Others suggested that a review of the patient's goals would be more appropriate. (1) The hospice must report the following information to CMS: (i) Each unexpected death that occurs while a patient is in restraint or seclusion. Aggregation of data must be done in accordance with the policies and procedures established by the hospice. The time and cost burden for these providers is less than that of the average hospice used in part B of this section because a portion of the burden associated with these regulations is directly related to patient care and the staff necessary to provide care. (iv) Operated under temporary management that was appointed by a governmental authority to oversee the operation of the home health agency and to ensure the health and safety of the home health agency's patients. The existing plan of care requirement at 418.58(c) mandated that the hospice describe the scope and frequency of services. Condition of participation: Drugs and biologicals, medical supplies, and durable medical equipment. We have adopted the suggestion and have incorporated a broader description into the requirements for counseling services at 418.64(d). (ii) By trained staff using both video and audio equipment. In this way, the election form is not linked to the content of the written agreement. In 418.58(c) of the existing hospice regulations, hospices are required to state in detail the scope and frequency of services needed to meet the patient's and family's needs. We note that the proposed requirement that the plan of care include, [a] detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs is very similar to the requirement that has existed for the last two decades. An average hospice that does not operate its own inpatient unit and does not need to hire an MSW, accounting for the vast majority of hospices, will expend $11,151 to comply with this final rule in the first year. (ix) Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: (x) Safe transfer techniques and ambulation. (a) Licensed professional services provided directly or under arrangement must be authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under 418.114 and who practice under the hospice's policies and procedures. (2) Dietary counseling. However, due to the rapidly changing status of hospice patients, it is standard practice for a hospice to update a patient assessment at least every 15 days, and often more frequently. Comment: One commenter suggested that we should delay implementing the criminal background check requirement until completion of the background check demonstration project called for by the MMA. All of these standards require the hospice to maintain documentation that each hospice aide meets these qualifications. The wound care provided by the registered nurse results in the pressure ulcer healing. If a hospice chooses to include any of these areas that are directly related to providing direct patient care or administrative services in its percentage calculation of volunteer hours, it must ensure that the time spent by its paid employees and contractors for the same activity is also included in the calculation. In addition to consulting with the hospice interdisciplinary group (IDG) regarding the patient's hospice care, the attending physician retains responsibility for meeting the patient's needs that are not related to the terminal illness and that terminal illness's related conditions. A hospice may also enter into a written agreement with another Medicare-certified hospice program for the provision of the core services. Some larger hospices have several physicians who may serve on IDGs, and it is the physician member of the IDG, whether he or she is the medical director or not, who shares the responsibility with the rest of the IDG for communicating with other physicians and health care providers and for ensuring that the care furnished by the hospice reflects hospice policy. Comment: A commenter was confused about the requirements for chapter 9 of the Life Safety Code, as included in proposed 418.110(d)(4). A multiple location must meet all of the conditions of participation applicable to hospices. The multiple location is part of the hospice and shares administration, supervision, and services with the hospice that was issued the certification number. The ability of hospices to tailor the exact content of the comprehensive assessment, and the individuals who complete it, to the needs of patient and families addresses concerns about extremely short stay patients who may not be contacted by all disciplines before death. Hospices must complete this abbreviated assessment in 48 hours. Hospices would also have been required to document the patient's or representative's understanding of the notice of rights. We believe that this review will allow the collection of the necessary information from which to make a determination. Response: We agree that defining this term will help clarify what responsibilities this individual has as well as when those responsibilities are assumed. Start Printed Page 32151. Comment: A commenter suggested that hospices be required to educate the facility staff regarding the individualized plan of care for each hospice patient who resides in the facility. Before the recertification period for each patient, as described in 418.21(a), the medical director or physician designee must review the patient's clinical information. (h) Standard: Toilet and bathing facilities. These standards further proposed that staffing must meet the needs of patients to ensure that each patient's plan of care is adhered to