Cite the Immediate Jeopardy at the Condition-level on the CMS-2567 Basic Hospice

246 Basic Hospice Lesson 10: Immediate Jeopardy Termination If Immediate Jeopardy not abated on site: Cite the Immediate Jeopardy at the Condition-level on 2567 Proceed with 23-day termination procedures Basic Hospice Documentation on 2567 Immediate Jeopardy is removed but deficient practice is present at Condition-level: Cite the Condition-level deficiencies Proceed with 90-day termination procedures Basic Hospice Lesson 10 Questions? Basic Hospice

247 Basic Hospice Lesson 10: Immediate Jeopardy Activity 10-1 Immediate Jeopardy Case Study Patient 11 was admitted to hospice care on 2/27/ with a terminal diagnosis of end stage CVA (stroke) and had swallowing problems that required a pureed diet and nectar-thick liquids. S/he weighed 105 pounds at the time of hospice admission. Prior to initiation of opioid therapy on 5/8/ Patient 11 s strongest pain medications were Tylenol and ibuprofen. The attending physician ordered Lortab (Vicodin-like oral narcotic) 5 mg. every four hours for wrist/hand pain on 5/8/. The patient received four doses of Lortab in a 24-hour lapse of time. The attending physician ordered a fentanyl transdermal patch 25 mcg. (morphine-like narcotic, placed on adhesive patch to deliver a constant dose of medication through the skin and into the bloodstream) at 3:30 PM on 5/9/. The patch was applied to Patient 11 s skin at 7:30 PM on 5/9/. Review of hospice documentation revealed that a caregiver at the Assisted Living Facility where Patient 11 resided contacted the hospice on 5/11/ at 6:24 PM to report that the patient was having difficulty swallowing. The triage nurse instructed the caregiver not to give any food or fluid to the patient. There was no documentation to indicate that she had notified the attending physician of the patient s change in condition. The patient s daughter called the hospice at 7:30 PM on 5/11 to report that the patient was having increasing difficulty with swallowing and had choked and panicked when s/he couldn t swallow a thickened liquid. A home visit was made by LPN 2 at 8:15 PM. According to the home visit documentation, the patient s daughter had questioned the use of the fentanyl patch, saying that she thought it was too strong for her mother. The LPN documented, RN to reassess tomorrow morning. There was no documentation to indicate that LPN 2 had notified the attending physician of the patient s change in condition. Continued review of hospice documentation revealed three additional calls from the Assisted Living Facility on 5/12/. The first call note, at 5:40 PM stated, problems with aspiration had water and pudding gurgling, yelling. The triage nurse notified the on-call administrator and LPN 2 but not the physician. The second call note, at 6:05 PM stated, Gurgling, eyes rolling back in head. Will try to position on side is sitting up. Placed oxygen. The third call note, 13

248 Basic Hospice Lesson 10: Immediate Jeopardy at 6:35 PM read, Is nurse coming? The documentation indicated that a home visit was made jointly by LPN 2 and the RN Admission Nurse 1 at 6:45 PM. LPN 2 had visited the patient the previous evening and was aware of the concerns regarding the fentanyl patch. There was no indication that the physician was contacted about the patient s change in condition. Review of the Patient 11 s clinical record at the Assisted Living Facility revealed that the patient was treated for a fever over 101 degrees Fahrenheit the morning of 5/14/. Physician clinical note dated 5/15/ stated, 2 episodes of possible choking + aspiration over past 4 days. Patient 11 continued to receive Tylenol for fever until her death at 8:30 AM on 5/18/. The hospice pharmacy supervisor was interviewed on 6/10 at 3:05 PM. He stated that the fentanyl patch order was taken by phone on 5/9/ and that the dispensing pharmacist had warned Case Manager 1 that the four doses of Lortab were equal to only 30 mg. of morphine. Pharmacy documentation indicated that Case Manager 1 was warned twice that the fentanyl patch narcotic dose was a 100% increase in the analgesic effect of the narcotic currently given to the patient; this was equivalent to administering 100 pain pills instead of one. Pharmacy documentation further showed that Case Manager 1 had insisted that the medication be dispensed because the patient was too thin to absorb it anyway, and the doctor is aware of the equivalents. The hospice pharmacist did not call the physician to warn him that administering the fentanyl patch was in direct conflict with an FDA black box warning and dispensed the medication. When interviewed on 6/11/ at 10:50 AM, Case Manager 1 stated, That s the smallest dose they make. It takes 24 to 48 hours for good control. I wouldn t have used the patch. But the doctor visited the patient and wrote the order. What can you do? ******************************************************** As a table, answer the following questions: 1. What did the hospice fail to do? 14

