Home Health & Hospice Week

Deficiencies under these 11 CoPs can trigger SFP selection.

Check out the information that Medicare will use to single out hospices for stepped-up survey enforcement when the Special Focus Program takes effect.

The Centers for Medicare & Medicaid Services proposes using the most recent three years’ worth of data on condition-level deficiencies for these 11 Conditions of Participation it deems most related to quality of care:

1. §418.52 Patient’s rights.
2. §418.54 Initial and comprehensive assessment of the patient.
3. §418.56 Interdisciplinary group, care planning, and coordination of services.
4. §418.58 Assessment and performance improvement.
5. §418.60 Infection control.
6. §418.64 Core services.
7. §418.76 Hospice aide and homemaker services.
8. §418.102 Medical director.
9. §418.108 Short-term inpatient care.
10. §418.110 Hospices that provide inpatient care directly.
11. §418.112 Hospices that provide hospice care to residents of a SNF/NF or ICF/IID.

CMS also sets out four CAHPS Survey measures that will go into the algorithm for SFP selection:

• help for pain and symptoms;
• getting timely help;
• willingness to recommend the hospice; and
• overall rating of the hospice.

For the CAHPS scores, “we propose to use adjusted bottom-box scores of the four measures … to create a CAHPS Hospice Survey Index,” CMS explains. “‘Bottom-box’ scores are calculated for each respondent as ‘100’ if the respondent selected the least positive response categories for that question and ‘0’ if the respondent selected a different response category.”

Data from 2019 to 2021, excluding January through June 2020, shows that “49.3 percent of eligible hospice programs (2,929 of the 5,943 SFP-eligible hospices) report the four CAHPS Hospice Survey measures,” CMS notes.

Further, “the average CAHPS Hospice Survey Index value for these four measures combined is 24, with an overall range of 2 to 83 from the SFP-eligible hospices,” CMS reports in the rule. “Lower scores indicate better performance; total possible range: 0-300,” the agency adds.

Source: HH proposed rule including Table F2 at https://www.govinfo.gov/content/pkg/FR-2023-07-10/pdf/2023-14044.pdf.