and that the outcomes described in each patient's plan of care are achieved. It requires a hospice to include all relevant patient care information in each patient's clinical record in order to facilitate communication and coordination among all disciplines involved in a patient's care. Read together, these requirements require hospices to develop, implement, and assess performance improvement projects that reflect their areas of weakness, as identified through the data that they have collected, and the needs of their organizations. As a result of changes made to the Act by the BBA, we also proposed to add a provision to the CoPs permitting hospices to contract for physician services. The description of these phases, and the hour and dollar estimates that accompany them were not available at the time that the proposed hospice rule was published. In particular, commenters suggested that we eliminate the requirement that hospices assess spiritual or potential bereavement issues as part of the comprehensive assessment. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small government jurisdictions. (1) The hospice must ensure that the interdisciplinary group confers with an individual with education and training in drug management as defined in hospice policies and procedures and State law, who is an employee of or Start Printed Page 32213under contract with the hospice to ensure that drugs and biologicals meet each patient's needs. Under section 1861(dd) of the Act, the Secretary is responsible for ensuring that the CoPs, and their enforcement, are adequate to protect the health and safety of individuals under hospice care. Clinical records. Comment: Many commenters requested that changes be made to the proposed definition of attending physician. Some of these commenters requested that, in addition to nurse practitioner, we also add advanced practice nurse, clinical nurse specialist, and physician's assistant to the definition of attending physician in order to broaden the category of individuals who could receive payment in that capacity. We require that before staff apply restraints, implement seclusion, perform associated monitoring and assessment of the restrained or secluded patient, or provide care for a restrained or secluded patient, the staff must be trained and able to demonstrate competency in the performance of these actions. Educate hospice employees and contractors on the new domains and measures, as well as the policies and procedures for them. A primary concern of the commenters was the proposed requirement that the written agreement must include the written consent of the patient or the patient's representative that hospice services are desired. This guidance presents four areas for hospices to consider when developing and implementing strategies to meet the needs of limited English proficient persons. Commenters believed that one of the biggest barriers to the EHR was the potential to allow personal health records to automatically be left available to the patient/caregiver. Modifying the requirement does not mean that hospices are prohibited from identifying and/or addressing issues and areas of patient need outside of the hospice benefit, even though hospices are not responsible for providing services for these issues. A hospice may also enter into a written arrangement with another Medicare certified hospice program for the provision of core services to supplement hospice employee/staff to meet the needs of patients. Section 418.100(g) describes the standard for training. These commenters suggested that we require hospices to have a board certified chaplain as a member of the IDG because board certified chaplains are routinely educated and trained to work with individuals from various, non-Judeo-Christian faiths. Except as otherwise provided in this section, the hospice must meet the applicable provisions and must proceed in accordance with the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 122, TIA 123, TIA 124, TIA 125 and TIA 126). Only personnel authorized to administer controlled drugs as noted in paragraph (d)(2) of this section may have access to the locked compartments; and. Therefore, we agree with the commenters that the plan of care must be individualized to meet all of the needs of the patient and family related to the terminal illness and related conditions. Condition of Participation: Personnel Qualifications (418.114), 18. Many of these commenters requested that hospices not be required to furnish written notices in obscure or otherwise uncommon languages. Hospices are permitted to use the written or electronic form or tool that best suits their needs and their patients' needs, provided that the information gathered in the assessments is complete and available in each patient's clinical record. This final regulation reinforces those positive infection control practices and addresses the serious nature of infectious and communicable diseases. We replaced the proposed extraordinary lengths requirement with a requirement that reasonable efforts must be made. Executive responsibilities: The hospice's governing body is responsible for ensuring the following: (1)That an ongoing program for quality improvement and patient safety is defined, implemented and maintained; That the hospice-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; and, That clear expectations for patient safety are established, Infection Control: The hospice must maintain and document an effective infection control program that protects patients, families and hospice personnel by preventing and controlling infections and communicable diseases, A plan for the appropriate actions that are expected to result in improvement and disease prevention, Licensed professionals must actively participate in the coordination of all aspects of the patient's care, in accordance with current professional standards and practice, including participating in ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, and contributing to patient and family counseling and education; and, Core Services: A hospice must routinely provide substantially all core services directly by hospice employees. This final rule revises the existing conditions of participation that hospices must meet to participate in the Medicare and Medicaid programs. