Heather Wilson provided a discussion of H.R. 4994, the Improving Medicare Post Acute Care Transformation (IMPACT) Act of 2014 in her recent blog post Will the IMPACT Act Really Help the Hospice Industry? Although I agree with her contention that increased surveys and oversight are not a silver bullet or a panacea for the many challenges facing hospices, nevertheless, hospices need to prepare for the increased scrutiny.
This is the first of two blog posts I am writing on what hospices need to do now to prepare for more frequent surveys and the medical review audits of long length of stay patients. This first post focuses on preparation for more frequent surveys of a hospice’s compliance with the Medicare Conditions of Participation (CoPs).
Unless a hospice is accredited, it may not have experienced a survey from a State surveyor in many years, even, quite possibly, since before the “new” CoPs became effective at the end of 2008. With increased survey frequency on the immediate horizon for all hospices, it is time to ensure your hospice has not become complacent or lax with compliance with the CoPs.
The following are activities to consider:
The hospice’s Executive Director (or the appointed designee – e.g., Compliance Officer, QAPI Coordinator, etc.) should obtain and review, at a minimum, the following documents:
- The regulatory text of Subparts C and D of the hospice regulations;
- The Interpretive Guidelines, which can be found in the State Operations Manual (Appendix M – Guidance to Surveyors: Hospice); and
- The top ten survey deficiencies in hospice.
Prepare, schedule, and facilitate department-specific education that focuses on the pertinent regulatory requirements and common survey deficiencies (e.g., physician services, nursing, social work, spiritual care, bereavement, volunteers, medical records, QAPI, etc.).
- Using the CoPs and Interpretive Guidelines, develop audit tools that focus on regulatory requirements for each department.
- Schedule and conduct department-specific mock surveys at least annually, including:
- Providing the audit tool to the department manager;
- Ensuring that s/he knows the regulations and how to use the audit tool;
- Setting an audit completion date;
- Obtaining the completed audit tool from the department manager and reviewing the results together; and
- Identifying areas of non-compliance and having the department manager establish a Performance Improvement Plan (PIP).
When developing a PIP, ensure that:
- The root cause of the problem (i.e., the non-compliant issue or practice) is accurately identified;
- All relevant people, paper, and/or processes are included in the corrective action (i.e., the staff know what is expected of them and what is required for compliance; the hospice’s forms, tools, policies, and other documents are valid and compliant; and, internal systems and staff practices support compliance); and,
- Follow up auditing and monitoring occurs to ensure that the PIP was successful and full compliance was achieved and maintained over time.
When conducting mock surveys, it is important to include information from as many sources as possible and to validate the veracity of all information. For example, surveys often include the following:
- A review of documents (e.g., policy and procedure manuals; QAPI, census, and other data; patient/family satisfaction, incident, and complaint logs; on-call logs; etc.);
- Staff interviews (to identify knowledge gaps, etc.);
- Direct observation (e.g., interdisciplinary group meetings; the provision of patient care during home visits; a tour of the hospice’s inpatient unit; etc.); and
- A review of internal systems and processes (e.g., the process for involving the patient’s attending physician in developing and updating the plan of care; whether the interdisciplinary team is meeting its minimum patient visit frequency each week; etc.).
Proactively conducting a mock survey provides an opportunity to evaluate your hospice’s level of regulatory compliance while allowing you to “see” the organization through fresh eyes. The overarching goal is to achieve a state of constant survey readiness. When the surveyor arrives, unannounced on your doorstep, everyone will know what to expect and what to do to demonstrate your hospice’s compliance with regulations.
Stay tuned for our next post that deals with the Impact Act’s second type of survey – medical reviews of long length of stay patients.
- National Association of Home Care's resource on Top Ten Hospice Deficiencies
If you need help achieving survey readiness, Weatherbee Resources, Inc. offers Baseline Compliance Auditing and mock surveys. For more information, contact our consulting division at 866-969-7124 or visit our website.
Posted by Joy Barry, RN, M.Ed., LNC, President, Weatherbee Resources, Inc.