Home Health & Hospice Week

But providers have a lot of work ahead to assure compliance.

Hospices will need every second of their six-month grace period to gear up for their newly finalized Medicare conditions of participation.

The Centers for Medicare & Medicaid Services issued the CoPs final rule in the June 5 Federal Register, after first proposing the new standards in May 2005. They will take effect Dec. 2. The lengthy regulation contains wide-ranging changes to the CoPs, many of which have been unchanged since the hospice benefit's inception in 1983.

"Without a doubt, after 25 years ... it was time to update the regulations and reflect the current thinking on patient care during end-of-life," says hospice consultant Beth Carpenter with Beth Carpenter and Associates in Barrington, IL.

"The CoPs ... will require that hospices en-gage in considerable compliance efforts, [but] overall they contain a strong emphasis on promoting quality patient care," praises attorney Mary Michal with Reinhart Boerner Van Deuren in Madison, WI.

Hospices Talked, CMS Listened

Hospices seem to approve of the new regulations. "We were pleased that many of the suggestions made by [the National Hospice and Palliative Care Organization] during the public comment period for the proposed rule were incorporated into the final rule," NHPCO's Judi Lund Person tells Eli.

"The final regulations are significantly better than the current CoPs and the areas of weakness in the proposed regulations have been fixed," cheers hospice consultant Heather Wilson with Weatherbee Resources in Hyannis, MA.

For example: CMS loosened up a bit its timeframe for assessments. The CoPs will now require hospices to conduct an initial patient assessment within 48 hours instead of the proposed 24 hours. And providers must complete comprehensive assessments within five days, up from the proposed four.

"The move from 24 to 48 hours for the initial assessment was a welcome change and viewed as doable by providers," Person says.

CMS recognized "the need for sufficient time to conduct both the initial and comprehensive assessments," Michal says. Hospices also must conduct reassessments within 15 days, up from the proposed 14.

Even those more relaxed timeframes will keep hospices hopping. "The pace at which hospices will process patients for end-of-life care will certainly pick up!" Carpenter notes. Those quicker deadlines will lead to improved patient care, Carpenter believes.

Other provisions in the CoPs include:

• Patient rights. In announcing the new regulations, CMS is pushing the topic of patient rights. "Medicare beneficiaries with terminal illnesses have their right to determine how they receive end-of-life care outlined for the first time" in the CoPs, CMS says in a release. The conditions "include explicit language on patient rights that had not existed under the previous regulations."

Reprieve: CMS relented on the requirement that patients show understanding of the patient rights paperwork, NHPCO notes. Now "a signature is required that the patient received a copy of the patient's rights document," the trade group points out. And hospices don't have to address patient liability during the initial assessment.

Challenge: Hospices may have difficulty getting across patient rights information to beneficiaries who don't speak English, Carpenter predicts. Hospices should have written materials in languages commonly spoken in their service areas and should be prepared to use translation services, she says.

• Quality improvement. Not much changed about the quality assessment and performance improvement (QAPI) requirement in the new CoPs, Michal notes. That's a bonus for hospices that have been preparing for the quality initiative since it was proposed three years ago.

The QAPI requirements will require considerable time and resources, Michal warns. "Hospices should begin serious implementation efforts immediately, if they have not done so already."

"QAPI is certainly the overarching new CoP," Wilson judges. "In the past three years ... it has been absolutely astounding the amount of work, collaboration, time, resources and thought that have gone into figuring out how to meet the requirements of the QAPI CoP."

Stumbling block: "It will be particularly challenging for hospices to figure out how to aggregate the patient level data to use at the hospice level in their QAPI program," Wilson predicts. At least CMS has granted hospices an extra 60 days past the COP implementation date to collect the QAPI data, NHPCO notes.

Improvement: CMS won't require the medical director to head up the QAPI program, as proposed. But the medical director must still actively participate in the program, Michal notes.

• Medical directors. Get ready to revamp your contracts with your medical directors. Hospices must employ or contract with only one main medical director and one "physician designee" or associate medical director, who is a backup.

The medical director must supervise hospice physicians and certify terminal illness, the new CoPs note. And while the CoPs don't rule out a hospice medical director also serving as a nursing home director, "these relationships can raise complicated issues under the anti-kickback laws," Michal cautions.

Hospices should start renegotiating medical director contracts now, Michal recommends. (You can sign up for Mary Michal's July 15 Eli-sponsored audioconference, "Medical Director Contracting: Hospice Physicians and the New CoPs," at www.audioeducator.com.)

• Social worker qualifications. Much to current social workers' disappointment, CMS will now allow individuals with bachelor's degrees in "psychology, sociology or related fields" to serve as hospice medical social workers if supervised by a social worker with a master's degree (MSW).

"The new social worker personnel requirements ... do not adequately consider the specialized nature of medical social services," Wilson laments.

"Adding the degrees of psychology, sociology and related fields really diminishes the professional role of a social worker," Person adds.

Don't miss: Social workers with bachelor's degrees (BSWs) must also be supervised by an MSW, except for BSWs employed prior to Dec. 2.

• Respite care. CMS also relented on a requirement for inpatient respite care providers to have a registered nurse on site 24 hours per day. General inpatient care facilities still must have an RN 24 hours a day, though, NHPCO points out.

This is a "quiet change" that will benefit hospices, Carpenter forecasts.

"By eliminating this requirement ... nursing facilities that might have previously been ineligible to provide respite care may now be able to do so," Michal expects. "However, assisted living facilities remain ineligible to provide respite care."

• Drugs. New requirements about drugs meeting the patients' needs will add responsibilities to hospices. Providers will contract with a pharmacist, pharmacy benefit manager or other person with education and training in drug management, Michal points out.

• Criminal background checks. Get ready to run checks on all staff with direct patient care duties or with access to clinical and financial records. That includes volunteer and contract staff, NHPCO highlights.

Note: The COP final rule is online at http://edocket.access.gpo.gov/2008/pdf/08-1305.pdf.