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a metropolitan statistical area and has fewer than 100 beds. This section requires hospices to review a patient's prescription and over-the-counter drugs in use at the time of the assessment, including, but not limited to, an identification of the effectiveness of the drug therapy regimen, any potential or existing drug side effects, any potential or existing drug interactions, any duplicate drug therapies, and any drug therapy requiring laboratory monitoring. In addition, CMS can waive the requirement that a hospice provide dietary counseling directly. The core services requirement at 418.64 applies equally to both facility and community residents. Therefore, we believe that this maintenance requirement does not impose a burden. We believe the requirements in this final rule compliment and encompass the existing Medicare hospice certification requirements and may enhance the health and safety of patients by ensuring that hospices have all relevant information about a patient in the patient's record. Likewise, the hospice would have to ensure that the patient, family, and other caregivers could demonstrate the safe use of such equipment and supplies to the satisfaction of hospice staff. (2) The hospice must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. We are hesitant to make impact estimates in this final rule that may not account for these and other unforeseen variations. Additionally, as the commenters noted, the term toxic is unnecessary. As the patient's condition changes, the plan of care changes as well. One commenter suggested that the role of the governing body should be augmented by requiring it to monitor the QAPI program rather than simply ensuring that is it functioning. Individuals providing staff training must be qualified as evidenced by education, training, and experience in techniques used to address patients' behaviors. While we would expect the hospice to adhere to best practices, we are not requiring any specific approaches. The hospice may seek a waiver of the requirement that it make physical therapy, occupational therapy, speech-language pathology, and dietary counseling services (as needed) available on a 24-hour basis. Another commenter suggested that by contracting with a DME supplier that met the Medicare Supplier Standards, hospices would have more assurance that the DME provider would safely and effectively perform its maintenance and instruction duties. Therefore, this rule will cost most hospices $11,151 in the first year. Thus, it is the hospice's ultimate responsibility (as it is with respect to all of its contracted services) to ensure that maintenance is performed on DME equipment, regardless of the source of such equipment. Revised 418.76 by changing its name from Home health aide and homemaker services to Hospice aide and homemaker services.. The 1,161 surveys in 2006 represent approximately 30 percent of all hospices. The burdens associated with this requirement is considered to be usual and customary as stated in 5 CFR 1320.3(b)(2) and is thereby exempt from the PRA. The hospice must organize, manage, and administer its resources to provide the hospice care Additionally, we required recordkeeping for documenting in each trained individual's personnel record that he or she has successfully completed training. All care provided must be in accordance with this plan, The plan must reflect the hospice's policies and procedures in all aspects and be based on an assessment of the patient's needs and unique living situation in the facility. Of these employees and volunteers, 32,412 employees and volunteers were nurses and physicians. (4) An agreement that it is the SNF/NF or ICF/MR responsibility to continue to furnish 24 hour room and board care, meeting the 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 care was elected. Other commenters stated that the proposed rule fails to recognize the national nursing shortage. Start Printed Page 32150. However, patient assessment and monitoring are standard components of patient care, and this requirement does not pose a burden to a hospice. We require in 418.104(a)(4) that the patient care outcome measure data be included in the patient's clinical record because hospices must use such data for individual care planning and coordination of services (418.54(e)(2)). and. If no State license exists for a particular discipline, and if that individual meets all other personnel and training requirements as required by this rule and any other applicable Federal, State, or local laws, regulations, policies, and requirements, then it is acceptable for that individual to furnish services to hospice patients absent a State license. (f) Standard: Use and maintenance of equipment and supplies. Hospices are free to choose the method that best suits their needs when documenting the comprehensive