We believe that this approach, rather than carving out certain sections of the comprehensive assessment, best meets the flexibility needs of hospices and the care needs of patients. This guidance presents four areas for hospices to consider when developing and implementing strategies to meet the needs of limited English proficient persons. This in no way prohibits a hospice patient from residing in an assisted living facility or licensed group home. Providing comfort to residents, regardless of whether those residents receive hospice care or not, would positively impact their well-being. The second proposed standard at 418.58(b), Program data, would require the hospice program to incorporate quality indicator data, including patient care, administrative, and other relevant data, into its QAPI program. In order to fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995 requires that we solicit comment on the following issues: The need for the information collection and its usefulness in carrying out the proper functions of our agency. The attending physician is typically someone with whom the patient had a relationship before electing to receive hospice care. Section 418.76(h)(3) details the contents of the registered nurse's assessment required in 418.76(h)(3). As hospice quality measurement and best practices continue to evolve, we believe that a set of measures and practices may be identified, and that such measures and practices may be appropriate for inclusion in the hospice rules. Condition of participation: Hospice aide and homemaker services. Predicting changes in patient status and the related plan of care is too difficult; therefore, we agree that this requirement should be deleted. The commenters requested that hospices be allowed to have multiple locations (previously known as satellite locations) and also asked about the procedures for the approval of such locations. (6) Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property; (7) Receive information about the services covered under the hospice benefit; (8) Receive information about the scope of services that the hospice will provide and specific limitations on those services. The hospice philosophy focuses on using multiple treatment modes to make patients physically, emotionally, and spiritually comfortable. Response: These levels of care are payment rather than health and safety issues, and therefore we are not addressing them in this rule. We also revised 418.56 (a)(1)(iv), to retain the existing hospice requirement that the hospice IDG must include a pastoral or other counselor. If a hospice does not fulfill its responsibility and take all appropriate actions to ensure the health and safety of its patient in accordance with the requirements of this final rule, then that hospice will be held accountable for its actions. (vi) Before January 1, 1966 was licensed or registered, and before January 1, 1970, had 15 years of fulltime experience in the treatment of illness or injury through the practice of physical therapy in which services were rendered under the order and direction of attending and referring doctors of medicine or osteopathy. However, if the patient is admitted for a reason other than the need for short-term respite care, or for symptom management or pain ---control, then the patient is not receiving an inpatient level of care that counts toward the 20 percent inpatient cap. The official, published CFR, is updated annually and available below under Condition of Participation: Hospice Aide and Homemaker Services (418.76), 14. Counseling services must include, but are not limited to, the following: (1) Bereavement counseling. (3) Ensure that the care and services provided are based on all assessments of the patient and family needs. Response: While the results of the MMA background check demonstration project may provide further clarification on the particulars of implementing background check requirements in health care, we do not believe that it is appropriate to delay this important requirement. The National Quality Forum also issued the National Framework and Preferred Practices for Palliative and Hospice Care Quality (2006, www.qualityforum.org). Response: The term unnecessary drugs did not appear within the proposed rule. A commenter also asked us to include a waiver for individuals who have been reformed as well as protections for hospices to choose to terminate an individual's employment based on the results of the criminal background check. Periodic training is one way to assure that staff take all appropriate infection prevention and control precautions. Response: We agree with the commenter in that care of the general inpatient and respite patient must be coordinated by the hospice. (g) Standard: Training. Response: Effective supervision of medical social services is essential for ensuring high quality care. Comment: Many commenters requested that we broaden the definition of counseling services to address the purpose of counseling services rather than naming precisely which types of counseling services are included in hospice. These markup elements allow the user to see how the document follows the Additional commenters suggested that language from the home health agency CoPs at 42 CFR 484.10 should be used in the hospice CoPs. Response: We do not believe that the medical director requirement in the current regulation is sufficient, because it does not address the issues of contracting for medical director services, physician