Point-of-Care Documentation Impacts Hospice Compliance, Safety and Payment

Incomplete or inaccurate patient documentation poses risks both to hospice patients and their providers. These errors can jeopardize patient safety, lead to delays in treatment and adversely impact payments to hospices from Medicare.

Incorrect documentation also attracts regulatory scrutiny. 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.

Fulfilling documentation requirements can be particularly difficult when clinicians are updated records at the point of care. While historically staff have completed point-of-care documentation on paper, most hospices have transitioned to electronic systems on portable devices brought to the patient’s bedside.


“Because of the holistic nature of hospice, pretty much all the data regarding the patient and their care is available in a point-of-care format. As we think about a timely sharing of information by the team, from nursing to social work and spiritual support,  all those pieces go into building a picture of the patient as we start,” said Cindy Campbell, director of operational consulting for the post-acute tech firm WellSky. “This documentation is all regularly done in a point-of-care, as well as ongoing visit work. The team becomes better informed in their work through real-time capture of patient information.”

The U.S. Centers for Medicare & Medicaid Services (CMS) often views inconsistent or incomplete documents as red flags that could trigger an audit. Even if a hospice performs the correct procedures in compliance with current CMS or accreditation standards, they can receive a survey deficiency or an audit if those actions are not appropriately documented. Many of the most commonly cited deficiencies have a documentation component, such as standards related to the care plan, comprehensive assessments and medication regimens.

Inaccurate documentation can also lead to incorrect claims to Medicare, which can cost a hospice money in addition to the risk of an audit.


“In our industry, it’s more the incomplete documentation that causes problems, which is why we focus so much on point-of-care delivery and documentation. You certainly find that in chart audits or documentation and in regulatory-based audits as well. Incomplete documentation does have a tremendous impact, not only from a fine or reduction to your reimbursement, but on labor time,” Christy Jeffcoat, executive vice president for the hospice provider Medical Services of America, said. “If you’re going through an audit or following up on outstanding billing, you have to spend a lot of time going back and really evaluating what happened. It has a reduction to your expected payment plus an increased expense on labor.”

Hospice staff face the difficulty of documenting care and changes in the patient’s condition at the bedside while also remaining attentive to the individual and the family. The patient or family may not understand why the clinician is working on a device during their interactions.

“If you’re my patient, or a family member going through a real crisis right now around their loved one, I don’t want the device to become an obstacle between us. Clinicians and team members need to successfully integrate the use of that device, so it doesn’t threaten the relationship. There is a best practice methodology for managing this”, Cindy said. “Documenting at the point of care doesn’t get in the way of connecting if the patient understands that the clinician is here for them and listening to them. We can let the patient see that this is a tool for us to serve them better and be in communication with their support team, and that we will not use it to the point where we distract from their needs.”

That perceived barrier of a device between the clinician and a patient is a common pitfall that can lead to documentation errors. Staff training and education on the importance of documentation, how to communicate that importance to patients and families is necessary, as is training on how to use the devices and related software.

Compliance is more likely when the hospice has buy-in from clinicians on point-of-care documentation.

“A lot of that is in our training process, and then going back and recording educational sessions so that they can review those on their own time. We spent a lot of time on outcomes for the patient and reviewing the verbal recall of the patient’s condition and their family members’ progress. Then we’ll compare that account to the documentation in the system. It’s very easy to see any discrepancies,” Jeffcoat told Hospice News. “I think that’s the best way to really explain that to them and to get buy in that we have to document as much as we can at the delivery of care, It’s hard to fully document all of that after the fact. It needs to be done while we are there with the patient.” 

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