Compliance demands emerge as focus for hospice industry
Providers need to return to basics of Medicare rules
Compliance has become one of the hottest issues for the hospice industry, attendees at the National Hospice Organization (NHO) annual meeting in Atlanta discovered in October. The hospice industry is the target of heightened, ever-stricter scrutiny by state and federal surveyors who in the past may have let certain compliance issues slide because of hospice’s reputation for compassion and idealism. The lack of follow-up certification surveys for providers and training for surveyors may also have contributed to a tendency for some hospices to become careless on the finer points of Medicare regulations.
Reports at the Atlanta meeting from the front lines of Operation Restore Trust (ORT) surveys in California make it clear that the days of letting things slide are gone for good. Experiences of seven hospices surveyed in the Health Care Financing Administration’s (HCFA) Region IX underscore this new climate of heightened scrutiny. "This is one of the most important issues facing our industry," says Mary Taverna, RN, president of Hospice of Marin in Corte Madera, CA, and chairwoman of the California State Hospice Association (CSHA) ORT Task Force.
"Everybody’s experience will be different from now on," adds Claire B. Tehan, MA, vice president of hospice for Hospital Home Health Care Agency of California in Torrance, one of the "California Seven" ORT hospices. Her program required three certification surveys this year to satisfy regulators’ compliance demands. "I’d recommend that every one of you go back, pull out the conditions of participation, and reread them."
Allowing for local variations in surveyors’ expectations, the main issue for most providers involves going back to Medicare’s conditions and interpretive guidelines and scrupulously reviewing all facets of their programs on the basics of hospice regulations which they should have been following all along. Consultants also recommend setting up formal compliance programs, in order to institutionalize the process of continuous internal review. (See related story, p. 135.)
A new climate of scrutiny
"Lots of people are into ferreting out fraud and abuse. Sometimes it’s not even a violation of the rules but something the government calls waste," observes NHO general counsel Ann Morgan Vickery, JD. Multiple government agencies are involved in health care fraud efforts, and the number of convictions is rising. "They are spending money, bringing cases, and winning cases and getting settlements in a lot more," because providers may feel powerful incentives to settle out of court, Vickery says.
"We all have a tendency to make things go away in our minds that we don’t like," she adds. "If there’s a problem in the rules and laws, we need to change them, not ignore them."
What happened in the California ORT compliance audits, which began in March, caused "feelings of shock and disbelief," Taverna says. One hospice was decertified on the spot, while the other six were found to have conditions out of compliance for which they would be closed if not corrected. One passed on its second survey, and the remaining five required unprecedented third survey visits before passing. The hospices learned that when deficiencies are discovered, HCFA automatically launches a timetable to terminate certification, while plans of correction must contain evidence of actual change in practice. Hospices also discovered that in cases where they disagreed with surveyors’ interpretations, they still were obliged to make the changes because the alternative was termination.
"For all of us who went through this process, none of us would disagree that there’s always room for improvement," Tehan says. "But the process as it unfolded in California was inconsistent at best and openly hostile at worst. That may be an aberration. But I’ve been through a lot of surveys, and I was never treated like this." Hospices in other states may believe this kind of thing won’t happen to them, "but we’re giving you a heads-up."
"Because they had not done recertification surveys in California in years, providers haven’t been as precise as they should be," adds Sue Wells, MSW, a hospice consultant in San Diego. "We need to get back to what the regs say, but there also appear to be new interpretations of common practices that have never been articulated before. One thing people can do is to make sure they meet every letter of the law. But even so, an individual surveyor could come along with a whole new interpretation," she says. "And you either do it the way they want or you’re gone even if they are wrong."
CSHA responded quickly to the crisis, organizing an ORT Task Force within a week of the first surveys and setting up a process to meet regularly with HCFA Region IX staff. This group served as a liaison between HCFA, NHO, and CSHA members and developed educational tools, such as two workshops for providers. The meetings with HCFA focused on trends and issues identified by surveyors, rather than specific issues from any one program, Taverna says. "We feel the Task Force has been very successful in what we’ve been able to do. We kept the door to HCFA open and friendly." Twenty more ORT-like surveys are on tap for the next few months, and it is believed that every certified hospice in California will be surveyed in 1998.
