By Maureen Kelleher RN, MBA Senior Manager
As we head into the new year, hospice providers should take note of nine new survey and enforcement provisions established in 2021 by an important new addition and several amendments to the Social Security Act.
Although many of these provisions became effective on Oct. 1, 2021, the full impact of the changes is expected to become more evident as 2022 progresses. Over the next few months, for example, hospice providers can expect to see surveyors ramp up scrutiny on compliance with Medicare’s Conditions of Participation (CoPs). Providers may also expect to see more multi-disciplinary teams of surveyors as both State Agencies (SA) and Accrediting Organizations (SA) build multi-disciplinary teams of surveyors.
In a few cases, including the establishment of some new enforcement remedies, the full changes set out under these changes to the Social Security Act do not have to be fully implemented until Oct. 1, 2022.
The process is the same
It is important to note that the survey process for hospice has not changed. It remains as outlined in the State Operations Manual at Chapter 2 and Appendix M, including the completion of the statement of deficiencies and submission to the facility for review and response.
All SAs and AOs will be required to conduct Standard Surveys no later than 36 months after the date of the previous standard survey.
Although requirements for hospice programs are not changing, the new survey and enforcement provisions will make survey results more transparent to the general public and will require hospice programs to focus on improving their compliance with CoPs.
9 Important Changes
Here is a look at the 9 changes brought about by Division CC, section 407 of the Consolidated Appropriations Act (CAA) 2021, which amended Part A of Title XVIII of the Social Security Act to add a new section 1822 to the Act, and amended sections 1864 (a) and 1865 (b) of the Act. These changes were outlined by the Centers for Medicare and Medicaid Services (CMS) in the CY 2022 Final Rule for Hospice.
- The law requires public reporting of hospice program surveys conducted by SAs and AOs, as well as enforcement actions taken as a result of these surveys, on the CMS website in a manner that is prominent, easily accessible, searchable, and presented in a readily understandable format.
- It removes the prohibition at section 1865(b) of the Act of public disclosure of hospice surveys performed by AOs. AOs are now required to release deficiency reports for hospice surveys to increase transparency.
- The law requires that AOs use the same survey deficiency reports as SAs (Form CMS-2567, “Statement of Deficiencies” or a successor form) to report survey findings.
- It requires programs to measure and reduce inconsistency in the application of survey results among all surveyors.
- The law requires the Secretary to provide comprehensive training and testing of SA and AO hospice program surveyors, including training with respect to review of written plans of care. All surveyors will need to utilize the current online CMS basic training. CMS is updating its basic training to include enhanced guidance for surveyors. There will be an emphasis on four “core” hospice CoPs:
• Patient rights
• Initial and comprehensive assessment of the patient
• Interdisciplinary group, care planning and coordination of care
• Quality assessment and performance improvement
- Prohibits SA surveyors from surveying hospice programs for which they have worked in the last 2 years or in which they have an immediate family or financial interest in the hospice program.
- Requires hospice program SAs and AOs to use a multidisciplinary team of individuals for surveys conducted with more than one surveyor. (At least one registered nurse [RN] must be included.) CMS does recognize that it may take some time for AOs to hire and train surveyors from the needed disciplines. However, surveyors are not required to have hospice experience.
- Provides that each SA must establish a dedicated toll-free hotline to collect, maintain, and update information on hospice programs and to receive complaints.
- CMS originally directed the Secretary to create a Special Focus Program (SFP) for poor-performing hospice programs — but has since removed the Special Focus Program for now and added a new Subpart N – Enforcement Remedies for Hospice Programs with Deficiencies. This subpart spells out remedies for noncompliant hospice programs and requires the development and implementation of a range of remedies as well as procedures for appealing determinations regarding these remedies.
These enforcement remedies can be imposed instead of, or in addition to, termination of the hospice program’s participation in the Medicare program. These remedies include civil money penalties (CMPs), suspension of all or part of payments, and appointment of temporary management to oversee operations. Specific criteria would be used to determine whether a hospice program participates in the SFP. The proposed criteria are as follows: a history of condition-level deficiencies on two consecutive standard surveys, two consecutive substantiated complaint surveys, or two or more condition-level deficiencies on a single validation survey (the validation survey with condition-level deficiencies would be in addition to a previous recertification or complaint survey with condition-level deficiencies).
A subset of hospice programs that meet the proposed criteria would be selected to be in the SFP, and those hospice programs would be surveyed every 6 months, which may result in additional enforcement remedies and/or termination.
SimiTree can help.
SimiTree’s friendly and knowledgeable regulatory team is made up of current and former surveyors who have the industry knowledge and experience to assist hospice agencies as they implement new and changing regulations and shore up survey readiness.
We help hospice organizations of various sizes across the country create an intrinsic survey readiness culture, providing staff training and focusing on operational changes. Our thorough mock surveys, offered on-site as well as remotely, identify an agency’s vulnerabilities. We work with organizations to develop and implement a work plan to prioritize and correct weak areas and sustain improvements for ongoing compliance.
Ready to get started? Reach out to us today at 1-844-215-8823 or use the contact form below to start the discussion about how we can help your agency.
Maureen Kelleher RN, MBA
Senior Manager
