Regulations & Standards for Hospice Managers A Level I Module of the Hospice MDP Objectives Identify the difference between regulations, standards and guidelines Describe and discuss the regulations for Medicare certified hospices Determine the hospice manager s role in compliance and accountability Describe and discuss NHPCO s Standards of Practice for Hospice s Organization, 2 Collateral Materials Clean copy of federal hospice regulations (inclusive of all subparts) Components of the Medicare Hospice Certification and Recertification Form Organization, 3 Palliative Care Organization 1
Regulatory Compliance/ Quality Crossover Compliance with regulations Excellent patient care Promotion of excellence in hospice care through use of standards Organization, 4 Compliance Meets Quality Hospice Quality Reporting (HQRP) Quality Assessment performance improvement (QAPI) Organization, 5 Compliance with Regulations Organization, 6 Palliative Care Organization 2
Regulations, Standards and Guidelines Regulations: Requirements published which provide details for compliance with the law Standards: Voluntary program requirements to ensure quality services and clarify regulations Guidelines: Translate regulations and standards into practice Organization, 7 Regulations and Standards as Management Tools Answer questions about how something should be done Address questions about why something must be done in a particular way Provides a foundation for orientation of new employees and volunteers Guides the development and implementation of quality assessment and performance improvement programs Organization, 8 Regulations and Standards as Management Tools (Con t) Provides assistance for leadership development of organizational structure and operations Provides a solid foundation for strategic development and future direction Organization, 9 Palliative Care Organization 3
Why are Regulations So Important? Set a standard for care Ensure consistency in broad care concepts Ensure quality care Patients/families Colleagues in health care, internal/external payers Required to receive Medicare revenue to fund operations Organization, 10 Regulations and Compliance Compliance starts at the leadership level Compliance with regulatory requirements shapes: Policies Procedures Job descriptions Performance evaluations Code of conduct Everyday interaction and behavior of staff within the hospice program Organization, 11 Compliance is. Every staff member s responsibility Part of a quality hospice provider s culture Organization, 12 Palliative Care Organization 4
Culture of Compliance Educating all levels of your staff about the federal and state hospice regulations, including the federal Conditions of Participation (CoPs), should be a part of your compliance plan, orientation for new staff, and continuing education for all staff A compliant organization is one that follows the rules, provides quality patient care and builds a reputation in the community as a hospice with integrity Organization, 13 Culture of Compliance Characteristics Strong leadership commitment to compliance Compliance program in place Education about compliance related topics upon hire and ongoing Regulations (hospice and other federal) Violation of practice Accountability Consequences Organization, 14 Compliance Resources for the Hospice Manager 15 Palliative Care Organization 5
Who s Watching Hospice? Survey entities Federal Audit entities Medicare Medicaid State (SSA) Accreditation org Medicare (PI, MAC, RA, UPIC) Medicaid (MIC) OIG, DOJ Organization, 16 What Are They Looking For? Documentation that evidences regulatory compliance Examples: Eligibility of patient (admission, ongoing) Valid certification of terminal illness Documentation that validates eligibility for patient s service period Documentation that validates the need for higher levels of care Organization, 17 Why? Federal government committed to reducing fraud, waste and abuse across the government Combined forces - Health Care Fraud Prevention and Enforcement Action Team (HEAT) U.S. Department of Health & Human Services, Office of Inspector General (HHS OIG), the Centers for Medicare & Medicaid Services (CMS), and the U.S. Department of Justice (DOJ) Strategy - Shift from a pay and chase approach toward fraud prevention Organization, 18 Palliative Care Organization 6
The Pay Day Department of Justice and Health and Human Services Return $2.6 Billion in Taxpayer Savings From Efforts to Fight Healthcare Fraud. Medicare Fraud Strike Force charged more than 3,500 people with Medicare fraud for more than $12.5 billion as of early 2017 and recovered $2.52 billion of that money. Organization, 19 Hospice Regulations Where are the federal regulations? Title 42 Public Health Chapter IV- Centers for Medicare and Medicaid Services Department of Health and Human Services Part 418 Hospice Care http://www.gpo.gov/fdsys/pkg/cfr-2011-title 42-vol3/pdf/CFR-2011- title 42-vol3-part 418.pdf Organization, 20 Hospice Regulations-Subparts Subpart A Statutory basis Definitions Subpart B Subparts C & D (CoPs) Subpart B - Eligibility, Election and Duration of Benefits (Compliance assessed via MAC, federal, or state based audit) Patient Care Organizational Environment (Compliance assessed during an initial and recertification survey by state or accreditation organization) Organization, 21 Palliative Care Organization 7