249 Basic Hospice Lesson 10: Immediate Jeopardy 2. Does the case study meet the three components of Immediate Jeopardy? Harm Immediacy Culpability 3. What regulation(s) did the agency fail to comply with? 15

250 Basic Hospice Lesson 10: Immediate Jeopardy 16

251 Basic Hospice Lesson 10: Immediate Jeopardy 17

252 Basic Hospice Lesson 10: Immediate Jeopardy 18

253 Basic Hospice, November 2008 Student Manual Lesson 11: Hospices that Provide Inpatient Services Directly 42 CFR and 42 CFR Learning Objectives At the conclusion of this lesson, you will be able to: Explain Conditions of Participation (CoPs) for hospices that provide inpatient care directly. Discuss at least five requirements for patient care areas and patient rooms. Describe requirements for restraint or seclusion. State who can administer medications. 1

254 Basic Hospice Lesson 11: Hospices that Provide Inpatient Services Directly 42 CFR and 42 CFR

255 Basic Hospice Lesson 11: Hospices that Provide Inpatient Services Directly 42 CFR and 42 CFR Lesson 11 Hospices That Provide Inpatient Care Directly 42 CFR and 42 CFR Basic Hospice 11-1 Learning Objectives Explain Conditions of Participation (CoPs) for hospices that provide inpatient care directly Discuss at least 5 requirements for patient care areas and patient rooms Describe requirements for restraint or seclusion State who can administer medications Basic Hospice Condition of Participation Condition Hospices that provide inpatient care directly A hospice that provides inpatient care directly must comply with all of the following standards: L721 through L758 Basic Hospice

256 Basic Hospice Lesson 11: Hospices that Provide Inpatient Services Directly 42 CFR and 42 CFR (a) Standard: Staffing The hospice is responsible for ensuring that staffing for all services reflects its volume of patients, their acuity and the level of intensity of services needed to ensure that plan of care outcomes are achieved and negative outcomes are avoided Basic Hospice (b) Standard Twenty-four hour nursing services Hospice must provide 24-hour nursing services that meet all patient s nursing needs and furnished in accordance with each patient s plan of care If one patient is receiving general inpatient care, each shift must include a registered nurse (RN) who provides direct patient care Basic Hospice (c) Standard: Physical environment Maintain a safe physical environment free of hazards for patients, staff & visitors Basic Hospice

257 Basic Hospice Lesson 11: Hospices that Provide Inpatient Services Directly 42 CFR and 42 CFR (c) Standard: Physical environment (cont.) Safety management: Address real or potential threats to the health and safety of patients, others and property Written disaster preparedness plan in effect for managing power failures, natural disasters and other emergencies Periodically reviewed and rehearsed Basic Hospice (c) Standard: Physical environment (cont.) Physical plant and equipment Develop procedures for controlling reliability and quality of: Routine storage and disposal of trash and medical waste Light, temperature and ventilation/air exchange Emergency gas and water supply Scheduled and emergency maintenance and repair of all equipment Basic Hospice (d) Standard: Fire protection Life Safety Code surveyor: Must meet fire safety code for 2000 Waiver provision if: Compliance causes unreasonable hardship Waiver would not adversely affect the health and safety of the patients Basic Hospice

258 Basic Hospice Lesson 11: Hospices that Provide Inpatient Services Directly 42 CFR and 42 CFR (e) Standard: Patient areas The hospice must provide a home-like atmosphere Ensure dignity, comfort and privacy of patients for family visits Basic Hospice (e) Standard: Patient areas (cont.) Physical space for private patient & family visiting Accommodations for family members to remain with the patient throughout the night Basic Hospice (e) Standard: Patient areas (cont.) Patient must be permitted to receive visitors at any hour, including infants and small children Basic Hospice

259 Basic Hospice Lesson 11: Hospices that Provide Inpatient Services Directly 42 CFR and 42 CFR (e) Standard: Patient areas (cont.) Accommodations for family privacy after a patient s death Basic Hospice (f) Standard: Patient rooms Designed and equipped for nursing care; and Dignity, comfort and privacy of patients Basic Hospice (f) Standard: Patient rooms (cont.) Accommodate request for single room (if possible) Basic Hospice

