Eli's Hospice Insider

Home in on these key areas before surveyors beat you to the task.

"Be prepared" is the best motto for dealing with interim final interpretive guidance for surveyors now in effect.

The new survey guidance is based on the Conditions of Participation or CoPs that went into effect on Dec. 2. And in terms of challenges posed by the guidance, "two big areas" keep coming up in industry discussions, says Janet Neigh, with the National Association for Home Care & Hospice. One involves the initial and comprehensive assessments -- and the other involves the quality assessment and performance improvement (QAPI), "which is totally new for hospice," she notes. For example, the initial assessment isn't a "meet and greet" visit but rather one to "gather the essential information necessary to begin the plan of care and provide the immediate necessary care and services," the guidance instructs.

Surveyors will focus on individualized care planning, predicts attorney Mary Michal, with Reinhart Boerner Van Deuren in Madison, Wis. In fact, "we are telling our clients that they have to be absolutely meticulous about an individualized hospice care plan ..."

Sidestep this pitfall: Hospices with electronic charting systems sometimes end up with more of a "cookie cutter approach" to care planning if staff aren't properly trained -- and don't pay enough attention to the specific patient's and family's needs, Michal cautions. (To review the elements of a comprehensive assessment,
see the sidebar on the left below.)

The guidance focuses heavily on how hospices should perform quality assessment and performance improvement or QAPI.
Key point: Hospices shouldn't limit their QAPI data collection efforts to information gleaned from patient assessments. Instead, the guidance directs hospices to evaluate "all patient services and all activities that may impact patient/family care ..." The list includes patient-care and related services (medical social work, nursing, physician, hospice aides, pharmaceutical, DME), patient rights, administrative services, volunteers, adverse events, and more. Since hospices don't have quality measures, it's up to the individual hospice to decide what to measure as part of performance improvement, says Judi Lund Person, with the National Hospice & Palliative Care Organization. NHPCO has developed several measures, including one that rates patients' pain at admission and at 48 hours, to see how well the hospice has the pain under control, Person notes.

Another NHPCO-developed performance improvement measure looks at whether patients died where they choose, says Person. Doing a chart review, the hospice looks at "self-determined life closure," Person says, to see if the person had the experienced they wanted.

Good news: The January version of the guidance gives surveyors latitude for evaluating a hospice's QAPI program rather than just looking at the QA committee minutes, Person notes.

Expect these questions: The guidance directs surveyors to ask the hospice "how it uses the data analysis to select performance improvement projects, how it implements such projects, and how it uses the data to evaluate the effectiveness of those projects."

Resource: Download the January 2009 advance interpretive guidance at www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter09-19.pdf. CMS says it will publish the guidance "eventually" in Appendix M of the State Operations Manual, which may differ slightly from the advance copy.