UTAH DEPARTMENT OF
HEALTH
UTAH HOSPICE & PALLIATIVE CARE ASS’N
ANNUAL CONVENTION
NOVEMBER 1-2, 2016
Presenter:
Shauna Craig, NLTC Survey Team
Home Health and Hospice Lead
INTRODUCTIONS
Nancy Smith
Elizabeth Ross
New Hospice Lead
[email protected]
New Home Health Lead
[email protected]

2 years NLTC Team

17 years State of Utah

2 years home health & hospice

1 year NLTC team

7 years transplant & trauma

2-1/2 years LTC team

Home health & hospice
REGION VIII CERTIFIED
ACTIVE HOSPICE AGENCIES FISCAL YEAR 2016
State
# of Hospice
Agencies
*2015 Population
Utah
88
2,995,919
Colorado
63
5,456,574
Montana
28
1,032,949
North Dakota
11
756,927
South Dakota
14
858,469
Wyoming
17
586,107
*From U.S. Census Bureau
TERMINATED HOSPICE PROVIDERS
FISCAL YEAR 2016
State
Terminated Providers
Utah
2
Colorado
2
Montana
0
North Dakota
0
South Dakota
0
Wyoming
3
HOSPICE SURVEYS COMPLETED
FISCAL YEAR 2016
State
Recertification
Surveys
Complaint Surveys
Total
# of
Surveys
% of
Providers
# of
Surveys
% of
Providers
Utah
22
25.0%
6
6.8%
28
Colorado
18
28.6%
5
7.9%
23
Montana
7
25.0%
0
0.0%
7
North
Dakota
4
36.4%
0
0.0%
4
South
Dakota
4
28.6%
0
0.0%
4
Wyoming
4
23.5%
0
0.0%
4
HOSPICE DEFICIENCY COUNT
FISCAL YEAR 2016
State
Standard
Level
Deficiencies
Condition
Level
Deficiencies
Total
Utah
81
54
135
Colorado
44
0
44
Montana
24
0
24
North Dakota
14
0
14
South Dakota
8
0
8
Wyoming
19
0
19
HOSPICE AVERAGE DEFICIENCIES
ALL SURVEYS (RECERTIFICATION & COMPLAINT)
FISCAL YEAR 2016
State
Average
Number of
Surveys
Utah
4.7
29
Colorado
1.8
24
Montana
3.4
7
North Dakota
3.5
4
South Dakota
2.0
4
Wyoming
4.8
4
HOSPICE AVERAGE DEFICIENCIES PER
RECERTIFICATION SURVEY FISCAL YEAR 2016
State
Standard
Level Deficiencies
Condition
Level Deficiencies
Utah
2.7
1.2
Colorado
2.1
0.0
Montana
3.4
0.0
North Dakota
3.5
0.0
South Dakota
2.0
0.0
Wyoming
4.8
0.0
HOSPICE AVERAGE DEFICIENCIES
PER COMPLAINT SURVEY FISCAL YEAR 2016
State
Standard
Level Deficiencies
Condition
Level Deficiencies
Utah
3.3
4.3
Colorado
1.0
0.0
Montana
N/A
N/A
North Dakota
N/A
N/A
South Dakota
N/A
N/A
Wyoming
N/A
N/A
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Rank
Tag #
Description
Quality Assurance CONDITION
Includes all standard-level deficiencies L 560 through L 576
1
L 559
L 576
•
Ongoing, hospice-wide, data-driven
•
Focuses on indicators to improve palliative outcomes – outcome
measures
•
Involves all hospice disciplines, including contract
•
Investigation and analysis of adverse events
•
Includes infection control surveillance data
•
Continual assessment – is what we’re doing working?
•
Performance improvement fosters “blame-free” environment
•
In addition to aggregated data, if part of a larger organization,
QAPI documentation should include data specific to local agency
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Rank
Tag #
Description
Quality Assurance CONDITION (Continued)
• Administrative Responsibility – Governing
Body
1
L 559
L 576
•
Frequency and detail of data collection must be
approved by the governing body; GB must appoint
responsible individual(s) for QAPI
•
Regular review and use of QAPI analysis by
management and governing body to make systemic
improvements
•
Documentation of hospice’s own review of QAPI
program
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Rank
Tag #
Description
Comprehensive Assessment CONDITION
Includes all standard-level deficiencies L 521 through L 535
2
(tie)
L 520
L 535
•
Reflects patient’s current health status
•
Includes documented involvement of all members of IDG and
must be completed within 5 days after election of benefit
•
Addresses physical, psychosocial, emotional & spiritual needs
•
Initial bereavement assessment of needs of patient’s family
and other individuals focusing on social, spiritual and
cultural factors that may impact their ability to cope with
patient’s death
•
•
•
•
•
•
History of previous losses
Family problems
Financial concerns
Mental health issues
Presence or absence of support system
Drug or alcohol abuse
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Tag #
Description
Comprehensive Assessment (continued)
•
L 520
L 535
Pain Assessment
•
Intensity
•
Descriptors (burning, stabbing, tingling, aching)
•
Pattern (constant, intermittent)
•
Location & radiation
•
Frequency, timing, duration
•
Impact of pain on quality of life
•
Factors that precipitate or exacerbate pain
•
Strategies and factors that reduce pain
•
Additional symptoms associated with pain (nausea, anxiety)
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Tag #
Description
Comprehensive Assessment (continued)
Drug Profile
L 520
L 535
•
Review of prescription and OTC drugs & herbs
•
Effectiveness of drug therapy
•
Drug side effects
•
Actual/potential drug interactions
•
Duplicate drug therapy
•
Drug therapy w/lab monitoring
•
Must be updated along with comprehensive assessment every 15 days
•
Must evaluate and document patient/family’s ability to safely
administer drugs
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Tag #
Description
Comprehensive Assessment (continued)
• Updates by IDG
L 520
L 535
