Proposed Changes to SNF/NF Conditions of Participation Regarding Hospice

On October 22, CMS released a proposed rule entitled “Medicare and Medicaid Programs; Requirements for Long Term Care Facilities; Hospice Services” which can be found at http://edocket.access.gpo.gov/2010/pdf/2010-26395.pdf.
In the rule, CMS proposes that long term care (LTC) facilities (that is, SNFs and NFs) that choose to arrange for the provision of hospice care through an agreement with one or more Medicare-certified hospice providers would have in place a written agreement with the hospice that specifies the roles and responsibilities of each entity.

To have your comments included in AHCA’s comment document to CMS, please send them to Lyn Bentley at lbentley@acha.org by December 6.

Background

Under current regulations, a LTC facility may choose to have a written agreement with one or more hospice providers to provide hospice care to a Medicare eligible resident who wishes to elect the hospice benefit. However, if the facility chooses not to contract with a Medicare-certified hospice to provide hospice services for the resident who wishes to elect the benefit, the LTC facility is responsible for assisting the resident in transferring to a facility that will arrange
for the provision of such services, as requested by the resident.

CMS states in the proposed rule that “there is a lack of clear regulatory direction regarding the responsibilities of providers in caring for LTC facility residents who receive hospice care from a Medicare-certified hospice provider, which could result in duplicative or missing services.” CMS believes this problem would be remedied by a regulatory requirement for a written agreement between the hospice and the SNF/NF which would specify what services each provider will provide. Per CMS, beneficiary health and safety could be endangered by a lack of coordination between hospice and LTC providers.

CMS states that “the language in this proposed rule was crafted to mirror the hospice final rule [June 5, 2008 hospice final rule (73 FR 32088) “Medicare and Medicaid Program: Hospice Conditions of Participation”] as much as possible to ensure that both entities are held equally responsible for the written agreement.”


Provisions of the Proposed Rule

• As previously stated, CMS is proposing that LTC facilities may either arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospice providers or not arrange for such services and assist a resident in transferring to a facility that will arrange for the provision of these services when the resident requests such a transfer.

• The proposed rule “…seeks to clarify the role of the LTC facility and the Medicare-certified hospice by requiring clear delineation [in the agreement] of each provider's responsibility for maintaining continuity of care.” The agreement requirements would apply even when the hospice and SNF/NF are under common ownership and/or control. The signatures of authorized representatives of the hospice and the LTC facility would be required.

• The LTC facility would be required to ensure that the hospice services meet professional standards and principles that would apply to individuals providing services in the facility, and the timeliness of the services. “Timeliness of services'' means that the facility “…would be required to ensure that, from the time the resident elected the hospice benefit until the services were terminated, the Medicare-certified hospice would provide hospice services meeting the resident's needs in a timely manner, without any delay in the provision of services for the resident.”

• Written agreements would need to define:

1) the services to be provided by hospice and the SNF/NF, respectively, in accordance with the care plans;

2) how the facility and hospice would communicate; and

3) conditions under which the facility would need to contact the hospice immediately (including significant changes in condition/status; clinical complications that would alter the care plan; need for transfer for any condition not related to the terminal condition; or resident death).

• Agreements would have to include the following provisions:

1) the hospice assumes responsibility for determining the appropriate course of hospice care, including changing the level of services, if necessary;

2) the facility provides 24-hour room and board and meets the resident's personal and nursing care needs in coordination with the hospice.

3) delineation of the hospice's responsibilities, including providing medical direction and management of the hospice care; nursing; counseling; social work; medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services necessary for care of the terminal illness and related conditions; as well as bereavement services to LTC facility staff.

4) requirement that facilities report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the facility becomes aware of the alleged violation.

5) facility designation of a member of the facility's interdisciplinary team to be responsible for working with hospice representatives to coordinate care provided. The rule outlines responsibilities of the interdisciplinary team

6) Each resident's written plan of care would include both the hospice plan of care and the services provided by the SNF/NF.

Specific Feedback to CMS

In addition to the specific provisions of the proposed rule, CMS requests feedback on the following two issues:

1) How LTC facilities can provide orientation for hospice staff who provide occasional coverage for a member of the identified hospice interdisciplinary group that is quick and efficient, but sufficient to protect residents who receive hospice care.

2) CMS efforts to mirror existing hospice requirements notwithstanding, some differences occur. For example, the proposed rule would require that the facility report all alleged violations by hospice personnel to the hospice administrator immediately when the facility becomes aware of the alleged violation. However, the hospice is required in the June 2008 hospice final rule to report these same violations within 24 hours of the hospice becoming aware of the alleged violation. CMS is requesting feedback on whether the differences between the requirements that are found in the proposed rule would create a barrier to forming agreements between LTC facilities or interfere in coordination of residents' care between LTC facilities and hospices.

To view the rule in its entirety, go to http://edocket.access.gpo.gov/2010/pdf/2010-26395.pdf. To have your comments included in AHCA’s comment document to CMS, please send them to Lyn Bentley at lbentley@acha.org by December 6.

New OSHA SST Inspection Directive

The Occupational Health & Safety Administration (OSHA) has issued its 2010 site specific targeting (SST) directive. Inspection criteria include:
• The primary inspection criteria using the 2009 Data Collection Initiative will target healthcare facilities in SIC code 805 (which includes long term care) with a Days Away, Restricted or Transferred (DART) rate at or above 16.0, or a Days Away From Work, Injury and Illness (DAFWII) case rate at or above 13.0 (only one of these criteria must be met.) 300 of the highest rated DART and DAFWII facilities will be surveyed under SST-10.
• A secondary inspection list will be created for healthcare facilities reporting DART rates of 13.0 or greater but less than 16.0, or a DAFWII case rate of 11.0 or greater but less than 13.0.
• As in past years, surveys of nursing and personal care facilities will focus on ergonomic stressors; exposure to blood and other potentially infections materials, as well as tuberculosis; and slips, trips, and falls. When additional hazards come to the attention of the compliance officer, the scope of the inspection may be expanded to include those hazards.
• When conditions indicate that a General Duty Clause citation relating to ergonomics may be warranted, the Area Office will contact the Regional Ergonomics Coordinator.

To view the directive in its entirety, go to http://www.osha.gov/OshDoc/Directive_pdf/CPL_02_10-06.pdf.