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