Hospices Avoid Regulatory Deficiencies with Effective Care Planning

Regulators have been zeroing in on hospice providers in recent years as utilization and expenditures continue to rise. Deficiencies in care planning is one area that is attracting increasing attention.

A recent report from the U.S.Department of Health and Human Services Office of the Inspector General (OIG) indicated that more than 87% of the 4,563 hospices operating in the United States between 2012 and 2016 had at least one instance of noncompliance with quality, administrative and safety standards set by the U.S. Centers for Medicare & Medicaid Services (CMS).

OIG examined state agency and accreditor survey findings as well as complaint data from 2012 through 2016. Regulators and accreditors surveyed nearly all hospice providers in the nation during those years. Most deficiencies are minor and pose no risk to patients, but issues with care planning stuck out. Nearly 60% of hospices surveyed during those years had a strike against them related to care planning.


“Many hospices with care planning deficiencies failed to ensure that they provided the services called for in the care plans that they established. For example, one hospice did not provide nurse visits for two consecutive weeks despite a beneficiary’s care plan ordering weekly nurse visits. Also, for at least 5 weeks, the nurse did not follow the care plan to assess the beneficiary’s gastrostomy tube site or colostomy stoma at each visit,” OIG reported. “Hospices also failed to ensure that the care plans were appropriately individualized. For example, one hospice did not address the needs of a beneficiary with dysphagia who had to be fed very slowly with small bites due to frequent choking.”

OIG in its report called for CMS to step up its enforcement efforts, particularly among hospices that experience persistent problems. OIG also recommended that CMS do a better job of educating hospices about what the agency requires.

In its Conditions of Participation (CoPs) CMS requires hospice interdisciplinary teams to develop a plan of care that is individualized to each patient as part of its initial comprehensive assessment. The team must update the plan at a minimum of every 15 days. CMS mandates that the plan include measurable goals as well as the care, treatment or services the hospice will provide to meet those goals.


“Ultimately, the hospice plan of care serves as the hospice roadmap for each patient and family in their transition through end of life,” Jennifer Flugaur, director of quality and compliance for Agrace HospiceCare, told Hospice News. “We need to ensure, as providers, that we are constantly following that roadmap and — when patients and families are having changes or unexpected [symptoms] — that we can respond in a meaningful way and change course in a way that’s meaningful to the patient and their family.”

Common care planning issues found by CMS surveyors include inadequate documentation of services provided to patients and establishing goals of care that are not measurable, according to Flugaur. For example, the care team can include “reduced pain,” as a goal of care, but the hospice must quantify what that term means to an individual patient, such as reduced pain according to a numerical scale or an ability to be more active or attend events.

“Hospice providers need to be able to quantify what ‘reduced pain’ means to each individual patient because it could look very different depending on patient diagnosis or level of functioning,” Flugaur said.

Effective documentation is also essential. Even if the hospice provides all the services the patient needs within appropriate time frames, CMS will cite them for noncompliance if the care is not documented correctly.

Staff training is essential to effective care planning, particularly among the interdisciplinary teams that care for the patient. All members of the team, as well as the patient and family should be involved. This training can occur at hire and recur as needed.

“Everyone who is working within the hospice organization should receive training on policies and procedures, including care planning, so they have a thorough understanding of their employer’s expectations as well as the regulatory expectations,” Linda Elizaitis, president of the consulting firm CMS Compliance Group, told Hospice News. “All members of the interdisciplinary team should be provided with education during their orientation on how to develop that comprehensive care plan and how to evaluate the effectiveness of the interventions that are implemented.”

Agrace Hospice has systems like this in place. New hires receive training in a classroom orientation that explains the rationale behind care planning, the organization’s policies, associated regulatory requirements and instruction on how to build the care plan within the electronic medical record. The hospice builds on that education in the field as preceptors work with new staff to operationalize their classroom training.

The hospice’s survey results help inform the training. Agrace leaders discuss surveyor expectations and what they are seeing in other organizations and incorporate that feedback into training programs.

“It’s helpful if you can learn directly from the surveyors themselves about what a beautiful plan of care looks like, because there is a lot of gray in the regulations and a lot that is left up to individual EHRs and to the interpretation of the hospice,” Flagaur told Hospice News.

Conducting self-audits is also sound advice, according to Elizaitis. A qualified staff member should review care plans, carefully checking them against orders and other information in the medical record to ensure the plans are complete and accurate and updated within the appropriate time frame. They can also verify that the interventions in the medical record correspond to the care plan. Elizaitis recommends quarterly audits of at least 20% of current patient records.

“You have got to audit. You have got to open up those medical records and look at that plan of care and make sure that it is comprehensive, but you also have to do something with the results of that audit,” Elizaitis said. “Use that audit to put corrective actions in place. If plans need updating or staff need additional education, you want to find those issues and correct them before a surveyor comes in.”

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