NewsLine - August 2011 - (Page 46)

Tip of the Month Survey Readiness Do you know the top 10 survey deficiencies that were identified by the Centers for Medicare and Medicaid Services (CMS) last year? CMS and its contractors, the state survey agencies, completed 613 recertification surveys in 2010 and identified the 10 most frequently cited survey deficiencies. These deficiencies are listed below, according to the Condition of Participation Standard. Also noted are the Interpretive Guideline “L-Tag” identifiers. y Deficiencies Compliance Recommend ations CMS Top Ten Surve Compliance National Hosp ice and Palliative Care Organizat ion www.nhpco.o rg/regulatory Tip Sheet Free Tip Sheet Offers Compliance Guidance To help members prepare for future surveys, NHPCO has developed a tip sheet with the following information: • The list of survey deficiencies for federal FY 2010. • Examples of the deficiencies based on actual CMS survey deficiency data. • Compliance suggestions from clinical, documentation and administrative perspectives. • Listing of related standard and practice examples from the NHPCO Standards of Practice for Hospice Programs (2010). Be sure to also visit the NHPCO website for other helpful tools and information. The cover story in the December 2010 issue of NewsLine also addresses this important topic. ice Conditions govern all Medi of Participatio care-certified n (2008) (CoP hospice progr s) contain the ams. federal regul ations that **The State Oper ations Manu al, Appendix personnel cond M – Guidance ucting surve to Surveyors: ys of hospices. Conditions of Hospice (2010 It serves to Participation ) contains guida explain the through “L-tag the Guidance nce to intent of the s” that corre to Surveyors Medicare Hosp spond to each – also referr Federal requi ice CoP. Surveyors ed to as Interp rements. The are required retive Guide purpose of provide the to use lines – in asses the Interpretive surveyor with sing compliance Guidelines Surve direction to with prepare for yor Procedures the survey, cond and Probes uct the surve is to y and evalu CMS TOP TEN ate the result HOSPICE s. DEFICIENCIES COMPLIANCE R ECOMMEND ATIONS INTRODUCTION The Centers for Medicare and Medicaid deficiencies Services (CMS cited during ) identified the Medicare hosp This complian top ten most ice recertifica ce tip sheet frequent surve tion surveys will: y for federal fiscal  List the year 2009-2010. survey defic iency by corre (CoP) and by sponding Med Hospice Progr icare Hospice am Interpretive  Provide Condition of an example Guidance** Participation* of the deficiency L-Tag. data. based on actu al CMS surve  Provide y deficiency suggestions for regulatory  List the compliance. standard and practice exam Hospice Progr ple from the ams (2010) relate NHPCO Stand d to the cited ards of Pract deficiency. ice for *The Medicare Hosp CMS TOP TEN HOSPI CE SURVEY SURVEY DEFICI 1. The top ten ENCIES 2. s listed in order Medicare Hosp of the most frequ ice CoP: §418. ently cited are: The hospice 56(c) Standard: must develop Content of the an individuali must reflect plan of care. zed written plan patient and family goals of care for each comprehen and interventio sive, and upda patient. The ns base ted comprehen plan of care necessary for sive assessmen d on the problems ident the palliation ified in and manageme ts. The plan of the following: care must includ the initial, nt of the termi Interpretive nal illness and e all services Guidelines L-Tag related cond itions, includ : L545 ing Medicare Hosp ice All hospice care CoP: §418.56(b) Stand ard: Plan of and services care. written plan furnished to of care estab patients and lished by the their families attending physi hospice interd must follow an cian (if any), isciplinary group individualized the patient or with the patie in collaborat nt’s needs if representative, ion with the any Interpretive and the prima Guidelines L-Tag of them so desire. ry caregiver in accordanc : L543 e hospice surve y deficiencie © National Hospic e and Palliat ive Care Organ ization 2010 Page 1 of 16 1. §418.56(b) Standard: Plan of care - L543 2. §418.56(c) Standard: Content of the plan of care - L545 3. §418.76(h) Standard: Supervision of hospice aides - L629 4. §418.56(d) Standard: Review of the plan of care – L552 5. §418.54(b) Standard: Timeframe for completion of the comprehensive assessment – L523 6. §418.54(d) Standard: Update of the comprehensive assessment – L533 7. §418.56(c)(2) Standard: Scope and frequency of services – L547* 8. §418.54(c)(6) Standard: Drug profile – L530 9. §418.114(d) Standard: Criminal background checks - L795* 10. §418.64(d) Standard: Counseling services; Bereavement counseling - L596* *First-time citation since implementation of the 2008 CoPs. 46 NewsLine http://www.nhpco.org/files/public/regulatory/CMS_TopTenHospice_SurveyDeficiencies.pdf http://www.nhpco.org/files/public/regulatory/CMS_TopTenHospice_SurveyDeficiencies.pdf http://www.nhpco.org/files/public/quality/Standards/NHPCO_STANDARDS_2010CD.pdf http://www.nhpco.org/files/public/quality/Standards/NHPCO_STANDARDS_2010CD.pdf http://www.nhpco.org/files/public/quality/Standards/NHPCO_STANDARDS_2010CD.pdf http://www.nhpco.org/i4a/pages/index.cfm?pageID=6402 http://www.nhpco.org/i4a/pages/index.cfm?pageID=6402 https://www.nxtbook.com/nxtbooks/nhpco/newsline_201012/#/0

Table of Contents for the Digital Edition of NewsLine - August 2011

Marketing Hospice: Ethical Practices
A Message From Don
We Earned Our Merit Badge in Clinical Excellence (display ad)
Recruiting Problems? HMR (display ad)
Helping Children Grieve
ChiPPS: A Gold Mine for Pediatric Palliative Care Resources
The Voice of NCHPP
Providing Seamless Hospice Care
Hospice in the Continuum: Partnering to Provide PACE
Collaboration. Big Picture Perspective. Masterful Results (display ad)
We Honor Veterans Products from Marketplace (display ad)
Back into the Spotlight: Hospice Behind Prison Walls
Free Online Videos About Hospice Care
WHV: Earning Your Stars May be Easier Than You Think
Hospice Outreach: Tailoring Your Message to Your Audience
New Pediatric Training Module
Member News and Notes
Regulatory Tip of the Month
Educational Offerings
Back Cover

NewsLine - August 2011