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Tuesday, September 3, 2019

Nervous about your upcoming survey? Try these pointers to ease your anxiety. Hospice Readiness Helpful Hints to reduce your fear and dread!

For Survey have these available in a binder: ♣ Organizational chart ♣ Unduplicated admissions number for previous 12 months ♣ Current census, live discharges, revocations, deaths/bereavement ♣ Current schedule of visits ♣ Personnel list, volunteers, contract staff ♣ Contracts for Therapy ♣ Contracts for Medical Director/Alternate Medical Director ♣ Contracts for SNF/orientation to SNF staff ♣ Contracts for inpatient care ♣ Contracts for pharmacy ♣ Contracts for DME ♣ Admission packet ♣ Patient education materials ♣ Volunteer Program information ♣ Cost savings ♣ Activity level ♣ Governing Body members & meeting minutes ♣ QAPI activities and initiatives ♣ Current Hospice License ♣ CLIA waiver, if applicable ♣ Complaint/Grievance logs ♣ Incident reports
Have Staff Files pulled and ready for review with these areas Identified in the file: ♣ Review personnel records for key staff, contract staff, and volunteers ♣ Verification of qualifications ♣ Orientation records, competencies ♣ Background checks ♣ Based on unduplicated admissions ♣ Representative of the care provided ♣ Pediatric-geriatric ♣ Environment served ♣ Medically complex Unduplicated Admissions For a recent 12 months Minimum # of Record Reviews Without Home Visit Minimum # of Record Reviews With Home Visit Total Record Reviews <150 admission is 8 no home visit, 3 with 150-750 admissions is 10 no home and 3 home visits, 751-120 is 15 no home and 5 home visits
Get the family and the patient ready for home visit: Prepare patients and families ♣ Explain the intent of the visit ♣ Ask the surveyor how consent is demonstrated ♣ Common questions asked of the patient: ♣ Do you know how to reach your hospice after hours? ♣ Who comes to visit you? ♣ Have you had for services, medications, equipment? ♣ Have you had a time where you were in pain and couldn’t get the hospice to respond? ♣ Do you know how to file a complaint about the hospice And Staff: ♣ Prepare staff ♣ Observe ♣ Ensure staff are providing care according to agency policies and procedures ♣ Infection control ♣ Following the Plan of Care ♣ Desensitize staff to being observed Assess staff knowledge of: ♣ Policies and procedures ♣ Medicare Conditions of Participation ♣ State hospice regulations ♣ Practice act/scope of practice ♣ Comprehension of knowledge ♣ Competency ♣ Application of knowledge ♣ Observe on home visits ♣ Review post visit documentation
These are the top problematic deficiencies that are seen in the past six months of audits: ♣ 418.54 Initial and Comprehensive Assessment ♣ L523 Timeframe for Completion of Assessment ♣ L530 Content of Comprehensive Assessment • Drug profile/review ♣ L533 Update of Comprehensive Assessment 418.56 Interdisciplinary Group, Care Planning and Coordination of Services ♣ L538 POC specified care/services to meet the needs of the patient/family ♣ L543 Plan of care ♣ L545 Content of the plan of care ♣ L547 Detailed statement of scope and frequency of services ♣ L548 Measureable outcomes anticipated ♣ L552 Review and revise POC at least every 15 days or more if patient’s condition warrants ♣ L553 Revised plan of care includes information from updated comprehensive assessment ♣ L554 Coordination of care ♣ L555 Ensure care/service in accordance with the plan of care ♣ L557 Sharing of information 418.76 Hospice Aide Assignments and Duties ♣ L625 Written hospice aide instructions ♣ L626 Hospice aide assignment and duties ♣ L629 Hospice aide supervisory visits END.