Hospices are taking stock of their comprehensive patient assessment processes in the wake of two government reports on quality deficiencies that received widespread media coverage.
The U.S. Department of Health and Human Services Office of the Inspector General (OIG) released the reports in July, indicating that more than 87% of the 4,563 hospices operating in the United States between 2012 and 2016 had at least one deficiency identified during a regulatory or accreditor survey.
OIG examined state agency and accreditor survey findings as well as complaint data from 2012 through 2016, focusing on a sample of 50 types of serious deficiencies. The reports called upon regulators to step up their enforcement strategies for hospices.
The most frequently occurring deficiencies were related to care planning, vetting of hospice staff and comprehensive patient assessments, according to OIG.
“Forty-two percent of the hospices surveyed in the five years had deficiencies related to patient assessments. The care provided to a beneficiary is dictated by the hospice’s assessment of the beneficiary,” the OIG report indicated. “Without timely or thorough assessments, beneficiary and family needs may be overlooked or inadequately addressed. Many of these hospices failed to include key content in the comprehensive assessments.”
The U.S. Centers for Medicare & Medicaid Services (CMS) Conditions of Participation require hospices to conduct and document in writing a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. This assessment must include all areas of hospice care related to the palliation and management of the terminal illness and related conditions. These assessments must be conducted at admission and repeated every 15 days or as frequently as the patient requires it.
As with many CMS requirements, documentation of the assessments is essential to compliance. Even if hospice staff conduct the assessment effectively, surveyors will indicate a deficiency if the activity isn’t adequately documented.
“The question from the Inspector General’s point of view isn’t just about performing them, it’s how you document them and the paperwork from a clinical point of view,” Robert Arnold, M.D., medical director for the University of Pittsburgh Medical Center’s Palliative and Supportive Institute, told Hospice News. “Hospice and palliative care follows the whole person assessment that is about the quality of people’s lives, which is related not just to their physical symptoms but their psychological well being and their spiritual needs.”
Nearly 42% of hospices had a deficiency related to patient assessments between 2012 and 2016. Some common issues that CMS identified during surveys include failure to document key information such as medication profiles or the patient’s history of pain. In many cases, hospices failed to update the assessments within the required 15 days.
Hospices can benefit from a careful review of the regulations and ensuring staff have a solid understanding of what CMS requires.
“There is room for misinterpretation based on the regulations; some of which are not as specific to what actually needs to occur. Some hospices don’t interpret the rules as they were intended,” Sarah McSpadden, president and CEO of San Diego-based Elizabeth Hospice. “This is a multifaceted process, and there are multiple reasons why surveyors would come back and say that you didn’t complete a comprehensive assessment.”
McSpadden, who in the past has performed compliance audits of hospices, has seen some common errors related to a lack of understanding of the requirements. She too pointed to documentation as a key source of deficiencies, such as staff using a short-version note rather than a long-version note. The short note may be very symptom specific, such as a pain assessment, but to meet the requirements the assessment must address the entire body as well as the patient’s psychosocial and spiritual needs.
Sometimes hospices fail to document assessments in the correct form or neglect to document team discussions of the assessments to determine whether care plans need to be updated in response to changes in the patient’s condition.
Elizabeth Hospice built comprehensive assessment reminders into this scheduling system to help ensure that they were updated within the required timeframe. Staff plot 60 days worth of patient visits on an electronic calendar in two-week increments, indicating in each entry the type of visit that is occuring on a particular day, including those on which assessments should occur. This practice helps staff as well as patients understand what to expect in forthcoming visits.
While the calendar entries can be adjusted as needed, the system prevents staff from moving assessment appointments outside of the 15-day window.
Other approaches leverage the interdisciplinary team model allowing different team members to perform discipline-specific portions of the assessment, with careful coordination and documentation.
“It can be challenging to complete the entire assessment in one visit, not only for the provider but for the patient, who may get fatigued, feel weak or find it difficult to be engaged during the process, which can potentially take two to three hours,” Arnold told Hospice News. “You can use your full multidisciplinary team so different people can focus on different aspects of the assessment, and a single clinician isn’t responsible for acquiring all of that data.”
Arnold pointed out that complications and misunderstandings related to comprehensive assessments are not limited to hospice. These challenges exist across the health care continuum, and the hospice model of patient-centered interdisciplinary care could position hospices to be an example to organizations in other health care settings.
“I think hospices that are figuring out how to do this are going to be a model for the rest of health care, as health care at large increasingly worries about a whole variety of non-biological issues ranging from social determinants of health to helping people cope with chronic illness,” Arnold told Hospice News. “The rest of health care needs to look at how hospices provide whole-person care in an efficient manner, because it’s crucial to good care that all patients need. We can all sit down and learn from the struggles hospices have in trying to collect these data, document it and use it in a way that is clinician friendly and best serves the patient and family.”