Submitting inadequate or incomplete required written documentation is a sure-fire way to bring surveyors or auditors to a hospice’s doorstep. As regulators increasingly fix their eyes on the hospice space, providers are stepping up their efforts to ensure their documentation is airtight.
The U.S. Centers for Medicare & Medicaid Services (CMS) often treats issues such as longer lengths of stay, live discharges and recertification of a patient for hospice as red flags that could trigger an audit. Documentation – such as certification and recertification statements, hospice election statements and others – is a key component of each of these processes.
In addition to being correct and comprehensive per the requirements, hospices must also complete the documentation within the required time frames.
“When I first started working with home health and hospice nurses, I started hearing the phrase ‘If it isn’t documented, it wasn’t done,’” Angela Rhoads, Vice President of Hospice Operations for Interim HealthCare, Inc., told Hospice News. “There is a laundry list of reasons why things don’t get documented, but those reasons don’t change what is required or the way in which documentation is reviewed.”
CMS is likely to strengthen its oversight of hospices in the wake of several reports from the U.S. Department of Health & Human Services Office of the Inspector General that detailed compliance deficiencies among hospices nationwide, including one report that discussed examples of serious safety issues that put patients at risk.
OIG called for CMS to take further action to address such deficiencies, and late last week the Ways and Means Committee of the U.S. House of Representatives asked the agency to report on the status of those efforts.
“Some of the primary challenges with hospices and their documentation have to do with documenting the patient’s decline or documenting the progression of the disease. CMS is looking for how the patient is declining and progressing through their terminal illness,” Catherine Dehlin, director of Hospice Services for the consulting firm Fazzi, Inc., told Hospice News. “The documentation has to be specific, objective, and avoid vague and subjective terms such as ‘The patient is stable,’ or ‘the patient is progressing slowly.’ These don’t adequately describe the decline, and that doesn’t fly well with CMS.”
Using standardized tools can help staff ensure the documents they prepare are on point. Dehlin and Rhoads pointed to the Local Coverage Determinants forms used by Medicare Administrative Contractors to help ensure consistency of measurement against the terminal prognosis.
Organizations can also develop checklists to help staff ensure they have completed every step and accounted for each piece of necessary information. A process for chart reviews or self-audits can also be beneficial.
Ensuring appropriate signatures is another challenge in some instances, according to Rhoads. For a patient to be eligible for hospice, an attending physician must certify in writing that the illness is terminal and the patient is expected to die within six months. While a nurse practitioner can serve as an attending physician in some circumstances, CMS mandates that a medical doctor or doctor of osteopathic medicine sign the certification paperwork.
Complete and accurate patient assessments, care plans, and updates to care plans within specified time frames are also essential, Dehlin and Rhoads told Hospice News.
“We must document all things going on with the patient – not just those related to the terminal diagnosis, for example,” Rhoads said. “We need to make sure to document the full picture of the patient. In hospice, we need to document achievement of goals while also documenting the progress of a patient’s disease which in most cases is declining. When patients are having good days, I think it is sometimes natural to focus on that in documentation and not always accurately document the physical things that are still going on.”
Staff education is a key part of ensuring that documentation is compliant with corresponding regulations. This is particularly important for new staff and those who are new to hospice care, but any clinical employee can benefit. Rhoads recommends mutli-modal training that includes classroom-style education as well as videos, written materials, group activities and one-on-one mentoring.
“It is important to understand the hospice benefit and how eligibility is determined. For clinical staff, the next steps are making sure they are clear on their role in the interdisciplinary group and their responsibilities for documenting both care and coordination of care,” Rhoads said. “Ongoing training is just as critical. Providing targeted training opportunities based on changing regulations, as well as continued performance improvement, is key to providing quality care. The key is to keep [training] as short as possible and focused on the objective.”
Dehlin recommends that staff as much as possible perform clinical documentation at the bedside with the patient present to help ensure timeliness and accuracy, and to reassure the patient that the members of their care team are communicating with one another.
“If you can do one thing to really create accuracy in your documentation and improve the quality of care and customer satisfaction all is one action is to create good and accurate point of care documentation, in other words capturing the documentation at the bedside with the patient to the fullest extent possible,” she said. “We have the capability now to capture that information at the bedside as it is happening. It really improves the accuracy, and the documentation that they are providing will give others nurses and team members the information they need to provide quality care.”