Long-Term Care Survey Alert

Find out what this focus means for your facility.

If you don't feel like your facility is definitely on the same page with its hospice providers, it might be time to see what surveyors will be expecting in that regard.

The January 2009 interim final interpretive guidance for hospices emphasizes coordination of care between the two providers. And the word is that both hospice and nursing surveyors will be looking closely to see if that is indeed happening.

"We're hearing from surveyors on both ... sides" that they are focusing on ensuring communication and coordination between the two providers related to the plan of care, documentation -- and communication about changes in the hospice patient's condition, reports Judi Lund Person, with the National Hospice & Palliative Care Organization (NHPCO).

And if hospice surveyors find a problem with the nursing home's coordination of care or communication, don't count on them keeping it to themselves. "There's good communication between the agencies, in my experience," says Beth Carpenter, president of Beth Carpenter and Associates in Lake Barrington, Ill.

Coordinate the Care Plan

The new hospice conditions of participation that went into effect on Dec. 2 talk about hospices having one care plan, notes Cherry Meier, RN, MSN, with VITAS Innovative Hospice Care in Flat Rock, N.C. Yet, as many in the industry had hoped, the January 2009 hospice interpretive guidance clarifies that the hospice and nursing home may divide the coordinated care plan into two parts. "CMS folks expect the hospice plan of care to relate to the terminal illness -- and the nursing home plan of care to relate to every other part of care provided to the resident," says NHPCO's Person.

"The coordinated plan of care must identify which provider (hospice or facility) is responsible for performing a specific service," states the guidance. And "based on the shared communication between providers," each provider's part of the care plan should identify:

• A common problem list

• Patient goals

• Responsible discipline and provider.

Watch out: Nursing home and hospice care plans that appear to be in conflict make it fairly easy for surveyors to write deficiencies, cautioned Harold Bob, CMD, MD, a nursing home and hospice medical director in a presentation on palliative care and survey regulations at the 2008 American Medical Directors Association annual meeting. "When the care plans don't coincide, it probably leads to poor care," he said.

Risk management: Lay the two plans side by side to see if they jibe, experts suggest.

Make sure you're in synch with the hospice in managing hospice patients' pain. Maryland survey agency head nurse William Vaughn, RN, has seen nursing home patients on hospice -- usually nonverbal patients -- who get their PRN dose of pain medication only when the hospice nurse comes in. And when that happens, surveyors may take a look at what's going on, cautioned Vaughn, who co-presented with Bob in the AMDA session.

Also develop a standardized system, if you haven't already, to notify the hospice when a patient requires an increasing number of PRN doses of pain medication. "Hospice uses PRNs to supplement scheduled medications," says Meier. And if the patient needs too many PRNs for break-through pain, hospice will change the regularly scheduled pain medication to improve relief.

Beware: If hospice surveyors have concerns about coordination and implementation of the hospice patient's plan of care for pain control and symptom management, the guidance directs them to interview the facility's nurse aides who provide direct care to the patient to determine:

• If they are aware of any complaints of pain from the patient or signs and symptoms that could indicate the presence of pain or discomfort;

• To whom they report the patient's complaints, signs, or symptoms;

• If they are aware of and implement interventions for pain/discomfort management for the patient consistent with the patient's plan of care (for example, allowing a period of time for a pain medication to take effect before bathing and/or dressing).

Risk management tip: If your facility admits a lot of hospice patients -- and has higher-than-average pain QM scores -- dig deeper to see what's going on. The expectation is that in most cases, hospice patients' pain will be under control, says Rena Shephard, MHA, RN, RAC-MT, CE-NE, a consultant in San Diego and founding chair and executive editor for the American Association of Nurse Assessment Coordinators. When confronted with an elevated QI/QM, including pain, look to see who's in the numerator, Shephard advises. Then review their charts to see if the items are coded correctly in most cases or each case, she adds. "And if the score still isn't good," the next step is to look at resident assessment and process improvement systems, Shephard counsels.

Resource: You can download an advance copy of the hospice interpretive guidance at www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter09-19.pdf. CMS says the guidance will ultimately be published in Section M of the State Operations Manual and may differ slightly from the advance copy.