260 Basic Hospice Lesson 11: Hospices that Provide Inpatient Services Directly 42 CFR and 42 CFR (f) Standard: Patient rooms (cont.) Each room must: Have adequate size Be at or above grade level Contain bed/furniture Have closet space Accommodate no more than 2 patients & family members Have device for calling for assistance Basic Hospice (g) Standard: Toilet and bathing Each patient room must be equipped with, or conveniently located near toilet and bathing facilities Basic Hospice (h) Standard: Plumbing facilities Adequate supply of hot water at all times Plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients Basic Hospice

261 Basic Hospice Lesson 11: Hospices that Provide Inpatient Services Directly 42 CFR and 42 CFR (i) Standard: Infection control The hospice must maintain an infection control program that protects patients, staff and others by preventing and controlling infections and communicable diseases Basic Hospice (j) Standard: Sanitary environment Provide a sanitary environment by following current standards of practice, including recognized infection control precautions, and avoid sources and transmissions of infections and communicable diseases Basic Hospice (k) Standard: Linen A sufficient quantity of clean linen available at all times Linens are handled, stored, processed and transported in a manner that prevents the spread of contaminants Basic Hospice

262 Basic Hospice Lesson 11: Hospices that Provide Inpatient Services Directly 42 CFR and 42 CFR (l) Standard: Meal services and menu planning Patient meals: Consistent with plan of care Meet nutritional needs & therapeutic diet Palatable, attractive, at proper temperature Sanitary conditions Basic Hospice (m) Standard: Restraint or seclusion Patient has the right to be free from: Abuse and corporal punishment Restraint or seclusion imposed as coercion, discipline, convenience or retaliation Basic Hospice (m) Standard: Restraint or seclusion (cont.) Least restrictive intervention; used to ensure immediate safety Discontinued at earliest possible time According to plan of care Follows safe and appropriate techniques Physician orders required Not a standing order/prn Consult medical director Basic Hospice

263 Basic Hospice Lesson 11: Hospices that Provide Inpatient Services Directly 42 CFR and 42 CFR (m) Standard: Restraint or seclusion (cont.) Management of violent/self-destructive behavior Orders only renewed as follows for up to a total of 24 hours: 4 hours for individuals 18 and older 2 hours for individuals 9 to 17 1 hour for individuals under 9 Prior to writing a new order, physician must see/assess patient after 24 hours Face-to-face 1 hour after initiation Basic Hospice (m) Standard: Restraint or seclusion (cont.) Patient monitored by physician or trained staff Documentation in clinical record Basic Hospice (n) Standard: Restraint or seclusion staff training All patient care staff trained and demonstrate competency Specific content required Qualified trainers Documentation of training Basic Hospice

264 Basic Hospice Lesson 11: Hospices that Provide Inpatient Services Directly 42 CFR and 42 CFR (o) Standard: Death reporting requirements Deaths associated with restraint or seclusion must be reported to CMS Regional Office Unexpected death while in restraint/seclusion Unexpected death within 24 hours after restraint/seclusion removed Death that occurs within 1 week after restraint/ seclusion Basic Hospice Condition: Drugs and biologicals, medical supplies, DME Employment of licensed pharmacist or formal agreement with a licensed pharmacist Orders from physician or nurse practitioner (if State law permits) Orders for medications (given to qualified individual, dated, signed) Basic Hospice Administering Medications Medications are administered only by one of the following individuals: A licensed nurse or physician An employee who has completed a Stateapproved training program in medication administration The patient, upon approval of IDG Basic Hospice

265 Basic Hospice Lesson 11: Hospices that Provide Inpatient Services Directly 42 CFR and 42 CFR Labeling, disposing and storage Labeled in accordance with standards of practice Procedures for controlled drug use/disposal Accountability for all drugs/drug records Drugs stored in secure areas Locked compartments Locked storage Basic Hospice Lesson 11 Questions? Basic Hospice

266 Basic Hospice Lesson 11: Hospices that Provide Inpatient Services Directly 42 CFR and 42 CFR

267 Basic Hospice Lesson 11: Hospices that Provide Inpatient Services Directly 42 CFR and 42 CFR Notes Page 15

268 Basic Hospice Lesson 11: Hospices that Provide Inpatient Services Directly 42 CFR and 42 CFR