AN OVERVIEW: THE BASICS OF MEDICARE CONDITIONS OF PARTICIPATION

We all need to know and understand the (CoPs) Conditions of Participation, because if hospice agencies do not comply with the conditions then they can  (and do)  lose their Medicare certification.   Nationwide Medicare covers 40 million beneficiaries, an average over 80% of all Hospice patients.  
In future articles we will deal with many of these areas individually, but in this post I want to go over all of the basics needed to comply with the CoPs:
 
Why It Is Important To Know CoPs:

• To always be in compliant with CMS
• To avoid even the appearance of fraud or abuse
• CoPs assure a certain standard of care to our patients
• CoPs provide a foundation for a strong hospice program

The 2 conditions that are exempt are:

1. The 80/20 Inpatient Rule
   1. § 418.98c: The total payment to the hospice for inpatient care cannot exceed 20% of the total days of hospice care per cap period.
2. Continuation of Service
   1. § 418.60: A hospice may not discontinue or diminish care provided to a Medicare beneficiary because of the beneficiary's inability to pay for care.

What Qualifies For A Patient to Be Eligible for Medicare Hospice Benefits

• A prognosis of six months or less if the disease follows its expected course
• Entitle to Part A of Medicare
• Election of the Medicare Hospice Benefit from a Medicare certified hospice agency 
• Hospice can only admit a patient on the recommendation of the hospice’s Medical Director in consultation with the patient’s attending MD (if they have one)

When A patient Elects to receive Medicare Hospice Benefits

• Medicare beneficiaries must have the hospice benefit thoroughly explained to them
• In “electing” to receive hospice care, the patient (&/or responsible guardian) understands that other Medicare benefits related to the terminal illness are then waived.

The Patient’s Rights

• The Hospice agency must provide the patient and responsible family members notice of their rights at the time of the initial assessment in advance of providing care-verbally and in writing.
• The patient’s rights must be explained in a language and manner that the patient understands.
• The Hospice agency must obtain patient’s or responsible representative’s signature confirming that they have received of copy of the notice of rights and responsibilities.

Dealing with Patient’s Rights

• Investigate any and all violations and complaints. 
• Report any violations to the hospice administrator.
• Take corrective action if any violation is verified.
• Report verified significant violations to state/local bodies within 5 days of the report.

Hospice Benefit Periods

• Medicare hospice benefit consists of two 90-day benefit periods and an unlimited        number of sixty-day benefit periods, and must be used in that order (90-90-60).
• Hospice care is considered continuous from one benefit period to another, unless the beneficiary revokes the hospice benefit, or the physician discharges or does not recertify the beneficiary. On rare occasions, the hospice may discharge the beneficiary from the benefit due to patient or hospice staff safety.
• If a beneficiary revokes or is discharged from care, the remaining days in the benefit period are lost. If/when the beneficiary meets the hospice coverage requirements, they can re-elect the hospice benefit, and will begin with the next benefit period.

Information to Know concerning Benefit Periods

• The Number of benefit periods.
• The process for assessing continued hospice eligibility & recertification.
• Tracking recertification dates for each patient.
• Recertification of terminal illness signed by the Medical Director within 2days of a new benefit period.
• Each hospice provider should determine if a patient has ever enrolled in hospice care to determine their benefit period.

The 4 Levels of Care

• Routine Home Care
• Inpatient Respite Care
• General Inpatient Care
• Continuous Care

Routine Home Care

• This is the most common level of care.  Almost 95 percent of the time, hospice is provided in the home by team members including a physician, registered nurse, hospice aid, social worker, chaplain, volunteer and bereavement specialist, who come for scheduled visits depending on the needs of the patient and family.
• Routine home care includes, but is not limited to, nursing and home health aide services. Patients may receive Routine Hospice Care in their home or what they “call home”—in a long-term care or assisted living facility.

Inpatient Respite Care

• Designed to provide temporary relief to the patient’s primary caregiver.
• The contracted inpatient unit must have the capability to provide 24-hour nursing.
• Hospice retains professional management responsibilities. 
• Respite care is provided for a maximum of 5 consecutive days.

General Inpatient Care

• It is provided for pain control or other acute symptom management that cannot feasibly be provided in any other setting.
• Treatment must conform to the patient’s plan of care and hospice retains professional management responsibilities. 
• General Inpatient Care begins when other efforts to manage symptoms have been ineffective. 
• General Inpatient Care can be provided in a Medicare certified hospital, hospice inpatient facility, or nursing facility that has a registered nursing available 24 hours a day to provide direct patient care.

Continuous Care

• Provided during times of crisis in an attempt to keep a patient at home, or facility where they live.
• This is care provided for between 8 and 24 hours a day to manage pain and other acute medical symptoms.
• Care does not require a hospice worker to be with the patient continuously during this care period.
• Nursing services (RN,LPN) must comprise more than half of the care and care must be provided by employees of the hospice.