•
At least every 15 days
•
Updates must be documented
•
What has changed? Document progress toward goals
•
What are needed frequencies for disciplines?
•
Have the patient’s medications been updated?
•
Can patient/family safely self-administer drugs? (L 692)
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Rank
Tag #
Description
IDG, Care Planning, Coordination of Services
CONDITION
Includes all standard-level deficiencies L 537 through L 558
2
(tie)
L 536
L 558
•
The plan of care must be specific to the individual patient’s
needs
•
The IDG supervises the patient’s care and services
•
IDG must include physician, RN (case manager), SW, and
pastoral or other counselor
•
Standing orders must be individualized to address patient’s
specific needs
•
Coordination of services is critical – information must be
shared with all disciplines and in all settings
•
Document! Document! Document!
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Rank
Tag #
Description
Core Services CONDITION
Includes all standard-level deficiencies L 588 through L 600
2
(tie)
L 587
L 600
•
Nursing, SW, and counseling must be provided by employees.
•
The Medical Director is responsible for meeting the patient’s
medical needs
•
Counseling must include:
•
Bereavement counseling – qualified professional with
experience or education in grief/loss counseling
•
Dietary counseling – dieticians, nurses
•
Spiritual counseling – pastoral counselors or others who
can support patient’s spiritual needs
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Rank
Tag #
Description
Organization & Administration CONDITION
Includes all standard-level deficiencies L 649 through L 663
2
(tie)
L 648
L 663
•
Provide necessary hospice care & services to patients and
families consistent with individual patient/family needs
•
Optimize comfort & dignity
•
Provides all required services
•
Organize, manage, administer resources
•
Governing body & administrator assume full
responsibility for hospice
•
Administrator responsible for day-to-day operation
•
Nursing, physician, drugs available 24/7
•
Multiple locations approved by Medicare & meet
requirements
•
Provide orientation to all employees, volunteers &
contracted staff - document
•
Assess skills & competence of all staff
•
Oversight of QAPI
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Rank
Tag #
Description
Clinical Records CONDITION
Includes all standard-level deficiencies L 671 through L 685
2
(tie)
L 670
L 685
•
Legible, clear, complete and appropriately authenticated
•
Readily available
•
Initial POC, updated POC’s, initial assessment, updated
comprehensive assessments, clinical notes from all disciplines
•
Signed patient rights, advance directives (if any)
•
Signed physician’s orders
•
Patient responses to medications and treatments
•
If patient revokes, transfers, or is discharged, the hospice must
forward a copy of the hospice discharge summary; and the
patient’s clinical record (if requested)
•
Discharge summary must include summary of patient’s stay,
current POC, latest physician’s orders, any other
documentation that will help in post-discharge continuity of
care
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Rank
Tag #
Description
Medical Director CONDITION
Includes all standard-level deficiencies L 665 through L 669
3
(tie)
L 664
L 669
•
Only 1 medical director for hospice, including all multiple
locations
•
Initial certification and recertification of terminal illness
•
Assumes overall responsibility for the medical component of
the hospice’s patient care program
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Rank
Tag #
Description
Drugs and Biologicals CONDITION
Includes all standard-level deficiencies L 687 through L 703
4
(tie)
L 686
L 703
•
IDG, as part of POC, must determine the ability of
patient/family to safely self-administer drugs to patient
•
Hospice must supply medications for terminal condition
•
Meds must be ordered by physician or Nurse Practitioner
•
•
VO’s must be signed immediately by receiving person
& then signed by prescribing physician/NP
Safe use & disposal of controlled drugs
•
Must have P&P for safe use & disposal of controlled
medications
•
Must have documentation that controlled P&P were
discussed with patient and written copy given to
patient
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Rank
Tag #
Description
Infection Control CONDITION
Includes all standard-level deficiencies L 578 through L582
4
(tie)
L 577
L 582
•
Protects patients, families, visitors & personnel by
preventing & controlling infections and communicable
diseases
•
Includes a method of identifying problems and a plan
to implement actions
•
Identifies risks in all settings; establishes protocols
•
Must be part of QAPI program
•
Provides education to employees, contract employees,
patients, family members, other caregivers
•
Documentation!
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Rank
Tag #
Description
Residents of SNF CONDITION
Includes all standard-level deficiencies L 760 through L 782
4
(tie)
L 759
L 782
•
Written agreement with SNF signed by hospice AND SNF
