Home Health & Hospice Week

Now you can legally discharge disruptive, abusive or uncooperative patients.

Hospices that felt they had nowhere to turn for problem patients have some new options, thanks to a newly finalized regulation on discharge for cause.

A final rule published by the Centers for Medicare & Medicaid Services in the Nov. 22 Federal Register spells out that hospices now may discharge a patient for more reasons than moving, transferring to another hospice or no longer being terminally ill.

"A hospice may discharge a patient if the hospice determines ... that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired," the rule specifies.

"The new regulations will be enormously helpful," says Burtonsville, MD-based health care attorney Elizabeth Hogue. "In the past, patients who engaged in these types of conduct were very problematic."

"The good part is that CMS has now stated officially that it is possible to discharge a hospice patient for cause," cheers Janet Neigh with the Hospice Association of America.

Mind These 4 Conditions

But discharging a patient for cause isn't exactly a simple affair. Hospices must do the following before seeking to discharge a patient for cause, CMS instructs:

1) Advise the patient that a discharge for cause is being considered;

2) Make a serious effort to resolve the problem(s) presented by the patient's behavior or situation;

3) Ascertain that the patient's proposed discharge is not due to the patient's use of necessary hospice services; and

4) Document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its medical records.

The hospice also must obtain a written discharge order from its medical director before discharging the patient. CMS dropped the requirement that hospices must obtain the attending physician's discharge order as well, but hospices still must consult the attending physician and include his review and decision in the discharge note, the regulation says.

Beware Surveyor Scrutiny of Discharges

Hospices that want to use this new provision had better be prepared for serious scrutiny of their practices. "Surveyors will be looking carefully at compliance in this area during both routine surveys and, of course, complaint surveys," Hogue warns.

"Hospices must develop internal policies and procedures that reflect the new regulatory requirements and must follow them to the letter," Hogue urges. And providers must carefully document their actions.

Example: Minor infractions will not necessarily qualify a patient for discharge, CMS notes. For example, in response to a comment on the proposed rule, the agency clarifies that a single instance of a patient going to the emergency room without contacting the hospice first likely wouldn't be grounds for discharge. "Failure to follow important clinical features of the POC may be a reason to consider discharge, but a panicked reaction to an emergency should not be, by itself, a reason to terminate services," CMS says in the reg.

Note: The final rule is at www.access.gpo.gov/su_docs/fedreg/a051122c.html.