Reasons for Continuous Care

• Uncontrolled, severe symptoms that require continuous skilled assessment, intervention, evaluation.
• When a medical intervention that needs monitoring is implemented (ex. IV)
• Highly unstable vital signs, e.g., diabetic management
• Severe anxiety, agitation or confusion that poses a safety threat
• Suicide ideation or related action
• The patient’s condition is deteriorating rapidly to the extent that death is imminent and the care needs are beyond the physical and emotional resources of the family.

Ending Hospice Services
Other than death, there are two ways a hospice can end hospice services:
  1. The hospice can discharge the patient:

• When the patient no longer has a prognosis of 6 months or less.
• When the patient moves out of the hospice service area. This can include patient who relocates or who goes on vacation outside of the hospice’s service area or patient who are admitted to a hospital or skilled nursing facility that does not have contractual arrangements with the hospice.
• Discharge for cause- when the patient’s behavior or situation is such that care cannot be provided to the patient even though all efforts have been made to resolve the situation.
• When we discharge a patient; there must be documentation in the patient’s documentation in the patient’s clinical record of the reason for the discharge, a physician’s order for the discharge and evidence of discharge planning.

  2. The patient can revoke hospice services. 

• The patient can revoke the Medicare Hospice Benefit.
• To revoke the benefit, a patient must sign the revocation.
• The patient may revoke for any reason.

Understanding General Provisions

• Compliance- a hospice must comply with the CoPs in order to be or remain certified.
• Required Services- a hospice must provide required hospice services including bereavement counseling- Bereavement must begin before the patient dies
• Some of the services, like nursing, MD and pharmacy, must be available 24 hours/day
• Services must conform to accepted standards of practice

Assessment of a patient

• The hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patient's need for hospice care and services, and the patient's need for physical, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions.

Initial Assessment

• This must be completed by Registered Nurse.
• It must occur within 48 hours after election of hospice care (§418.24)
• This is an initial overall assessment of needs for the patient and their family.

Comprehensive Assessment

• Competed by the hospice IDT/IDG (Social Worker, Chaplin, Volunteer Coordinator, Bereavement Coordintor) in consultation with the attending MD identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the patient’s well-being, comfort, and dignity throughout the dying process.
• Completed within 5 calendar days after the patient elects hospice care
• Must be updated at least every 15 days

Comprehensive Assessment must Consider the following factors

• The nature and condition causing admission.
• Complications and risk factors that affect care planning.
• Functional status, including the patient’s ability to understand & participate in his or her own care.
• Imminence of death.
• Severity of symptoms.
• Bereavement assessment 
• A review of all prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy.

Update of the Comprehensive Assessment
The update of the comprehensive assessment must be accomplished by the hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) and must consider changes that have taken place since the initial assessment. It must include information on the patient's progress toward desired outcomes, as well as a reassessment of the patient's response to care. 
The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days.

Plan of Care

• The plan of care is one of the most important documents in hospice care and tells the story of how and how well the patient was cared for. 
• It follows the patient from admission through discharge regardless of the treatment setting. 
• All services must follow a written plan of care.
• Patient and primary caregiver are educated and trained related to their care responsibilities identified in the plan of care.
• IDG consults with the following to establish plan of care:
• Attending physician 
• Patient and/or representative/primary caregiver

Review of the Plan of Care

• Revised plan of care includes information from the updated comprehensive assessment
• Information regarding the progress toward achieving specified outcomes & goals
• Plan of care must be reviewed as frequently as the patient’s condition requires but no less frequently than every 15 days
• Completed by IDG in collaboration with the attending MD

Initial & Comprehensive Assessment of the Patient

• The comprehensive assessment is not a single static document, a symptom & severity checklist, or a set of generic questions that all patients are asked
• It is a dynamic process that needs to be documented in an accurate and consistent manner for all patients
• Comprehensive assessment is about assessing what the patient needs, not all about who completes the assessment

How Hospice should work with Nursing Facility Residents

• Assume responsibility for professional management of the resident’s hospice care.
• Have a written agreement with the facility.
• Designate IDT/IDG member to coordinate implementation of plan of care with facility representatives. 
• To orient the nursing facility staff to hospice care.
• To provide all hospice services to nursing facility patients that is provided in the home setting.

More talking points

• How to communicate with staff at contracted facilities.
• How to ensure that the patient’s plan of care is followed.
• How to maintain continuity of care in all treatment settings.

The top 10 survey deficiencies listed in order of the most frequently cited are:

• Plan of care.
• Content of the plan of care.
• Supervision of hospice aides.
• Review of the plan of care.
• Timeframe for completion of the comprehensive assessment.
• Update of the comprehensive assessment.
• Scope and frequency of services.
• Drug profile.
• Criminal background checks.
• Counseling services - Bereavement counseling.

Sources: 

• National Hospice and Palliative Care Organization (NHPCO)
• Centers for Medicare & Medicaid Services (CMS)

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