designees, or the role of the medical director in certifying and recertifying terminal illness status. However, the commenters were divided on whether or not services should be allowed to be delegated by a nurse to a hospice aide and whether these delegated services should be considered nursing services. We also added a requirement that a hospice must apply to CMS to receive authorization for the opening of a multiple location. Response: We understand that traveling, providing care or services, documenting information, and calling patients all consume volunteer time, and we agree that the time may be used in calculating the level of volunteer activity in a hospice. Therefore, we do not believe that adding the phrase consistent with patient self-determination is necessary. The commenter noted that the proposed rule even required the initial step of bereavement counseling to begin before the patient's death by requiring that the initial bereavement assessment be completed at the time of the comprehensive assessment. In the third standard, (c), Content of the comprehensive assessment, we proposed that hospices identify the physical, psychosocial, emotional, and spiritual needs of the patient related to the terminal illness and related conditions. A hospice may, under extraordinary or other non-routine circumstances, 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, Circumstances under which a hospice may enter into a written arrangement for the provision of core services include: Unanticipated periods of high patient loads, staffing shortages due to illness or other short-term temporary situations that interrupt patient care; and temporary travel of a patient outside of the hospice's service area, Physician services: The hospice medical director, physician employees, and contracted physician(s) of the hospice, in conjunction with the patient's attending physician, are responsible for the palliation and management of the terminal illness, conditions related to the terminal illness, and the general medical needs of the patient, (1) All physician employees and those under contract, must function under the supervision of the hospice medical director, (2) All physician employees and those under contract shall meet this requirement by either providing the services directly or through coordinating patient care with the attending physician, (3) If the attending physician is unavailable, the medical director, contracted physician, and/or hospice physician employee is responsible for meeting the medical needs of the patient, Nursing services: (1) The hospice must provide nursing care and services by or under the supervision of a registered nurse. We believe this is a usual and customary business practice and is thereby exempt from the PRA under 5 CFR 1320.3(b)(2). (1) The patient has the right: (i) To exercise his or her rights as a patient of the hospice; (ii) To have his or her property and person treated with respect; (iii) To voice grievances regarding treatment or care that is (or fails to be) furnished and the lack of respect for property by anyone who is furnishing services on behalf of the hospice; and. Section 418.106(e)(2)(i)(C) requires a hospice to document in a patient's clinical record that the written policy for managing controlled drugs was provided and discussed. Deleted the requirement in section 418.104(b) that, [a]ll entries must be signed, and the hospice must be able to authenticate each handwritten and electronic signature of a primary author who has reviewed and approved the entry. We are requiring authentication and dating in accordance with hospice policy and accepted standards of practice. Medicare patients receiving hospice services and residing in a SNF, NF, or ICF/MR are subject to the Medicare hospice eligibility criteria set out at 418.20 through 418.30. The nature and condition causing admission (including the presence or lack of objective data and subjective complaints); Factors that must be considered in developing individualized care plan interventions, including, Bereavement. Additionally, as the commenters noted, the term toxic is unnecessary. The hospice aide is required to report changes in the patient's needs to a registered nurse, and complete appropriate records in compliance with the hospice's policies and procedures. Many of these commenters suggested that the medical director requirement should be entirely deleted. Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness through the prevention and relief of suffering by means of early identification, assessment and treatment of pain and other issues. WebYou qualify for hospice care if you have Medicare Part A (Hospital Insurance) and meet all of these conditions: Your hospice doctor and your regular doctor (if you have one) certify that youre terminally ill (with a life expectancy of 6 months or less). (v) Clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary. (2) The hospice must comply with the requirements of subpart I of part 489 of this chapter regarding advance directives. This requirement is currently approved under OMB control number 0938-0302, with an expiration date of August 31, 2009. Have a baccalaureate degree in psychology, sociology, or other field related to social work and at least one year of social work experience in a health care setting. We note that although we do not require hospices to obtain approval for warehouse and other single function sites, States may still require hospices to receive approval