Eli's Hospice Insider

Individualized care plans are more important than ever.

If your approach to potential compliance issues is "Why worry? We never get surveyed," you could be playing a risky game. Brush up on two top survey deficiencies to help prevent loss of reimbursement and potential accusations of fraud.

As of Oct. 2009, seven of the top 10 hospice survey deficiencies related to the new Conditions of Participation (CoPs) point to poor care planning and comprehensive assessment practices, said attorney Mary Michal, with Reinhart Boerner Van Deuren in Madison, Wis.

The best response to these findings is to take proactive corrective measures, starting with the way your interdisciplinary team operates, Michal said during a recent Elisponsored audio conference "Conquer New CoPs and MedPAC Challenges -- Get Your Hospice Up to Speed."

Hospice providers must create a written, individualized care plan for each patient. This plan must reflect the patient and family goals and interventions based on the problems identified in the initial comprehensive assessment and the updated comprehensive assessments as they occur.

Each patient's plan must include all services necessary for the palliation and management of the terminal illness and related conditions. Problems with the care plan content topped the suveyors' list of survey deficiencies, however. A lack of individualized care plans is a major contributor to this problem, Michal said.

Pitfall: While electronic medical records have their benefits, they can lead to a "cookie cutter" effect where the same plan of care language is added in and not tailored to each patient's individual needs, Michal warned.

This lack of individualization is a problem not only in the event your agency is surveyed, Michal said. But it can also come back to haunt you during a fraud investigation. It's important to create care plans that are specific to each patient and that describe what's going on with the patient. Otherwise, you'll have a hard time demonstrating that you provided services as described in the care plan and that the patient was eligible for hospice care.

Surveyors also found flaws in hospice providers' comprehensive assessment updating and coordination of services. To combat these problems, your interdisciplinary team (IDT) must be proactive, Michal said.

IDT meetings shouldn't focus only on reporting the care and services provided; instead, they should function as a planning opportunity, Michal said. The team should help develop the care plan and perform checks to see that the care your agency provides is consistent with the plan and that the plan is updated as appropriate.

Time for a change? If your IDT is stuck in reporting mode, look for resources on staff to help the team make the move to being more active in care planning, Michal said. Can your clinical director or compliance officer review the group's process and help them make the transition?

If not, try to hire a knowledgeable hospice consultant who can help make the change.

Agencies who haven't taken a recent look at their IDT process could be at risk of experiencing the perfect storm of compliance problems, Michal said. In such an agency, the care planning may not be especially individualized -- there might be lots of standing orders and cookie cutter care planning.

Each patient might get the same number of visits from the home health aide, social worker, and nurse. And care plans don't show much change from patient to patient or disease to disease.

If an agency with these issues also has a high average length of stay, they might be included in a probe edit by their Medicare administrative contractor (MAC). This could result in a high number of denied claims and a targeted medical review.

Claims pulled for the medical review show that the agency's charting isn't individualized and it's difficult to tell if the patients are really eligible. Then there's a disgruntled former staff member who feels that there's something improper going on and is ready to take whistle blower action.

Added together, these deficiencies take on more significance when you consider the Office of the Inspector General's (OIG) recent reports and call for greater scrutiny of hospice claims. (See the October 2009 issue of Eli's Hospice Insider for more on this.)

To prevent falling victim to compliance problems, hospice providers should take the following steps: place greater emphasis on care-planning and assessments, make sure their IDT is strong, and ensure that nursing services are well-documented, Michal said.

Quality, well-documented, and individualized clinical care and sound systems are key, Michal said. "Doing this keeps you mission-driven and protects against reimbursement and regulatory oversight issues."