assessment and the updates to that assessment. (iv) Develop a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery. (d) Standard: Update of the comprehensive assessment. Response: We agree that it is appropriate to re-name aides who furnish hospice care in order to differentiate them from aides who furnish care in other environments. Any additional effort by hospice personnel to meet these requirements will, we believe, be offset by the reduced costs associated with the provision of more effective and efficient patient care. The final rule makes several changes to the existing rule to improve patient care and lessen burden. We do not believe that it is appropriate to require hospices to use specific criteria to guide the selection of a spiritual counselor. It is the essential link between the needs of the patient and the actions of the hospice. Rather, the commenters stated, the SNF/NF or ICF/MR should furnish services in the role of the primary caregiver at the same level that would have been provided if the resident had not elected to receive hospice care. As part of CMS review process, a hospice's waiver request must meet the criteria outlined in 418.74(a)(1)-(2). Response: The commenters are correct in their assertion that the initial assessment must be completed, not just started, within the timeframe. In final 418.100(g)(1) we now require hospices to educate all hospice employees who have patient contact in the hospice philosophy. Therefore, we estimate that it will cost $1,680 annually to update each person's training. (2) A hospice that provides inpatient care directly in its own facility must provide pharmacy services under the direction of a qualified licensed pharmacist who is an employee of or under contract with the hospice. These tasks, which are often part of following-up on referrals from other providers, must already have been completed before the initial assessment is completed. Therefore, we have separated this requirement into two parts. Response: Hospices are responsible for furnishing all care and services related to the terminal illness and related conditions as those services are identified in the plan of care, regardless of where the patient resides. Deleting or greatly extending the timeframe, as a few commenters suggested, would be out of step with current standards of practice and would likely lead to negative patient outcomes. The commenters were particularly interested in proposed 418.76(g)(3)(iv), which would permit hospice aides to provide assistance in administering medications that are ordinarily self-administered. This may be particularly helpful to hospices that have occasion to furnish services under contract where a nurse or other practitioner may be more familiar with the rules governing restraints in hospitals. The Act permits hospices to contract for counseling services as well as other core services, only under extraordinary or otherwise non-routine circumstances such as short-term staffing shortages, periods of peak patient loads, and travel of a patient outside of a hospice's service area. Classroom and supervised practical training combined must total at least 75 hours, (2) A minimum of 16 hours of classroom training must precede a minimum of 16 hours of supervised practical training as part of the 75 hours. In the proposed rule we differentiated this initial assessment from the hospice's evaluation of a patient's appropriateness for hospice care. As defined in 5 CFR 1320.3(b)(2), this process is a usual and customary business practice. If a patient and family did desire spiritual counseling, then a hospice would be expected to facilitate visits by local clergy, pastoral counselors, or others to the best of its ability. Other commenters agreed with our proposal to require that the nursing services provided by the hospice must meet patient needs rather than requiring hospices to have a registered nurse on duty at all times. (1) Except as otherwise provided in this section. Second, we added a specification for the maintenance of in-service training records to help a hospice document its compliance with the provision of in-service training requirement. Rather, at 418.3, we are deleting the entire list of examples because they are unnecessary and may be confusing. Although hospices are not excluded from providing training, we caution all hospices to ensure that training furnished by other providers meets all of the requirements of this rule and is of the highest quality. All facilities providing the general inpatient level of care, whether operated by the hospice or under arrangement with the hospice, must provide 24-hour RN care if at least one hospice patient is receiving general inpatient care. As described above, if a State has criminal background check requirements for a specific discipline, and the hospice complies with the State requirements for that discipline, then the hospice is in compliance with this Federal criminal background check requirement. We believe the burden is exempt as stated in 5 CFR 1320.3(b)(2); this is a usual and customary business practice. Response: Ethical research practices dictate that patients must choose to participate in experimental research and that their participation or lack thereof may not negatively impact their well-being. This waiver would be based on whether the hospice was already providing direct inpatient care in a non-compliant facility when this regulation became effective. For this reason, we have extended the timeframe from four days to five days. Response: We agree that the proposed requirement implied that a new written