Home Health & Hospice Week

Surveyors will single out live discharges, CHC, GIP, and bereavement for sampling.

The time has come for many of the hospice survey changes enacted in the Consolidated Appropriations Act of 2021 to take effect — but not the ones most dangerous to hospices.

Reminder: The CAA, passed in December 2020, included a host of sweeping hospice survey reforms incorporated from the HOSPICE Act of that year. They ranged from alternative sanctions (now called enforcement remedies) to surveyor qualifications and training to a survey process revamp. Then many of those provisions were finalized in the 2022 home health (not hospice) final rule of 2022 published in November 2021 (see HHHW by AAPC, Vol. XXX, No. 42).

Congress passed the reforms after scathing HHS Office of Inspector General reports that found severe quality of care issues at some hospices. The initial OIG reports started a chain reaction of government reports and mainstream media coverage that have been highly critical of hospice provision — especially when furnished by for-profit agencies.

Now, the Centers for Medicare & Medicaid Services has issued implementing guidance for the survey changes in Revisions to Hospice-Appendix M of the Medicare State Operations Manual and accompanying surveyor training materials. The guidance is effective “immediately,” although state survey agencies have 30 days to communicate the changes to staff, CMS says in Jan. 27 memo QSO-23-08-HOSPICE.

“The revisions include an overhaul and reworking of the entire hospice survey process,” emphasizes attorney Matt Wolfe with law firm Baker, Donelson, Bearman, Caldwell & Berkowitz in Raleigh, N.C.

“These are changes that have overhauled the entire survey process, so they are quite significant,” highlights Katie Wehri with the National Association for Home Care & Hospice.

Brace yourself: And “the revisions signal CMS’s increasing focus on oversight of hospices,” Wolfe tells AAPC. “Although not specifically referenced in CMS’ transmittal, it is reasonable to anticipate these changes will be accompanied by an increase in the number and intensity of hospice survey activity over the coming months and years,” he predicts.

Overall, “the revisions are largely meant to develop a new way to structure and organize the survey process — specifically, by creating a greater emphasis on quality of care,” notes attorney Adam Royal with law firm Husch Blackwell in Austin, Texas.

“CMS’s goal with these revisions is to promote efficiency and effectiveness in the hospice survey process and identify low quality-of-care deficiencies,” judges consultant Kim Skehan with SimiTree.

“A significant change in the hospice survey protocol is an enhanced approach to investigating the quality of care provided to hospice patients,” CMS emphasizes in the memo.

Exception: While the revisions contain most of the survey reforms passed in the CAA, they do not reference those which may have the most impact on hospices — enforcement remedies including payment suspension and civil money penalties (see story, p. 46, for more details). Implementing guidance for those remedies will be in revisions to the Medicare Program Integrity Manual, Chapter 10, NAHC reports in its member newsletter. “CMS has not provided a timeline for those revisions,” the trade group adds.

4 CoPs Will Now Take Center Stage

While hospices wait for the other shoe to drop on enforcement remedies, they will have their hands full coping with this fundamental overhaul of the survey protocol, experts say.

“This is a significant change for the hospice survey process,” Skehan stresses.

Some of the biggest survey changes include:

• Structure. In a nutshell, hospice surveys now “are divided up into two ‘phases’ with the first focusing on quality-of-care issues and the second focusing more on administrative issues,” Wolfe explains.

“While each of the 23 [Conditions of Participation] continues to have equal weight in the final certification decision, special attention is directed to those Phase I CoPs directly impacting patient care,” CMS says in the memo. “Phase 1 CoPs include §418.52 Patient Rights, §418.54 Initial and comprehensive assessment of the patient, and §418.56 Interdisciplinary Group, care planning, and coordination of services,” the agency points out.

In Phase 2, COP §418.58 Quality assessment and performance improvement is the focus.

“Phase 1 & Phase 2 focus on four core requirements and 19 associated CoPs,” CMS summarizes.

• Pre-survey. CMS breaks the survey process into seven tasks, starting with Task 1: Pre-Survey Preparation and ending with Task 7: Formation of Statement of Deficiencies. A new “section dedicated to sampling strategy for record reviews and home visits” is Task 3.

Task 1 is now “an enhanced Pre-Survey task to boost surveyors’ understanding of the hospice’s operations and provide a foundation for the onsite survey,” the memo indicates. “Surveyors are directed to public media for potential concerns about the hospice, the hospice’s website, CMS Care Compare-Hospice, and prior survey reports for standard and complaint investigations,” CMS says.

“CMS expects [the task] will inform surveyors’ approach before they begin the survey,” Wolfe notes.

The “additional external and internal resources” will help surveyors “to assess the current characteristics and services of the hospices,” CMS says in the memo.

• Revised sampling. Get ready for CMS to cast a wider yet more targeted net to examine hot button hospice topics.

“The sampling strategy increases the number of records and ensures that a broader range of hospice activities are investigated (live discharges, bereavement follow-through, care for patients needing higher levels of care) from all of the locations where the hospice operates (‘multiple locations’), and the variety of home settings where patients live,” CMS says in the memo.

“The focus on live discharges, bereavement follow-through and care for patients needing higher levels of care are new focus areas for surveys,” points out Judi Lund Person with the National Hospice and Palliative Care Organization.

• Facility contracts. CMS is getting into specifics about some parts of contracts with facilities. “For example, CMS’s interpretive guidance relating to hospice professional management requirements under §418.1129(b) indicates that CMS wants hospices to address in facility contracts the potential ‘crisis-situations and temporary emergency measures’ where facility staff may be required to perform core services in place of hospice staff,” explains Husch Blackwell’s Royal.