Hospice Leadership Must know the federal hospice CoPs State and federal surveys for quality of patient care and hospice operation Must know the federal coverage regulations State and federal audits for proper payment, fraud, abuse, and waste Organization, 22 CMS Guidance Medicare Benefit Policy Manual; Chapter 9 - Coverage of Hospice Services Under Hospital Insurance https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c0 9.pdf Organization, 23 Chapter 9 Content Organization, 24 Palliative Care Organization 8
CMS Guidance Medicare Claims Processing Manual; Chapter 11 - Processing Hospice Claims https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Downloads/clm104c 11.pdf Organization, 25 Chapter 11 Content 26 CMS Hospice Center CMS Manuals & Transmittals Survey & Certification Policy & Memos to States and Regions Subscribe now to receive the weekly MLN Connects Provider enews for the latest Fee- For-Service program information, event announcements, claims and pricer information, and MLN educational product updates https://www.cms.gov/center/provider-type/hospice- Center.html Organization, 27 Palliative Care Organization 9
State Operations Manual 28 Pay Attention to. Chapter 2 - The Certification Process Appendix M - Guidance to Surveyors: Hospice Appendix Z - Emergency Preparedness for All Provider and Certified Supplier Types Interpretive Guidance (Nov. 15, 2017) Organization, 29 Compliance Readiness Organization, 30 Palliative Care Organization 10
Hospice Responsibility The hospice is responsible to provide and cover everything related to the terminal prognosis Terminal prognosis = primary diagnosis and all other diagnoses that contribute to the terminal prognosis Organization, 31 Subpart B Issues Eligibility Election of hospice Certification of terminal illness Discharge Revocation Change of hospice provider (transfer) Organization, 32 CoP Surveys Organization, 33 Palliative Care Organization 11
CY 2018 Top 10 CoP Survey Deficiencies (Standard) # CoP number L Tag Tag Description 1 418.56(b) L543 Standard: Plan of care 2 418.54(c)(6) L530 Standard: Content of the comprehensive assessment; Drug profile 3 418.76 (h) L629 Standard: Supervision of hospice aides 4 418.56(c) L545 Standard: Content of the plan of care 5 418.56 (c)(2) L547 Standard: Content plan of care 6 418.60(a) L579 Standard: Prevention (Infection Control) 7 418.78(e) L647 Standard: Level of activity (Volunteers) 8 418.54(c)(7) L531 Standard: Bereavement (Plan of Care) 9 418.54(b) L523 Standard: Timeframe for completion of the comprehensive assessment 10 418.56(e)(2) L555 Standard: Coordination of services 34 Organization, Federal & State Surveys Survey types: Certification and re-certification (Medicare) Licensure and re-licensure (State) Complaint (Both) States have been instructed by CMS that initial hospice certification surveys are a Tier 4 priority. Accreditation organizations can complete initial deem surveys as an alternative Organization, 35 State Licensure Required before care can be provided State regulations may not be the same as the federal regulations Know the rules for your state! Organization, 36 Palliative Care Organization 12
Preparing for a Survey Surveys are unannounced Be survey ready at all times! Develop a culture of compliance in your organization How to prepare: Annual program review with policy and procedure updates Staff and volunteer education on policies and procedures Conduct a mock survey Organization, 37 How Do You Ensure Compliance? Leadership Supervision Direct i.e. joint visits Indirect i.e. documentation review Education Mentoring Accountability Organization, 38 Bad Outcomes Who s Responsible? Everyone shares responsibility in success and areas for improvement Compliance and quality outcomes are dependent on the performance of each of the team as a whole Organization, 39 Palliative Care Organization 13
Standards Organization, 40 Standards Voluntary program requirements to ensure quality services and clarify regulations Organization, 41 Standards: Overview There is significant variability in the services and quality of services among hospice providers - sometimes the care is exceptional, sometimes not. Standards of Practice help define appropriate practice, hold hospice providers accountable for appropriate practice and/or help to improve service delivery models Organization, 42 Palliative Care Organization 14