A number of key themes and issues regarding compliance emerged from the Atlanta presentations on California’s ORT surveys. The following are some of the common areas questioned by surveyors or cited in deficiencies:
1. The plan of care must be established prior to initiating hospice care. The case manager must talk to the attending physician and one other member of the hospice interdisciplinary group (IDG) prior to starting care, and then confer with the rest of the group within 48 hours of admission. Changes in the plan of care must also be discussed by the IDG.
2. Professional management must be clearly spelled out in contracts for ancillary services, ideally with the contract written to display each required area as a titled section.
3. The role of the medical director must be specified, including intensive oversight and documented involvement in care planning for most patients. An earlier controversy over requiring a W-2 employment relationship with the medical director apparently was resolved by the 1997 Balanced Budget Act.
4. Continuous care must be provided by hospice employees, except in extraordinary circumstances.
5. Bereavement care requires demonstration of an individualized plan of care for each surviving client.
6. Documentation of volunteer hours and volunteers’ 5% contribution to overall hospice services, as well as of training and recruitment efforts, is needed.
7. Administrative separation of hospice and home health care operations, charts, payrolls and governing bodies is essential for dually certified hospices.
8. A nutritional assessment is required for every patient, and the hospice needs to employ a nutritional counselor as a core team member.
Throughout the California surveys, a theme emerged regarding the importance of process not just paper policies in demonstrating that the hospice team is truly interdisciplinary and involved in developing an individualized plan of care, with a high level of specificity and accuracy, for each patient. Standing orders and canned problem lists are discouraged. Surveyors are looking for evidence of collaboration and dialogue in the care planning. Outcomes need to be identified and pursued.
"It is important for you to have a good relationship with anybody who walks through your door. Don’t take an adversarial role" with surveyors, observes Alexander Peralta Jr., MD, medical director of Family Hospice in Dallas. Experts recommend a calm, polite, professional demeanor but avoidance of unnecessary casual conversation. Ask visitors for identification, type of survey being undertaken, schedule, and what they are looking for. Don’t face surveyors alone; get help from other agency staff. And give short, precise answers. Surveyors should be given an office on-site to do their work and prompt responses to their requests for information. The hospice may want to assign designated staff to the survey process until it is completed, as well as drawing in resources such as consultants or legal counsel. It should also notify its state and national trade associations.
These are some of the things that can be done after an ORT survey team arrives. More important is what the hospice does before any surveyors show up by developing an agency compliance plan aimed at preventing future survey problems (see related story, p. 135), running a mock survey and/or hiring someone from outside the agency to examine all phases of its operation with fresh eyes. "How recently have you taken 20 charts and gone through them to see what you could see?" Tehan asks hospice executives.
Hospices and their state associations need to develop positive working relationships with state surveyors, regional HCFA staff, and fiscal intermediaries. Work on problem solving together and push for regular surveys, Peralta says. But this should not preclude always challenging denials through appropriate channels for reconsideration, including administrative law judge hearings. The hospice medical director will have an essential role in such appeals, he adds.
"In retrospect, this is one of the better things that happened to us . . . although the process was extraordinarily painful," and cost hundreds of thousands of dollars, says Patricia Murphy, RN, MA, hospice coordinator for VNA and Hospice of Northern California in Emeryville. Because of the long hiatus between certification surveys, "we had not paid a lot of attention to the conditions of participation per se. No stone was left unturned in our survey; the level of detail is like nothing you have ever seen," Murphy tells hospices.
In response to citations and calls for evidence that the plan of care was developed before a patient was admitted to hospice, the VNA hospice established a whole new process of intake and initial care planning, she says. "The best hospice care has always been proactive hospice care trying to prevent crises. So now we’re rising to a new level of care. I think our staff would say they like care planning more now. Our psychosocial people say they feel more involved and have more communication with the nurses," Murphy says. But the process required going back and dusting off the Medicare conditions. "I look at the conditions of participation now and I wonder: How did we think we could get away with what we were doing before?"
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