Regulatory changes over the last few years have put hospice providers under the microscope and subject to more scrutiny than ever. Hospice programs are now surveyed at least once every three years, and since the launch of Hospice Compare last year, consumers are able to search for and compare hospice agencies based on quality data and the experiences of other families.
These changes are designed to put patients’ needs front and center and provide a framework for measuring care across the more than 4,000 Medicare-certified hospices. Yet, in today’s fiscally challenging environment—with understaffed hospices and an ongoing nursing shortage—it can be difficult to provide the detailed, measurable and comparative documentation that regulators require. The ramifications of not doing so, however, can result in citations, fines and low ratings on Hospice Compare.
How can hospices meet these demands?
Start with the CoPs
The best advice would be to function every day with compliant practices and never let your guard down. While this is easier said than done, it’s important to make this a daily priority. Compliance with the Hospice Conditions of Participation (CoPs) will significantly decrease your risk of a citation and prompt a deficiency-free survey.
The CoPs are your roadmap to the day-to-day operations of your hospice. They also provide the best guideline for effectively assessing your documentation, systems and practices—and avoiding the most common deficiencies that hospices are being cited for based on recent surveys.
According to the Centers for Medicare and Medicaid Services (CMS), the top citations for 2017 were:
- Plan of Care — 118 citations
- Drug Profile (content of comprehensive assessment) — 93 citations
- Supervision of Hospice Aides — 85 citations
- Timeframe for Completion of Assessment — 81 citations
- Content of Plan Care — 70 citations
These citations are all related to a lack of compliance with sub-parts C and D of the CoPs, which focus on patient care and the organizational environment. Indeed, the last three years had a similar theme, with Plan of Care being the top citation for the last two. If there is any indication of where your hospice should focus, it should be on shoring up your efforts around these areas of the CoPs and paying close attention to the Plan of Care.
5 TIPS TO PREPARE FOR A HOSPICE SURVEY
Taking steps to ensure your Plan of Care is adhering to the CoPs will not only prepare your hospice for a survey—whether expected or unexpected—it will significantly improve the level of care each patient receives. Here are five best practices that can put your hospice on the path to survey success:
1 – Be a student of interpretive guidelines/CoPs
Good practices always start with good leadership, but everyone needs to be involved. This means that all employees, not just management, should become students of the CoPs. The state operations manual appendix M, also known as the interpretive guidelines, should be handed out to each and every employee. Treat it as your “teacher’s manual” and encourage employees to use it as their road map for managing a successful Plan of Care. Remember, the CoPs are what surveyors will use during their visit to your agency, so it makes sense to follow the same guidelines.
2 – Avoid cookie-cutter care plans
As stated in the CoPs, “All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician, if any, the patient or representative, and the primary caregiver in accordance with the patient’s needs.”
The words “individualized” and “interdisciplinary” are key.
Refrain from creating cookie-cutter care plans. While the overall goal should be the same for all your patients—to relieve suffering and provide a comfortable, quality existence up to and including the time of death—you need to provide a unique plan for how you’re going to achieve this for each individual, keeping in mind the patient’s cultural, religious and other requirements.
The interdisciplinary group also needs to be involved. It’s a team effort, and each discipline brings its own expertise to the table. The care team can involve a wide range of practitioners, including:
- Medical director
- Attending physicians
- Social workers
3 – Compose disciplined narratives
When documenting care, compose disciplined narrative and avoid the use of checkboxes. The issue with checkboxes is they don’t tell the story of a patient’s clinical status and make it difficult to track disease progression over time. Each visit needs to incorporate clearly documented narrative that shows evidence of disease progression. This is accomplished by documenting the patient’s health—visit over visit, week over week, month over month—through descriptive examples and industry-standard tools that allow staff to easily identify and compare documentation for an individual patient.
At the end of the day, a detailed narrative provides more information than checkboxes and, most importantly, lends support to hospice eligibility.
4 – Avoid the use of vague words
This goes hand in hand with providing a more disciplined narrative. It’s possible to write a lot, but not be specific about the patient’s individual condition. All forms of documentation should avoid the use of words that are too general or vague in nature. A few examples of these words include: more, less better worse.
The goal of documentation is to accurately paint a picture of a patient’s current state of health and show how he/she is eligible for hospice care in the present compared to the past. It’s also not enough to simply talk about the patient in the interdisciplinary group meeting, the clinical record needs to include these observations in written detail.
5 – Ensure documentation is defensible
Finally, hospices must ensure that all documentation is defensible. If a claim period or entire length of stay were to be audited by a government agency, there must be evidence of disease progression, medical necessity and palliative care intervention.
The interdisciplinary group documentation in the clinical record is your best defense to mitigate scrutiny. Ensure that all interdisciplinary group members understand their responsibility for documenting patient eligibility during every visit. The clinical record needs to speak for itself by showing the patient’s disease trajectory and the individualized plan of care.
To support these efforts, look to your EMR vendor for support. EMR software should guide clinicians through all the required forms and deadlines, and make it easy to chart patients, raise issues and set goals that are aligned with the patient care plan. It should also empower staff to proactively track care and efficiently prepare for and run IDG meetings.
Hospice organizations can be audited at any time. While there is no magic bullet to ensure your hospice will avoid a citation, there are steps you can take to reduce risk. Ultimately, it’s about making the effort to do your best every day to follow the CoPs and be in a constant state of readiness for an unannounced survey.
To learn more about how Optima Hospice can help your hospice ensure survey success, watch our webinar: Surviving an Audit: Growth Without Compliance is Chaos