Connecting the hospice compliance dots

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Debbie Newsholme, Healthstream
Debbie Newsholme, Healthstream

In 2013, more than 1.5 million patients received hospice care in the United States. It is often the responsibility of the patient or caregiver to choose the best facility for end-of-life care.  So, as a hospice administrator or director, what would you want to communicate about your facility to those patients and caregivers to convince them that you were the best choice?

If you have an inpatient facility, you may give them a tour in order to show the cleanliness of the rooms, the peacefulness of the surroundings, and the friendliness of the staff. However, if someone asked you if your hospice was compliant with the Centers for Medicare & Medicaid Office of Inspector General's Effective Compliance Program Guidance for Hospice, what would you tell them?  

These may seem like off-the-wall questions for a caregiver or patient to ask, but the OIG Guidance has a significant impact on the quality of care patients receive and the hospice's bottom line. 

For example, hospice care risk areas identified by the Office of Inspector General include certifying ineligible persons, falsifying medical records or plans of care and incomplete services rendered by the interdisciplinary care team. Falsifying medical records or plans of care to either admit an ineligible person to hospice or keep them on hospice longer than necessary can increase revenue. However, in the event of an OIG investigation or qui tam (whistleblower) law suit, a hospice could wind up with a false claims action resulting in a Corporate Integrity Agreement (CIA). Individuals involved in the fraud may face criminal charges. There is a growing regulatory focus on post-acute organizations.

Over the past several years, more than a half dozen hospice organizations have entered into CIAs with the federal government. Settlement amounts are in the millions of dollars. The common thread among many of these false claims allegations is the certification of ineligible persons. In order for a patient to be eligible for hospice, he or she must meet the definition of terminal illness and be entitled to Medicare Part A. Terminal illness is defined as having a life expectancy of six months or less if the illness runs its normal course.

The financial impact is not the only consequence of a settlement agreement. Organizations must hire a compliance officer, and establish a compliance committee and compliance program, if they are not already in place. The hospice is subject to oversight by an independent review organization, must provide many hours of training, and report to the OIG on a regularly scheduled basis - usually annually. That's not even mentioning reputational cost.

The plan of care is another area that can be problematic. Because the plan of care is an essential part of the medical record, all members of the care team depend on current and accurate documentation. The creation of the plan of care is not a one-time event. It must be continually evaluated and adjusted as changes in the patient's condition and symptoms warrant. Failure to address this important risk area has a significant impact on the quality of care the patient receives. It may impact pain management, symptom control, dietary, therapeutic, as well as spiritual and emotional requirements. This is the organization's roadmap to support all care and services delivered to the hospice patient.

Another risk area identified by the OIG includes the interdisciplinary care team. The interdisciplinary care team is made of physicians, registered nurses, dieticians, mental health and spiritual counselors, as well as social workers and hospice aides. This team should meet regularly to assess the patient and family or caregiver situation. These meetings provide the opportunity to address any unmet needs identified by the patient or caregiver, as well as by members of the team. 

Hospice, like other segments of healthcare, is in the compliance spot light. Having a solid program in place reduces risk and promotes a culture of compliance and quality of care. Make sure everyone in the organization receives compliance training. The training requirements may vary depending upon the individual's role and responsibilities.  Ask the Board and leadership to be vocal in their support of the compliance program. This will help create the link between quality of care and compliance in the hospice setting. 

So, back to the original question. If someone asked you if your hospice was compliant with the Centers for Medicare & Medicaid Office of Inspector General's Effective Compliance Program Guidance for Hospice, what would you tell them?

Debbie Newsholme, CCEP, CHC, is senior director, content operations at HCCS – A HealthStream Company.

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