CA hospices wrestle with compliance surveys
Otherwise, ORT front remains quiet for hospice
The Operation Restore Trust (ORT) fraud-and-abuse front was mostly silent on hospice nationally in recent weeks as the industry awaited a much-discussed Office of Inspector General report on hospice care provided in nursing homes. This report, which was scheduled for release in July, is expected to find systemic problems with the nursing home hospice benefit in such areas as patient eligibility and different levels of service provided by hospices in the nursing home vs. private residences.
As far as Hospice Management Advisor’s inquiries could determine, ORT has so far produced no criminal charges against hospices, nor has there been any attempt to recoup money from hospices singled out in last year’s widely publicized ORT length-of-stay audits.
In California, however, providers continued to struggle with ORT-related compliance audits by staff from Health Care Financing Administration’s (HCFA) Region IX office in San Francisco, which could be a harbinger of things to come for hospices in the other 49 states. Earlier this year, seven audits of well-established hospice programs uncovered numerous violations of the Medicare conditions of participation, some of which have been hotly contested by the hospices. An ORT Task Force of the California State Hospice Association (CSHA) has been meeting with HCFA Region IX staff to clarify and iron out some of these differences. One concession by HCFA was to delay the 13 remaining audits in its hospice survey plan until after workshops on the conditions of participation could be provided to hospices across the state.
A total of 227 Northern California hospice managers attended a full-day session June 30 in Sacramento which walked participants through the Medicare conditions of participation as contained in HCFA’s State Operations Manual. Two days later, a slightly smaller number assembled for a similar session in Costa Mesa in Southern California.
At the Sacramento session, HCFA regional staff member H. Donna Dymon, PhD, explained the history of ORT and its progeny in federally funded regional and state compliance projects conducted since the formal expiration of ORT on March 31. She also explained what providers can expect from a compliance audit. Other major issues covered at the session included the following:
- core staffing requirements and hospice’s need to employ staff dietitians;
- the plan of care and the need for a single unified plan of care with skilled nursing facilities for hospice patients residing in nursing homes;
- the requirement that the hospice employ a medical director who assumes overall responsibility for the medical component of the hospice’s patient care program as well as documentation and continuity of care.
"It dawned on us that a number of hospices did not understand the routine survey process and procedures," explained presenter Mary Taverna, president of Hospice of Marin in Corte Madera and chairwoman of CSHA’s ORT Task Force.
One of the key points that emerged from discussions with HCFA is that surveyors will issue a notice of intent to close an agency when deficiencies are uncovered during a compliance audit a frightening prospect for providers. When providers issue plans of correction in response to cited deficiencies, these must be specific in every area cited, and every deficiency must be carefully considered.
"Our ability to comply with the regulations in 1983 is far different than it is today," Taverna says. Hospices in California have been infrequently surveyed in recent years, and many have let their compliance with regulations slide in certain areas that were not rigorously enforced.
Some of the controversies emerging from the recent round of HCFA audits in the state may reflect Medicare requirements "where you may not like the answer," Taverna said. Other issues may be addressed in the planned revision of hospice conditions of participation by HCFA or in the Medicare Hospice Benefit Amendments of 1997, which passed both houses of Congress earlier this summer. (See related story, p. 96).
Surprising interpretation
One of the biggest surprises for many hospices was discovering that more than one member of the core team is required to communicate with each other in the development of an initial plan of care prior to initiating hospice services. The nurse or hospice physician could do this in consultation with the attending physician and at least one other member of the core team. The other two members of the interdisciplinary group (IDG) would need to add their input, either by meeting or communicating over the telephone, within two calendar days after the start of care, to expand on the initial plan of care.
This requirement has led some surveyed hospices to convene the team for a brief meeting (with the hospice medical director present) two or three days a week.
This interpretation was confirmed in a June 27 memo to HCFA regional administrators by Thomas Hoyer and Robert Streimer of HCFA’s central office. "It is not permissible for the attending physician to provide the sole guidance for the plan of care or for the hospice medical director to do so. The law and regulations require that it be the combined work of the IDG."
Another area of uncertainty is the status of "pre-hospice" or bridge programs. Can certified hospices, as part of their hospice programs, provide something less than Medicare-mandated benefits to patients who have not elected the Medicare benefit and are not receiving certified home health care?
"You still must hold to the conditions of participation, regardless of payment source," or no payment, Dymon said in the memo. In a subsequent conversation with HMA, Hoyer expands on the question. "The answer is to look at the conditions of participation. There is a clear description of the things you have to do with all of your patients, just to do business with Medicare as a hospice."
HCFA Region IX plans to issue a provider advisory soon on whether the hospice medical director must be a direct, as opposed to contract, "employee" of the hospice. CSHA also plans additional workshops on two other difficult issues left unfinished by its recent workshops one on the plan of care and the other on how to separate the operations of home health and hospice for dually certified agencies. CSHA will also compile a list of outstanding questions and issues and submit this list to HCFA for further clarification.
[Copies of handouts from the California ORT meetings, including the June 27 Hoyer-Streimer memo, are available at cost from CSHA (916) 441-3770.]
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