agreement must be developed for each resident who receives hospice services. If a substitute supervising RN is used, this should be noted. (ii) The use of nonphysical intervention skills. However, the use of this type of written agreement is a usual and customary business practice; the associated burden is exempt from the PRA under 5 CFR 1320.3(b)(2). We have made this change in 418.64(d)(1)(i). The proposed QAPI requirement would raise the performance expectations for hospices seeking entrance into the Medicare and Medicaid programs, as well the expectations of those currently participating in Medicare and Medicaid. We are not mandating this as a requirement. Response: The phrase day-to-day, as used, requires hospices to incorporate volunteer services into their daily patient care and operations routine in order to retain the volunteer-based essence of hospice as it originated in the United States. Response: Notations in a patient's clinical record by individuals furnishing services on behalf of a hospice are standard practice. Comment: A majority of commenters addressed the issue of the length of time necessary to complete the comprehensive assessment. Response: We agree that hospices should only be held responsible for investigating and reporting violations pertaining to their own employees and contractors. (2) Hospice aide. The hospice must: (1) Designate a member of each interdisciplinary group that is responsible for a patient who is a resident of a SNF/NF or ICF/MR. By allowing hospices to contract with specialized nursing providers or others to provide these highly specialized nursing services to the few patients who require them, hospices would be able to better implement an efficient staffing plan and ensure proficiency in the skilled services being provided. An individual may furnish personal care services, as defined in 440.167 of this chapter, on behalf of a hospice agency. Hospices may also consider immunizing their patient care staff for influenza as part of their infection control programs. (d) If a hospice wishes to receive a 1-year extension, it must submit a request to CMS before the expiration of the waiver period and certify that conditions under which it originally requested the waiver have not changed since the initial waiver was granted. Therefore, we are not adopting the supervision requirements from part 483. contact the publishing agency. Hospices are seeking to use drugs more effectively and efficiently to improve patient outcomes and reduce costs. Response: We agree that a more definitive time point needs to be established and that patient and family wishes should be taken into account when establishing this timeframe. We also proposed that, as part of the contract, a copy of the inpatient clinical record and discharge summary would have to be available to the hospice at the time of discharge from the inpatient facility. In-service training may occur while an aide is furnishing care to a patient, (1) In-service training may be offered by any organization except one that is excluded by paragraph (f) of this section, and must be supervised by a registered nurse, (2) The hospice must maintain documentation that demonstrates the requirements of this standard are met. Therefore we are setting forth this requirement as final. (iii) Has a baccalaureate degree from a school of social work accredited by the Council on Social Work Education, is employed by the hospice before December 2, 2008, and is not required to be supervised by an MSW. Response: We understand that some hospices are confused by the proposed requirement that patient-specific comprehensive assessments should be updated at regular intervals. Comment: A few commenters asked us to define urban area.. In standard (b), Exercise of rights and respect for property and person, we proposed that the patient would be able to exercise his or her rights, be respected, voice grievances, and not be subjected to discrimination or reprisal. $14 an hour for an office employee to document compliance/60 minutes = $0.23 minute 5 minutes per aide to document compliance = $1.17 1 document per year = $1.17 per hospice, $1.17 per hospice 2,872 hospices = $3,360, 5 min to document 2872 hospices = 14,360/60min = 239 hours. The hospice must organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions. This standard was designed to ensure that all physicians, including those in leadership positions, were in agreement regarding the patient's care to ensure that duplicative and/or conflicting physician orders are not issued for patient care. Furthermore, hospices should make all reasonable efforts to have written copies of the notice of rights available in the language(s) that are commonly spoken in the hospice's service area. Section 418.76(b)(4) requires that a hospice maintain documentation demonstrating that its training program meets the requirement of the standard contained in 418.76(b). Have a Master of Social Work (MSW) degree from a school of social work accredited by the Council on Social Work Education, and one year of experience in a health care setting; Have a baccalaureate degree in social work (BSW) from a school of social work accredited by the Council on Social Work Education, and one year of experience in a health care setting; or. Webtips for survey readiness Even during a public health emergency (PHE), Home Health and Hospice providers are required to complete a Medicare re-certification survey.
List Of Doctors Who Accept Medi-cal Near Hamburg,
Why Does God Have Different Names,
Texas Comptroller Quarterly Sales Tax Due Dates,
Articles C