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
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