from State or local authorities. We note that hospitals are currently required to comply with a very similar performance improvement project regulation and have successfully determined their performance improvement project needs and goals without prescribed minimums. As with the initial assessment, some commenters questioned the exact time that the timeframe began. Section 418.106(f)(2) requires a hospice to ensure that the patient, family, and other caregivers receive instruction in the safe use of durable medical equipment and supplies. and services, go to Response: We agree that it is not necessary to describe the role and scope of services provided by nurse practitioners separately from the role and scope of general nursing services in the patient's plan of care. A hospice that has a written agreement with another agency, individual, or organization to furnish any services under arrangement, must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. (c) Standard: Program activities. We have retained the requirement that, when the patient's attending physician is not available, a hospice physician is responsible for meeting the patient's medical needs. Specifically, commenters suggested that the hospice registered nurse be required to complete the comprehensive assessment and that the IDG be required to review its content. Commenters suggested that the phrase nursing aide, certified nursing assistant, or hospice aide be used instead of the phrase home health aide.. We believe that a well-designed and openly implemented policy will help hospices choose the individuals best suited for hospice employment and service. This provision will make it easier for hospices to contract with long term care facilities. This content is from the eCFR and may include recent changes applied to the CFR. Comment: Some of commenters expressed concern regarding the manner in which the terms mistreatment and injury are used in the proposed patient's rights CoP. Since hospices have not, to our knowledge, had any difficulty in determining what constitutes nursing services, we see no reason to establish a definition for the term at this time. Section 418.110(m)(3)(i) specifies that the use of restraint and seclusion must be used in accordance with a written modification to the plan of care. This could lead to an over-or under-use of aide services, low quality aide services, patient and family dissatisfaction, and a wide variety of other negative outcomes that hospices wish to avoid. Comment: Several commenters suggested that requirements for nurse practitioner services should be included in the same standard as those for physician services. Many commenters believed that the discharge summary contains enough information to maintain continuity of care, and believed that a copy of the clinical record should only be sent upon request of the receiving entity. While allowing the patient to identify his or her family would be ideal, this may not be possible for patients who cannot communicate and who do not have written information available for the hospice. We believe that supervising the aide every 14 days to ensure that aide services are adequate and appropriate for each hospice patient is appropriate, given the length of time that most hospice patients receive hospice services. For example, a patient's representative may request that the hospice complete the initial assessment in a shortened timeframe because the patient is in acute distress and requires immediate hospice assistance. This IDG would be required to work together to meet the physical, medical, social, emotional, and spiritual needs of the patient and family. Comment: A majority of commenters requested that we revise the proposed definition of drug restraint to remove the stigma associated with the term drug. A minority of commenters requested that we delete the definition of drug restraint completely, and suggested that the hospice industry at large or hospices individually should be allowed to determine a definition. Hospice Care We have added a new requirement that the administrator be appointed by the governing body, to further clarify the relationship between the two parties. Start Printed Page 32116. Conversely, we are not aware of any need to address the role of physician assistants in hospice because, to our knowledge, physician assistant services are rarely used in hospices and are not recognized under the Medicare hospice benefit. This results in patients and families not receiving all of the services they need in order to maximize comfort and dignity and achieve the patient's and family's hospice care goals. Given this variability, it is difficult to estimate how long an average hospice may spend gathering and organizing data. Hospices are free to choose the data collection methods and tools that best suit their needs. "Published Edition". Subpart E is reserved for future use. Commenters described the need for the case coordinator to have solid knowledge of the biological, psychological and spiritual issues of terminally ill patients and their families. (6) The interdisciplinary group's documentation of the patient's or representative's level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice's own policies, in the clinical record. Therefore, we are requiring the coordinator to be a registered nurse. (d) Standard: Counseling services. Some commenters wanted to know how to determine which medications are ordinarily self-administered, while other commenters noted that the