It’s that time of year again when the blooming landscape and longer days inspire a thoughtful inspection of how well our homes are in order. As we know, it is not uncommon during this process to stumble upon some areas of wear and tear that need fixing (e.g., broken gutters, missing shingles, clogged vents, the dreaded discovery of mold, etc.). We know that taking a proactive approach can often prevent costly repairs down the line.

As a hospice provider, taking stock of your program, including both its preparedness for an audit and readiness for a survey, is no different.

Clinical Record Audit Preparedness

Clinical record audits conducted by the Medicare Administrative Contractor (MAC) or other government contractors (e.g., Zone Program Integrity Contractor (ZPIC), Recover Auditor (RA), or Medicaid Integrity Contractor (MIC), etc.) are related to the Conditions for Coverage (i.e., Subpart B – Eligibility, Election, and Duration of Benefits; Subpart F – Covered Services; Subpart G – Payment for Hospice Care; and Subpart H – Coinsurance). The focus of an audit rests on whether hospice eligibility and the medical necessity of hospice services have been established and supported by clinical record documentation.

Think of audit-preparedness as ensuring that the “bones” of the house (e.g., the foundation, the roof, support beams, etc.) are solid and well-constructed. Without these fundamental elements, the house is at risk of collapsing.

When faced with payment-related scrutiny (i.e., audits and investigations), hospice providers must prove that hospice eligibility and the medical necessity of services have been established by demonstrating compliance with the following clinical record documentation components:

  • All technical requirements were met (i.e., valid and timely Election of Benefit (EOB) statement, certification/recertification of terminal illness, physician narrative statement, face-to-face encounter, and plan of care);
  • The physician’s determination of a life expectancy of 6 months or less and the medical necessity of hospice services is supported by the documentation in the clinical record; and,
  • There is documentary evidence substantiating eligibility for any higher level of care episode (i.e., the General Inpatient (GIP) and Continuous Home Care (CHC) levels of care).

If the documentation associated with these requirements is deficient, providers are confronted with potentially significant payment denials, which could ultimately impact the viability of the hospice program itself.

So, how do you ensure that the “bones” of your hospice program are in order? Below are some ideas to help you get started.

Audit-Preparedness Checklist

__   Evaluate the organizational systems surrounding compliance with the Conditions for Coverage.

__   Are program policies and procedures supportive of compliance with these regulatory requirements?

__  Review, and revise as needed, the language in all technical forms to ensure that it complies with all regulatory requirements.

__  Consider using the Medicare Hospice Election Statement sample form recently published by the Centers for Medicare and Medicaid Services (CMS)

[1].

__  Evaluate whether sufficient internal processes are in place to ensure that all technical requirements are met prior to           submission of claims for payment.

__  Assess the systems surrounding interdisciplinary documentation practices to ensure that all IDG members’ documentation is sufficient to support payment. For example:

__  How and when are the applicable Local Coverage Determination (LCD) guidelines used?

__  Does the documentation speak to secondary and comorbid conditions, in addition to the principal terminal diagnosis?

__  Are assessment tools (e.g., Palliative Performance Scale (PPS), Functional Assessment Staging tool (FAST), New York Heart Association (NHYA) classification system, etc.) used consistently and appropriately and do narrative descriptions support the selected scores?

__  Does your hospice have systems in place to review clinical record documentation to ensure that it is sufficient to support payment prior to submitting a claim for payment?

__  Appraise the internal mechanisms pertaining to the determination of appropriateness for a higher level of care, including how this is captured in the clinical record. For example:

__ What is the process to validate medical necessity prior to a patient’s admission or transfer to the GIP or CHC levels of care? Is this process consistent with regulatory requirements and supported by organizational policy?

__ Does the documentation consistently illustrate the medical necessity of the higher level of care?

__ Does the clinical record reflect that the higher level of care was both needed by the patient and provided by the hospice?

__ Does your hospice have systems in place to review all higher level of care documentation to ensure that it is sufficient to support payment prior to submitting claims?

__  If you have opportunities for improvement related to technical requirements or clinical eligibility documentation, do you use your hospice’s Quality Assessment Performance Improvement (QAPI) program to initiate performance improvement projects?