before provision of hospice services
•
Agreement identifies who may receive/write orders
•
SNF’s must have physician’s orders/current plans of care
before they accept hospice patients
•
Hospice assumes responsibility for hospice services &
provides all supplies, medications, DME needed for terminal
illness
•
Core services must be routinely provided by hospice
employees; may not delegate to SNF staff
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Rank
Tag #
Description
Residents of SNF CONDITION (continued)
•
4
(tie)
L 759
L 782
POC established in consultation with SNF representatives
•
Specifies which provider is responsible for what
functions
•
Clearly outlines chain of communication in event of
crisis
•
Both providers’ portion of POC should include:
• Common problem list
• Palliative interventions and outcomes
• Responsible discipline
• Responsible provider
• Patient goals
•
POC changes must be discussed with patient and
approved by both the SNF and the hospice
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Rank
Tag #
Description
Residents of SNF CONDITION (continued)
•
4
(tie)
L 759
L 782
Coordination of Services – the hospice must designate a
member of IDG who is responsible for SNF patient (could be
RN, MD, SW, counselor)
•
Responsible to oversee and coordinate provision of care
between hospice and SNF
•
Documentation in both entities’ clinical records to
ensure continuity of communication and easy access to
information
•
Role of hospice in delivering medications/supplies
•
Ordering, renewal, delivery & administration of
medication
•
Role of attending physician and process for obtaining
and implementing physician orders
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Rank
Tag #
Description
Residents of SNF CONDITION (continued)
•
4
(tie)
L 759
L 782
Coordination of Services – hospice must provide the SNF:
•
Most recent POC specific to patient
•
Hospice election form; advance directives
•
Physician certification and recertification of terminal
illness
•
Names and contact information for hospice personnel
involved in patient’s care
•
Instructions on how to access 24-hour on-call system
•
Hospice medications
•
Hospice physician and attending physician (if any)
orders
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Rank
Tag #
Description
Residents of SNF CONDITION (continued)
4
(tie)
L 759
L 782
•
Hospice must orient and provide teaching to SNF staff r/t
hospice philosophy, hospice P&P regarding comfort, pain
control, symptom management, principles about death and
dying, individual responses to death
•
SNF remains responsible to furnish 24-hr room & board,
meeting personal care and nursing needs that would have
been provided by the primary caregiver at home at the same
level of care provided before hospice was elected
•
Facility staff should immediately contact hospice of:
•
Change in patient’s condition
•
Need to alter plan of care
•
Need to transfer patient from SNF
•
Patient dies
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Rank
Tag #
Description
Aide Competency Evaluation - must be completed before
aide furnishes hospice services
4
(tie)
L 615
The following skills must be evaluated after observation of aide’s performance with a
patient or real person:
• Reading & recording temperature, pulse and respiration
• Appropriate and safe techniques in personal hygiene and grooming that include
• Bed bath
• Sponge, tub or shower bath
• Shampoo, sink, tub or bed
• Nail and skin care
• Oral hygiene
• Toileting and elimination
• Safe transfer techniques and ambulation
• Normal range of motion and positioning
These skills may be evaluated through written examination, oral examination, or after
observation of an aide with a patient:
• Observation, reporting & documentation of patient status & the care or services
furnished
• Basic elements of body functioning and changes in body function that must be reported
to an aide’s supervisor
• Maintenance of a clean, safe & healthy environment
• Recognizing emergencies and knowledge of emergency procedures
• The physical, emotional & developmental needs of the patient, including the need for
respect for the patient, his or her privacy and property
UTAH MOST FREQUENT
HOSPICE DEFICIENCIES FISCAL YEAR 2016
Tag #
Description
Volunteer Cost Savings Report & Level of Activity
Documentation must include :
L 646
L 647
•
Identification of each position held by a volunteer
•
The work time spent by volunteers occupying those positions
•
Estimates of the dollar cost if paid employees occupied these
positions
•
Day-to-day administrative and/or patient care services that
equal 5% of total patient care hours of all paid staff
STATE OPERATIONS MANUAL
APPENDIX M:
Great Resource – includes guidance to surveyors
https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/som107ap_m_hospice.pdf
QUESTIONS????
Thanks for your time and participation!
Contact Information:
• [email protected]
• [email protected]
• [email protected]
• [email protected]
• Phone – 801.273.2994
• health.utah.gov/hflcra
• State Hotline – 800.999.7339