Hospice Survey Changes

CMS is tightening survey rules and increasing CoPs scrutiny for hospices. Here’s what your agency needs to know.

Regulatory agencies are taking a harder look at infection control measures under a lingering pandemic, ramping up training for hospice surveyors on some key Medicare Conditions of Participation (CoPs), and increasing transparency in the hospice survey process.

New survey and enforcement provisions for hospice were established under the CY2022 Final Rule for Home Health released by the Centers for Medicare and Medicaid Services (CMS) on Nov. 2.

A continuing focus on infection control, along with new OSHA requirements set out last summer, mean it’s more important than ever for hospice agencies to incorporate pandemic response practices, processes, and procedures into their daily operations, according to the compliance experts at SimiTree Healthcare Consulting.

For full survey readiness, it’s equally important to focus on compliance with CoPs, SimiTree consultants say.

“This new rule does not change the requirements for hospice programs, but it does make survey results more transparent to the general public and will require hospice programs to focus on improving compliance with the CoPs,“ said SimiTree Senior Manager Maureen Kelleher.

Four CoPs are targeted

Hospice agencies should focus on clinical documentation of assessments, care planning and service delivery, as well as medication management, according to SimiTree consultants. In addition, agencies should make certain clinical documentation reflects ongoing agency efforts to meet key COPs.

As CMS ramps up basic surveyor training, it is emphasizing:

  • Patient rights 
  • Initial and comprehensive assessment of the patient 
  • Interdisciplinary group care planning and coordination of care 
  • Quality assessment and performance improvement (QAPI)

“CMS is updating basic training for surveyors to include enhanced guidance, and there will be an emphasis on these core areas,” Kelleher said. “CMS will also provide training to accrediting organization surveyors to review written plans of care.”

Need QAPI assistance?

As CMS increases QAPI scrutiny for hospice, SimiTree consultants can help agencies strengthen their QAPI programs and demonstrate how to effectively use the QAPI program to shore up performance in key CoPs areas such as patient rights, care planning and coordination of care.

For agencies lacking the manpower and resources to focus on QAPI data collection and monitoring, SimiTree also offers full QAPI outsourcing services.

Infection control measures

Bag technique, hand hygiene, and equipment maintenance continue to be areas of scrutiny for surveyors, according to SimiTree consultants.

“These areas continue to top the list of most common survey findings for hospice and should be a priority focus for ongoing survey readiness within each agency,” said Kim Skehan, SimiTree’s Director of Compliance, Regulatory and Quality.

Skehan said surveyors will continue their focus on pandemic planning and response “for the foreseeable future.”

Changes under the Final Rule

Several measures to make the hospice survey process more transparent and prohibit conflicts of interest were established by the Final Rule. Many of the changes will require accrediting organizations to use the same survey procedures and be subject to the same survey requirements as state agencies.

A few of the changes include: 

  • Hospice survey findings by both state agencies and accrediting organizations – as well as enforcement actions taken as a result of those surveys – will be published on the CMS web site in a manner that is easily accessible, searchable, and presented in a readily understandable format. 
  • State agencies will be required to maintain a toll-free hotline for complaints and to collect information about hospice programs. 
  • A Special Focus Program (SFP) will be established for poor-performing hospices, with the development of a range of enforcement remedies. Procedures for appealing determinations will also be established. 
  • Other changes in the survey process include a requirement to use multidisciplinary survey teams, and a requirement for accrediting organizations to use the same form and follow many of the same requirements as state agencies. In addition, CMS-based surveyor training will be provided to accrediting organization surveyors.

SimiTree can help with survey readiness.

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 their 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.

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