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Home Health & Hospice Week

Hospice:

Proposed Survey Hit List Has Multiple Red Flags, Commenters Maintain

Published on Fri Oct 22, 2021

Implementing SFP too early could be catastrophic.

Among the many survey changes on deck for hospices in the near future is one raising major concerns — the Special Focus Program (SFP) for poor-performing hospice programs.

Recap: The Consolidated Appropriations Act enacted last December requires a variety of hefty hospice survey changes. The law followed two high-profile HHS Office of Inspector General reports critical of the process in 2019, which garnered significant mainstream media attention. Implementing regulations were included in the 2022 home health rule proposed rule published in the July 7 Federal Register.

One of the changes that is worrying hospices most is the implementation of the SFP, according to scores of comment letters submitted addressing the topic.

The CAA requires the Department of Health and Human Services to “conduct a Special Focus Program for hospice programs that [HHS] has identified as having substantially failed to meet applicable requirements of the Act,” the Centers for Medicare & Medicaid Services says in the rule. The SFP aims “to address issues that place hospice beneficiaries at risk for poor quality of care through increased oversight, and/or technical assistance,” the rule says.

How it will work: HHS will use specific criteria to identify such hospices and furnish a candidate list to the relevant CMS Quality, Safety & Oversight Group (SOG) and State Survey Agency (SA). The SOG and SA will work together to decide which hospices from the candidate list get placed on the SFP “based on State priorities,” CMS explains in the rule. The SA would survey SFP hospices “at least once every 6 months … and may include progressively stronger enforcement actions in the event of a hospice program’s continued failure to meet the requirements for participation with the Medicare and Medicaid programs,” the rule indicates.

Then, “once an SFP hospice program has completed 2 consecutive 6-month SFP surveys with no condition-level deficiencies cited, the facility would graduate from the SFP,” CMS describes. “If the hospice program did not meet the requirements to graduate, it would be placed on a termination track.”

CMS already operates an SFP for long-term care facility surveys, the agency notes.

The SFP is a “significant change,” notes Paula Thomas of UPMC Home Healthcare in the Pennsylvania health system-based agency’s comment letter. “Our hope is that … SFP will be appropriately utilized,” Thomas tells CMS.

The SFP program is a foregone conclusion, since it is required by law. But commenters have plenty of feedback and suggestions on the program specifics, including on these hot topics:

• Inclusion criteria. The criteria for hospices to land on the candidate list include “a history of condition-level deficiencies on two consecutive standard surveys, two consecutive substantiated complaint surveys, or two or more condition-level deficiencies on a single validation survey (the validation survey with condition-level deficiencies would be in addition to a previous recertification or complaint survey with condition-level deficiencies),” CMS specifies in the rule.

The rule fails to include a time period for the “two consecutive substantiated complaint surveys” or an indication that the “nature of the complaint” will affect the hospice’s inclusion, protests the National Association for Home Care & Hospice in its comment letter. “Depending on the nature and severity of the complaint, it could be some time before complaints are investigated. In fact, it could be years,” NAHC maintains. “Survey entities may receive complaints that are not of an urgent nature and investigation of the complaint is held until the next scheduled survey,” the grade group points out.

The rule also fails to include relevant details of the criteria including whether the deficiency was widespread or isolated and whether it resulted in patient harm and the level of harm, notes the Texas Association for Home Care & Hospice’s Rachel Hammon in the group’s comment letter.

And “should survey data be the only criteria for inclusion or should a combination of survey and program integrity data be utilized (i.e., Hospice Care Index performance, proportion of live discharges, etc.)?” Hammon asks.

“Multiple [condition-level deficiencies] may indicate a hospice in need of assistance to bring the program back into compliance,” but “focusing solely on CLDs has the potential to inadvertently exclude truly poorly performing hospices that would benefit from special attention,” says the National Hospice and Palliative Care Organization’s Edo Banach in the group’s comment letter.

Using survey results isn’t really fair anyway, argues insurer Humana, which purchased Kindred at Home. “Due to the lack of consistency between surveys, there is concern that results are too subjective,” Humana notes in its comment letter.

Instead: NAHC, Humana, and others urge CMS to use a Technical Expert Panel to help hammer out more detailed and specific criteria used for SFP selection.

• Graduation. As with inclusion criteria, multiple commenters question the “2 consecutive 6-month SFP surveys with no condition-level deficiencies cited” criteria for graduating from the SFP. They urge CMS to utilize a TEP for that information as well.

• Centralization. CMS notes that “in the event that no hospice programs in a State meet the established criteria [for the SFP list], then the State SA would not have a hospice program in the SFP at that time,” according to the rule.

“We are pleased that the proposed SFP design does not utilize a quota system as is used in the Special Focus Facility (SFF) program for long term care and thank CMS for this,” NAHC says.

However, “CMS does not comment on what type of State priorities may influence which hospices are chosen from the Candidate List for the SFP,” NAHC notes. “Introducing factors at the State or local level defeats the goal of providing oversight and/or technical assistance to the poorest performing hospices,” the trade group criticizes.

Instead, “NAHC strongly supports a standardized, centralized approach, using objective criteria to determine which subset of hospices will be placed into the SFP,” it says. “This builds an SFP that targets the poorest performing hospices.”

• Public reporting. “Careful consideration should be given to the information publicly reported about a hospice provider in the SFP,” NAHC urges. “Graphics and details about the special focus program should be carefully developed to convey information accurately and without undue alarm,” it urges.

“It is crucial to be thoughtful about the creation of the SFP candidate list because inclusion on the candidate list has proved to create irreparable damage for nursing homes, as the list is made publicly available on Nursing Home Compare,” Banach points out. “This lends even greater importance to the need to make careful and accurate decisions about the selection of facilities to include either on the candidate list or in the program itself.”

Perhaps most importantly, “when a provider corrects the deficiencies that placed it in the SFP and meets any other criteria for moving out of the SFP, public reporting of this information should be timely,” NAHC recommends.

• Timeline. The SFP program is complex, with many moving parts that need technical expert input, multiple commenters tell CMS. The CAA required immediate implementation of the SFP process, which obviously hasn’t taken place.

But CMS shouldn’t rush it into use, multiple commenters caution. NHPCO “calls on CMS to convene a [TEP] to gather stakeholder feedback on the SFP prior to design and implementation of such program,” Banach says in the group’s comment letter. CMS should also work on its other proposals, such as improving consistency between surveys, before SFP implementation, it Banach adds.

“It is important for CMS not to implement SFP until surveyor training and surveyor consistency are addressed,” offer Douglas Irvin and Pam Cramer of the Illinois Hospice & Palliative Care Organization. “We are also concerned about surveyor staffing to implement SFP, as new surveyor positions will be needed for implementation,” Irvin and Cramer note in IL-HPCO’s comment letter.

“Once CMS has successfully standardized the survey process, we recommend employing a gradual implementation schedule to allow hospices time to adjust to the changes and allow for CMS to thoughtfully and effectively implement the SFP,” NHPCO recommends.

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