Introduction to the Medicare Conditions of Participation

1
Introduction to the Medicare Conditions of
Participation

• Mandatory In-Service
• 2013

2
Medicare Conditions of Participation

• Written in 1983
• Few changes since 1983 despite changes in the
  hospice industry
• Revised in 2006 by the Center for Medicare and
  Medicaid Services (CMS)

3
Revisions to the CoPs

• Subparts, B,F,G were updated effective January
  2006
• Subparts A,C,D were revised and became effective
  in December 2008
• The new CoPs are
• Patient centered
• Focused on quality improvement and patient
  outcomes

4
Conditions of Participation

• Important to know because if hospices do not
  comply with the conditions then they could lose
  Medicare certification.
• Medicare covers over 80 of our patients

5
Hospice of the Bluegrass

• Licensed by the State of Kentucky and adheres to
  Hospice State Regulations 902 KAR 20140, KRS
  216B.042
• Medicare Certified and complies with the Medicare
  Conditions of Participation
• Accredited by Joint Commission
• Governed by a Board of Directors

6
Staff Must Know the CoPs

• Because we must be in compliance with CMS
• Because of fraud and abuse initiatives
• Because they assure a certain standard of care
• Because they provide a foundation for a strong
  hospice program
• Because all except two conditions apply to all
  hospice patients regardless of payer source.
• Those two are 1) continuation of care 2) the
  80-20 inpatient rule

7
Eligibility for the Medicare Hospice Benefit

• 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
• Hospice only admits a patient on the
  recommendation of the hospices Medical Director
  in consultation with the patients attending MD

8
Electing the Medicare Hospice Benefit

• Medicare beneficiaries must have the hospice
  benefit thoroughly explained to them
• In electing to receive hospice care, other
  Medicare benefits related to the terminal illness
  are waived.

9
Patient Rights

• Hospices must provide the patient and family
  notice of their rights at the time of the initial
  assessment in advance of providing care-verbally
  and in writing
• The rights must be in a language and manner that
  the patient understands
• Hospice must obtain patients/representatives
  signature confirming receipt of copy of the
  notice of rights and responsibilities

10
Patient Rights

• Hospice providers must
• Report violations to hospice administrator
• Investigate violations and complaints
• Take corrective action if violation is verified
• Report verified significant violations to
  state/local bodies within 5 days.

11
What You Need to Know About Hospice Eligibility
and Election

• How to assess for and document eligibility of
  patients with non-cancer diagnoses (Local
  Coverage Determinants, NHPCO Guidelines)
• How to explain the Medicare Hospice Benefit to
  patients and caregivers
• That the patients attending physician and the
  Hospice Medical Director must certify that the
  patient is terminally ill

12
Benefit Periods

• Initial period of 90 days
• Second benefit period of 90 days
• Unlimited number of 60 day periods when continued
  to be certified as terminally ill by the Hospice
  Medical Director

13
What You Need to Know About Benefit Periods

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

14
Levels of Care

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

15
Routine Home Care

• Care provided in the patients place of residence
• Reimbursement is approximately 137 per day.
• Most commonly billed level of care

16
Continuous Care

• Provided during times of crisis in an attempt to
  keep a patient at home
• The hospice must provide a minimum of 8 hours of
  care during a 24-hour day beginning/ending at
  midnight
• Care need not be continuous
• Nursing services (RN,LPN) must comprise more than
  half of the care and care must be provided by
  employees of the hospice
• Reimbursement at approximate rate of 33/hour

17
Situations that may require 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 patients 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.

18
Respite Care

• Designed to provide respite for caregivers
• Must be provided in a contracted inpatient unit-
  Do not need a RN in the facility 24 hours a day
• Hospice retains professional management
  responsibilities.
• Reimbursement is approximately 144 per day and
  is available for a maximum of 5 days at a time

19
Inpatient Care

• Sometimes needed for pain and symptom management
• Reimbursement rate is 620 per day in contracted
  facility
• Treatment must conform to the patients plan of
  care and hospice retains professional management
  responsibilities.

20
What You Need to Know About Inpatient Care

• How important it is to educate patient/families
  on calling hospice before 911
• How to determine if a hospitalization is related
  or unrelated to the terminal illness
• What hospitals the hospice contracts with
• What your responsibilities are in managing a
  patients care while hospitalized
• The hospitalization does not mean the same as
  discharge

21
What You Need to Know About Inpatient Care

• Staff should educate patients and families about
  hospitals that have a contractual arrangement
  with Hospice of the Bluegrass.
• If a patient is admitted to a hospital where no
  contractual arrangement exists, the hospice can
  either discharge the patient using Condition Code
  52 or the patient may revoke the hospice benefit.