Survey-Readiness

State or Accreditation Surveys, on the other hand, focus on the Conditions of Participation (i.e., Subpart C – Conditions of Participation: Patient Care and Subpart D – Conditions of Participation: Organizational Environment). As stated by CMS[2]:

“The hospice outcome-oriented survey process emphasizes the hospice’s performance and its effect on patients…The primary focus of the survey is on patient outcomes, the hospice’s practices in implementing the requirements, and provision of hospice services.”

Envision those aspects of a home that foster a safe environment and promote a positive living experience (e.g., effective plumbing, smoke detectors, natural lighting, etc.). Similarly, surveyors evaluate whether the operations of a hospice program support safe and favorable patient outcomes, and focus on the regulatory requirements surrounding patient care and the organizational environment. A deficiency found in any of these areas will result in the need for the hospice provider to correct the impairment. The most frequent survey deficiencies identified by CMS during calendar year 2016 were as follows:

  1. 418.56(b) Standard: Plan of care
  2. 418.56(c) Standard: Content of the plan of care
  3. 418.76 (h) Standard: Supervision of hospice aides
  4. 418.64(b) Standard: Nursing services
  5. 418.54(c)(6) – Drug profile
  6. 418.56 (c)(2) Standard: Content plan of care
  7. 418.60(a) Standard: Prevention
  8. 418.56(e)(2) Standard: Coordination of services
  9. 418.54(b) Standard: Timeframe for completion of the comprehensive assessment
  10. 418.78(e) Standard: Level of activity.

The nature of the deficiency will dictate the necessary course of action thereafter. That being said, it is important to have an understanding of all possible outcomes associated with a survey, including the dreaded “worst case scenario”.

Consider what happens in a “worst case scenario” for a home inspection. If the home has been deemed unfit for human habitation, it will be condemned and the homeowner will have to vacate the premises if the issue(s) cannot be resolved immediately.

Similarly, if a surveyor identifies, “A situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident”[3], then the hospice provider is placed on what is called “Immediate Jeopardy.” This can put the provider’s licensure to operate at risk if the problems are not rectified immediately.

So, how do you cultivate a culture of survey-readiness in your hospice program? Consider the checklist items listed below as a launching pad for your hospice’s “spring cleaning” efforts.

Survey-Readiness Checklist

__  Identify when the most recent survey of your program occurred (remember, all Medicare-certified hospice programs are now required to be surveyed at least every three years), and examine the outcome.

__  If deficiencies were cited, were the impaired systems corrected as indicated in the submitted Plan of Correction? If not, why not?

__  Were these findings incorporated into the hospice’s QAPI program?

__  Evaluate the organizational systems surrounding compliance with the Conditions of Participation.

__ Are policies and procedures supportive of compliance with the requirements identified in the Conditions of Participation?

__  Do any internal monitoring systems include assessment of whether these requirements are being met? If so, which ones? How often are they evaluated and what actions steps are taken if findings of non-compliance are discovered?

__ Examine the education and training model provided to staff members in relation to the Conditions of Participation.

__ Does compliance-related training occur during the orientation process? If so, what does it look it? Is it comprehensive or focused only on specific areas?

__ How do you ensure that ongoing training and education is provided to staff members, as needed, to ensure compliant practices?

__  Are there new members of your leadership team who have not had previous experience with a survey? If so, what sort of survey preparation training might be beneficial?

__  Consider conducting a mock survey of your program to identify any areas of risk and opportunities for improvement. The State Operations Manual Appendix M2 is a great resource to develop an internal mock survey process.

As you embark upon the spring cleaning of your hospice program, keep in mind that, as with a home, you will likely unearth some unanticipated areas in need of repair and fixing. Just like you’d probably want to fix a leaking roof before dealing with a leaky faucet, understanding the difference between and the potential ramifications of audits and surveys will help you prioritize which “repairs” to tackle first.

Happy Cleaning! (And Happy Spring!)

[1] CMS. (December 13, 2016). MLN Matters Number: SE1631

[2] CMS. State Operations Manual Appendix M – Guidance to Surveyors: Hospice (Rev. 149, 10-09-15).

[3] CMS. State Operations Manual, Appendix Q – Guidelines for Determining Immediate Jeopardy – Rev.1, 05-21-04.