Home Health & Hospice Week

‘A deficiency in Texas should be the same as a deficiency in Maine,’ hospice rep tells CMS.

The Consolidated Appropriations Act of 2021 enacted a host of sweeping hospice survey reforms, including burdensome new additions like a Special Focus Program for poor performing hospices and enforcement remedies including payment suspension. But hospices are actually looking forward to one change — an improvement in survey consistency.

“Survey consistency has been a longstanding concern for CMS at multiple levels — interstate and intrastate, as well as Federal to state,” the Centers for Medicare & Medicaid Services acknowledges in the 2022 home health proposed rule, which contains the CAA’s implementing regulations on the matter.

“To reduce inconsistencies in survey results among surveyors, CMS proposes to require agencies that review other entities’ survey findings for missed condition-level deficiency citations (disparities),” the rule says. That means State Survey Agencies would review Accrediting Organizations’ survey findings and the CMS Quality, Safety & Oversight Group would review SAs’ findings, CMS specifies.

The reviewing agencies would then “notify each survey entity of its disparity rate annually, and [CMS would] require a formal corrective plan as part of the survey entity’s (SA or AO) Quality Assurance program,” the agency proposes. “A disparity rate above 10 percent in 2 consecutive cycles would trigger remedial activity such as implementing corrective action through education, mentoring, or other processes to align surveyors’ actions, and determinations of deficiencies with regulatory requirements,” the rule adds.

Hospices are happy to see some attention to this problem.

University of Pittsburgh Medical Center Home Healthcare “owns six Medicare certified hospice agencies across the state of Pennsylvania,” notes UPMC Home Healthcare President Paula Thomas in the agency’s comment letter. “We have experienced variances in both the frequency and the focus of Medicare recertification surveys among our agencies,” Thomas relates.

“Due to the lack of consistency between surveys, there is concern that results are too subjective,” says insurer and Kindred at Home buyer Humana in its comment letter on the proposed rule. When those survey findings result in new enforcement remedies, it’s more important than ever to make sure they are fair.

“The current process is subjective and unpredictable even between SAs,” maintains the Accreditation Commission for Health Care, one of the survey AOs, in its comment letter. “As AOs that survey across the United States, we see firsthand the striking differences in SA COP interpretation and citation determination.”

The National Hospice and Palliative Care Organization “is concerned about the variability and inconsistency of surveys,” it says in its comment letter. For example, “it is unclear if there is guidance for surveyors on how to handle issues that are corrected during the survey. The decision to cite the issue in such situations is typically at the discretion of the surveyor, lending to inconsistencies between surveys, between SA surveyors and AO surveyors, and between states,” NHPCO tells CMS.

Hospices and their representatives seem to mostly approve of CMS’ proposal to address survey consistency, but they have ideas on how to improve it and misgivings about the proposal.

For example, the Home Care Association of New York State “is concerned that CMS is not requiring reviewers to identify inappropriate citations, which should be part of effort to achieve greater consistency,” HCANYS’ Pat Canole says in the group’s comment letter.

And CMS needs “to improve processes that provide for objectivity with citations,” ACHC maintains. “A document that lists protocols for deficiency citations should be created to direct SAs and AOs on when to elevate a finding to a Condition level,” the AO adds.

“The creation of protocols for deficiency citations could be helpful in providing decision-making support for all hospice surveyors, provided they include sufficient flexibility to allow for surveyor judgment,” agrees the National Association for Home Care & Hospice in its comment letter. “Such protocols could suggest that a certain level of compliance is needed to convey that a hospice has met the goals of the [Conditions of Participation] and that a single instance of non-compliance may not be indicative of a systemic problem. The protocol would need to consider the manner and degree of the offense when deciding that a citation is appropriate,” NAHC recommends.

“A deficiency in Texas should be the same as a deficiency in Maine and help from CMS central office is the best path to ensure this consistency across providers and states,” insists LeadingAge, which includes the Visiting Nurse Associations of America. “A matrix should … help with surveyor training and consistency. CMS central office should provide guidance and oversight regarding interpretation of the matrix, what remedies align with what type of enforcement remedies, and interpretation of the deficiencies,” the group says in its comment letter.

“While some subjectivity might be inherent in the process, development of guidelines such a matrices to determine whether or not a deficiency is cited, or not, could be beneficial,” offers Keith Myers, CEO of national chain LHC Group Inc., in the Lafayette, Louisiana-based company’s comment letter.

Many commenters want CMS to change how validation surveys — the surveys conducted to double-check the surveyors’ findings — are conducted.

The problem: “Validation surveys of hospice providers [are] not a valuable means of determining consistency,” Myers argues. “Hospice provider surveys are not static, but occur over time, which may result in changes from one survey to the next, particularly given the amount of time that may have transpired since the previous survey,” Myers warns. “This could result in inaccurate ‘disparity’ results, translating into inaccurate guidance and changes to survey practice.”

The solution: “If validation surveys are a requirement, we recommend that those surveys occur simultaneously to better ensure evaluation of the same occurrences,” Myers says.

Accrediting Organization CHAP “recommends a validation process modeled on the Validation Survey Redesign Pilot conducted in 2019,” it says in its comment letter. “A key element of the pilot was that the SA surveyors were on-site concurrently with the AO surveyors. The SA surveyors were present for observation and scoring only, not conducting a second survey,” CHAP recounts.

“The process informed both the AO and SA about review processes and how decisions were made regarding deficiencies,” CHAP explains. “The exchange was immediately effective and actionable. Implementing this process sooner than later would decrease the impact/burden on providers, as well as contribute to making the AO and SA survey process and findings more consistent,” the AO tells CMS.

Surveyor training is another key component of consistency, multiple commenters tell CMS (see story, p. 319).

Hospices will find out how much CMS has listened to their feedback when the final rule is issued. The regulation is expected out any day.

Note: The proposed rule is at www.govinfo.gov/content/pkg/FR-2021-07-07/pdf/2021-13763.pdf.