Eli's Hospice Insider

Craft Your Policies & Procedures Carefully

1. Craft your policy and train on it. "Policies should clearly spell out an employee's reporting obligation, to whom they should make the report, and how quickly the report should be made," counsels attorney Bob Markette Jr. with Benesch Dann Pecar in Indianapolis. (For specifics of the new Centers for Medicare & Medicaid Services' requirement, see story, p. 51.)

Then make sure employees understand the policy with specific training. The training will most likely be recurring, Markette offers.

2. Emphasize the reporting chain. "Hospices should train their staff members to report to management of the hospice first," recommends Washington, D.C.-based health care attorney Elizabeth Hogue. The survey and cert memo spells out that requirement.

3. Coordinate with the long-term care facility. Including nursing homes in the reporting process may ease some of the awkwardness. "Hospices should attempt to coordinate any reports they think they must make with management of SNFs," Hogue advises. "At a minimum, hospices should notify the management of SNFs that they are going to make reports, so long as applicable requirements regarding the timing of the reports can be met."

4. Emphasize what's reportable -- and what's not -- in training. Hospices should "train their employees on not only the duty to report, but what constitutes a reportable event," Markette urges. "Employees need to be aware that mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of the hospice all must be reported to the administrator."

5. Be clear about retaliation. It's not just long-term care facilities that are on the hook for survey penalties for retaliating against employees. You need to make sure your policy and training clearly state that your organization won't retaliate against hospice employees who report, either, Markette emphasizes.

6. Don't guarantee anonymity. Your policies and procedures and training "should make it clear that the hospice cannot guarantee the reporting individual's anonymity," Markette says. "Even if the [survey agency] does not care, when a report to law enforcement is made, law enforcement will want to speak to the individual."