22
Payment for Hospice Care

• Based on a per diem or daily rate according to a
  patients level of care.
• All services related to the terminal illness are
  included in the per diem rate.

23
What The Per Diem Rate Covers

• RN visits
• Social Worker visits
• Spiritual Care
• Certified Nursing Assistants
• PT, OT, Speech Therapy, Dietician
• Volunteers
• Bereavement Care
• All medications related to the terminal diagnosis
• DME services
• Medical Supplies
• 24-hour on-call services
• Inpatient care
• Labs
• Ambulance

24
Discharge Revocation

• Other than death, there are two ways a hospice
  can end hospice services
• The hospice can discharge the patient
• 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

25
Discharge Revocation Continued

• Reasons for discharge may include
• The patient no longer has a prognosis of 6 months
  or less
• The patient moves out of the service area or
  transfers to another hospice
• Discharge for cause- the patients 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 a hospice discharges a patient, there must
  be documentation in the patients documentation
  in the patients clinical record of the reason
  for the discharge, a physicians order for the
  discharge and evidence of discharge planning.

26
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

27
Governing Body

• Assumes legal responsibility for the hospices
  operations
• Designates administrator
• Ensures quality of care
• Approves policies and procedures

28
Medical Director

• A hospice must have one Medical Director
• The hospice may contract with a self-employed
  physician or a physician employed by a
  professional entity or a physician group
• The Medical Director may also be a volunteer
• The Medical Director is responsible for the
  initial certification and recertifications
• They are responsible for the medical component of
  the hospices patient care program

29
Professional Management

• Continuity of care in all settings
• Written contracts for arranged services that
  include
• How services are to be provided, coordinated,
  supervised and evaluated
• Delineation of roles and documentation
  requirements
• Professional management and financial
  responsibilities for hospice
• Contracts for care

30
What You Need to Know

• The four levels of hospice care available to
  hospice patients
• How to communicate with staff at contracted
  facilities
• How to ensure that the patients plan of care is
  followed
• How to maintain continuity of care in all
  treatment settings

31
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

32
Initial Assessment

• Completed by RN
• Must occur within 48 hours after election of
  hospice care
• This is an initial overall assessment of the
  patient and family needs
• Significant issue in one area, recommend that the
  specialty IDG member complete the comprehensive
  assessment

33
Comprehensive Assessment

• Time frame for completion of the comprehensive
  assessment
• Competed by the hospice IDG in consultation with
  the attending MD
• Completed within 5 calendar days after the
  patient elects hospice care
• Must be updated at least every 15 days

34
Plan of Care

• The plan of care is one of the most important
  documents in hospice care
• 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

35
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 patients condition requires but no less
  frequently than every 15 days
• Completed by IDG in collaboration with the
  attending MD

36
More You Need To Know

• The plan of care tells the story of how and how
  well the patient was cared for. That the plan of
  care follows the patient from admission through
  discharge regardless of the treatment setting.

37
In-Service Training

• Ongoing educational/training programs must be
  provided for hospice employees- whether directly
  employed or under contract.

38
Quality Assessment and PI

• Mechanisms for the ongoing assessment of the
  quality and appropriateness of care provided.
• Use of defined quality improvement programs that
  identifies and resolves problems and improves the
  care provided.

39
Interdisciplinary Group

• Must include MD, RN, SW and pastoral or other
  counselor
• Establishes and updates the plan of care
• The RN coordinates the plan of care

40
Volunteers

• Hospice providers must utilize volunteers and
  volunteer services must, at a minimum, equal 5
  of total patient care hours of all paid hospice
  staff and contracted employees
• Must document recruitment, retention, orientation
  and training of volunteers
• Must document cost-savings

41
Licensure

• The hospice must be licensed if it is a
  requirement of the state in which it is located
• Employees must be licensed, certified or
  registered in accordance with applicable Federal
  or State law

42
Central Clinical Records

• One for each patient
• Entries for All services provided
• Document, Document, Document
• Initial and comprehensive assessments
• Plan of Care
• Identification data
• Consents, election forms
• Medical history

43
Hospice Care for Nursing Facility Residents

• Hospice assumes responsibility for professional
  management of the residents hospice care
• Must have a written agreement with the facility
• Hospice designates IDG member to coordinate
  implementation of plan of care with facility
  representatives
• Must orient facility staff to hospice care
• Hospice provides all services to nursing facility
  patients that is provided in the home setting

44
Two Final Regulations

• Patients must be informed of their right to
  formulate advance directives
• The Medicare Secondary Payer questionnaire must
  be completed