hospice aide training requirement at proposed 418.76(b) does not require aides to be trained in medication administration. We believe that limiting this requirement to patients and representatives will help ensure that the patient's needs and goals are primary in the content of the plan of care. Response: We agree that clarifying the intent of the every-14-day supervisory visit will be helpful to hospices. In general, an adverse event would be any action or inaction by a hospice that causes harm to a hospice patient. We believe that this fulfills the commenters' request without limiting the opportunity for the registered nurse to gain the necessary experience. Since payment requirements are not within the scope of this rule, we are not accepting this suggestion. This proposed standard was similar to a requirement in the conditions of participation for hospitals. When a patient elects the hospice benefit she waives the right to receive all other Medicare covered services for the terminal illness and related conditions. (2) If the drug order is verbal or given by or through electronic transmission, (i) It must be given only to a licensed nurse, nurse practitioner (where appropriate), pharmacist, or physician; and. 552(a) and 1 CFR part 51. If the patient's status in one or more areas changes, hospice staff must update the comprehensive assessment to reflect the change(s). An initial contact when a patient is in need of timely assistance would be a disservice to the patient and family and would not lead to effective, high quality care. (3) That one or more individual(s) who are responsible for operating the quality assessment and performance improvement program are designated. A hospice that chooses to contract for core services or highly specialized nursing services must have a contract with the entity providing the contracted services. Therefore there is no additional burden associated with this provision. For this reason, we have extended the timeframe from four days to five days. We estimate that hospices that have not previously performed background checks, accounting for approximately 23,228 hospice employees, will each obtain 40 criminal background checks initially. In the last years of life, patients typically use five drugs or more at any one time, increasing the risk of duplicative drug therapy, drug interactions, or drug side effects, as well as the risk of dispensing or dosing errors. We replaced the term home health with the term home care, which is used broadly in this standard and encompasses both home health care and hospice care. (6) A method for verifying that the requirements in paragraphs (c)(1) through (c)(5) of this section are met. Response: It will be up to the individual hospice to decide how it will handle authentication of entries made by employees, contracted staff, attending physicians, and any other individuals who input information in a patient's clinical record. These percentages do not include amounts paid by Medicare for continuous home care days, respite care days, and regular inpatient care days. Some commenters suggested that all mention of the attending physician's involvement in the IDG should be deleted because not all patients would have attending physicians. We also believe that it is essential for the term seclusion to remain in this rule. Furthermore, hospices are required to have a system of communication to ensure that all disciplines furnishing hospice care to patients communicate with each other about patient needs. To restrict bereavement counseling to a select few would discourage hospices from providing this service, thus harming the bereaved and the larger community. (iv) A credentialing body approved by the American Occupational Therapy Association. We believe that this requirement is sufficient to ensure that QAPI programs benefit from the expertise of medical directors. Response: We agree that more expressive language is useful in introducing the elements that the comprehensive assessment must contain. We assume that these meetings will be one hour each, for a total cost of $480. If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes. (1) Training intervals. The provided pharmacist services must include evaluation of a patient's response to medication therapy, identification of potential adverse drug reactions, and recommended appropriate corrective action. However, the idea of drugs used as restraints is relatively new in hospice care and has provoked much anxiety in the hospice industry. Condition of Participation: Patient's Rights (Proposed 418.52), 4. Comment: One commenter stated that the reference to dietary counseling in proposed 418.74 is confusing because we use the term nutritional counseling in the proposed Core services requirement at 418.64. A new provision has been added at 418.58(e)(3) explicitly requiring the governing body to appoint QAPI leaders. (C) Document in the patient's clinical record that the written policies and procedures for managing controlled drugs was provided and discussed. The commenters suggested that further clarification was needed with regard to the requirement that hospices include a review of a patient's prescription and over-the-counter drugs. This may include a legal guardian. (8) A provision stating that the hospice must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF or ICF/MR administrator within 24 hours of the hospice becoming aware of the alleged violation.

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