Standards: Important Factors Establish a gold standard & keep raising the bar for end-of-life care Provide opportunities for self-assessment and ongoing performance improvement Offer quality assurance to constituents Patients/families Colleagues in health care, internal/external stakeholders Based on expert-opinion and are field tested Describe state of the art hospice care Organization, 43 Standards of Practice for Hospice s Organized around the core components of quality in hospice care. Specific standards and practice examples are included for each component, and appendices provide additional standards for hospice inpatient facility, nursing facility hospice care, and hospice residential care facility. Organization, 44 Standards of Practice for Hospice s Appendix to the NHPCO Standards is a guide for palliative and/or hospice programs providing care to patients in the perinatal period, infancy, childhood, adolescence and young adulthood in all care settings. Organization, 45 Palliative Care Organization 15
Compliance with Laws and Regulations (CLR) Principle: Ensuring compliance with applicable laws, regulations and professional standards of practice implementing systems and processes that prevent fraud and abuse. Organization, 46 CLR Standards CLR 1: The organization maintains full compliance with legal and regulatory requirements and standards of practice. CLR 2: The hospice has a program to identify, prevent and correct practices that are fraudulent or abusive. CLR 3: The hospice maintains a comprehensive, timely, and accurate clinical record of services provided in all care settings for each patient and family. Organization, 47 CLR 1 - Practice Examples Results of surveys are documented in governing body meeting minutes. Ongoing mock surveys or self-assessments are conducted to identify areas for improvement and changes are made based on the findings. The hospice has a procedure for reporting and investigating compliance concerns. Organization, 48 Palliative Care Organization 16
Accreditation Organizations (AOs) AO s develop their own standards for care Typically more stringent than federal/state organizations The Joint Commission (JC) Community Health Accreditation (CHAP) Accreditation Commission for Health Care, (ACHC) Organization, 49 Compliance Meets Quality Compliance Quality Organization, 50 Hospice Quality Reporting HIS CAHPS HQRP Must Report Hospice Item Set (HIS) Must participate in Hospice Consumer Assessment of Healthcare Providers and Systems (CAHPS) Organization, 51 Palliative Care Organization 17
Failure to Report Measures 2% reduction on future fiscal year payment rates Organization, 52 Composite Measure The Hospice Comprehensive Assessment Measure assesses the percentage of hospice stays in which patients who received a comprehensive patient assessment at hospice admission. It assesses whether hospices perform all of the seven critical care processes on admission (i.e., pain screening and assessment, dyspnea screening and treatment, ensuring Organization, 53 HIS Measures Organization, 54 Palliative Care Organization 18
Hospice Visits when Death is Imminent This measure is a measure pair assessing hospice staff visits to patients at the end of life. Measure 1: Percentage of patients receiving at least one visit from registered nurses, physicians, nurse practitioners, or physician assistants in the last 3 days of life. Measure 2: Number of patients from the denominator receiving at least two visits from medical social workers, chaplains or spiritual counselors, licensed practical nurses or hospice aides in the last 7 days of life. Organization, 55 Hospice CAHPS Measures Composite Measures Hospice Team Communication (6 items) Getting Timely Care (2 items) Treating Family Member with Respect (2 items) Getting Emotional and Religious Support (3 items) Getting Help for Symptoms (4 items) Getting Hospice Care Training (5 items) Organization, 56 Hospice CAHPS Measures Global Measures Hospice rating Willingness to recommend Organization, 57 Palliative Care Organization 19
Hospice Compare Organization, 58 Hospice Compare Hospice Organization, 59 Hospice Compare Organization, 60 Palliative Care Organization 20
Hospice Standardized Assessment Tool Is coming to hospice The tool is in development Organization, 61 Tying It All Together 62 Forewarned is Forearmed Know your risk before it is a audit problem Be proactive in all processes Admission Certification Ongoing service provision Live Discharge Documentation Levels of care Claims data Organization, NHPCO, August 2017 63 Palliative Care Organization 21
Improving Compliance & Quality Educate to improve Staff knowledge Patient care provision Staff documentation Monitor and self assess all parts of hospice operations to identify areas for compliance and performance improvement Communicate & coordinate continuously and capture in the clinical record Staff to patient Staff to attending physician Staff to entities outside of hospice organization Use available resources Organization, 64 NHPCO is Part of Your Team Ask a Regulatory or Compliance Question regulatory@nhpco.org www.nhpco.org/regulatory Ask a Quality Question quality@nhpco.org www.nhpco.org/quality Organization, 65 Key Points 1. 2. 3. Organization, 66 Palliative Care Organization 22