Home Health & Hospice Week

Watch out: Tougher enforcement is ahead.

The old adage “if it’s not documented, it’s not done” is once again proven in yet another government report criticizing Medicare oversight of hospices via surveys.

Reminder: The HHS Office of Inspector General already has issued three reports this year charging that surveyors are not overseeing hospices as well as they should, with the quality of hospice care suffering as a result (see Eli’s HCW, Vol. XXVIII, No. 42).

Now the OIG takes aim at registered nurse visits for aide supervision. Medicare hospice conditions of participation require RNs to conduct aide supervisory visits every 14 days, when aide services are ordered. RNs must document the visits in the clinical record, the CoPs say. Also, aides don’t need to be present during the supervisory visits.

The OIG audited about 189,000 “high-risk” RN visit date pairs in 2016: those more than 14 days apart — sometimes a lot more. Based on reviews of 78 claims from that pool, the OIG estimates that with 99,000 of the date-pairs (52.4 percent), RNs did not make supervisory visits as required. And with another 5,000 of the date-pairs (2.6 percent), RNs didn’t document the supervisory visits sufficiently.

Hospices don’t have much guidance on how to document visits, the OIG criticizes. The result: Some hospices use a mere checkmark system to indicate RNs made supervisory visits, while others included lots of details in their record entries.

“There are a wide range of practices,” agrees attorney Robert Markette Jr. with Hall Render.

CMS should “promote hospices’ compliance” with the aide supervisory visit standard and should “take action to ensure that all registered nurses’ supervisory visits of hospice aides are documented in accordance with applicable CMS regulations and interpretive guidelines,” the OIG urges in the report’s conclusion.

Promoting compliance could include educating both surveyors and hospices, as well as making the requirement a standard-level condition, the OIG suggests.

CMS pledges to increase “awareness of the requirement to State survey agencies and accredi­tation organizations in surveyor training, and further educat[e] hospices about the requirement,” but doesn’t address the idea of bumping the requirement up to a standard-level condition.

CMS also says it will educate hospices on documentation of the visits through its usual channels.

Note: The report is at https://oig.hhs.gov/oas/reports/region9/91803022.pdf.