Hospice - Citations and Description

2080 - Hospice - Citations and Description (Rev. 1, 05-21-04) 2080A - Citations (Rev. 73, Issued: 12-02-11 Effective: 12-02-11, Implementation: 12-02-11) Section 1861(u) of the Act establishes hospices as a provider of services. Section 1861(dd) of the Social Security Act (the Act) defines hospice care and the hospice program. 42 CFR 418 sets forth the Conditions of Participation (CoPs) that hospices must meet and applies to a hospice as an entity as well as to the services provided to each individual under hospice care. 42 CFR Part 418.110 is a condition applicable only to hospices that provide short-term inpatient care and respite care directly, rather than under arrangements with other participating providers. Section 1866(a)(1)(Q) of the Act requires hospices, among other providers, to file an agreement with the Secretary to comply with the requirements found in Section 1866(f) of the Act regarding advance directives. The Centers for Medicare & Medicaid Services (CMS) has a Web site for survey and certification information including hospice policy memos, the State Operations Manual, §§2080-2089 relating to hospices, and Appendix M, “Hospice Survey Procedures and Interpretive Guidelines.” This information is available at http://www.cms.hhs.gov/SurveyCertificationGenInfo/ Definition A hospice is a public agency or private organization or a subdivision of either of these that is primarily engaged in providing care and services to terminally ill individuals, meets the CoPs for hospices, and has a valid Medicare provider agreement. The law governing the provision of Medicare hospice services is found at Section 1861(dd) of the Act. The law further clarifies that “terminally ill individuals” are individuals having a “medical prognosis that the individual’s life expectancy is 6 months or less.” This definition is further clarified at 42 CFR 418.3 to provide for a life expectancy of 6 months or less “if the illness runs its normal course.” Although the law does not explicitly define its expectations for “primarily engaged,” CMS has interpreted it to mean exactly what it says, that a hospice provider must be primarily engaged in providing hospice care and services (Section 1861(dd)(2)(A)(i)). “Primarily” does not mean “exclusively.” This requirement does not preclude the hospice from providing services to terminally ill individuals who have not elected the hospice benefit or providing services to individuals who are not terminally ill, as long as the primary activity of the hospice is the provision of hospice services to terminally ill individuals and the hospice meets all requirements for participation in Medicare. Hospice Benefit Periods An individual may elect to receive Medicare hospice benefits for two periods of 90 days and an unlimited amount of periods for 60 days each. (See 42 CFR 418.21.) Eligibility Requirements In order to be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill. (See 42 CFR 418.20.) An individual is considered to be terminally ill if the individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course. Referrals may come from any source, but patients must be assessed by the hospice medical director for appropriateness of admission in consultation with the patient’s attending physician (if the individual has one). The hospice medical director must consider the diagnosis of the terminal condition of the patient, other health conditions, whether related or unrelated to the terminal illness, and current clinically relevant information supporting all diagnoses. The medical director may consult with the attending physician directly or through information obtained indirectly. Information could be obtained through the hospice nurse or others who would bring the attending physician’s knowledge of the patient to the medical director when the admission decision is being made. The hospice must obtain written certification of terminal illness within 2 calendar days for each of the benefit periods listed in 42 CFR 418.21, even if a single election continues in effect for an unlimited number of periods. If the hospice cannot obtain the written certification within 2 calendar days, after a period begins, it must obtain oral certification within 2 calendar days and written certification before a claim for payment is submitted. For the initial 90-day period, certification of terminal illness must be obtained from the medical director of the hospice or the physician member of the hospice interdisciplinary group (IDG) and the individual’s attending physician (if the individual has one). Recertification for subsequent periods only requires the certification of the hospice medical director or the physician member of the IDG. Certification statements must be on file and dated by the physician before the hospice submits a claim for payment. (See 42 CFR 418.22.) 2080B - Description (Rev. 69, Issued: 12-15-10, Effective: 10-01-10, Implementation: 10-01-10) Hospice care means a comprehensive set of services described in Section1861(dd)(1) of the Act, identified and coordinated by the individual’s attending physician, medical director and by an interdisciplinary group to provide for the physical, psychosocial, spiritual and emotional needs of a terminally ill patient and family members, as delineated in a specific patient plan of care. Hospice uses an interdisciplinary approach to caring for terminally ill individuals that stresses palliative care as opposed to curative care. Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and facilitating patient autonomy, access to information, and choice. The emphasis of hospice care is on effective symptom management, with the goal of making the patient as physically and emotionally comfortable as possible, and enabling the patient to remain at home as long as possible with minimal disruption to normal activities. Counseling and respite services are available to the family of the hospice patient. Hospice considers both the patient and the family as the unit of care. Although some hospices are located as part of a hospital, skilled nursing facility (SNF), and home health agency (HHA), hospices must meet specific CoPs and be separately certified and approved for Medicare participation as a hospice provider of services. (See Exhibit 129 for “Hospice Survey and Deficiencies Report,” Form CMS-643, and Exhibit 72 for “Hospice Request for Certification in the Medicare Program,” Form CMS-417.) 2080C - Hospice Core Services (Rev. 73, Issued: 12-02-11 Effective: 12-02-11, Implementation: 12-02-11) With the exception of physician services, substantially all core services must be provided directly by hospice employees on a routine basis. These services must be provided in a manner consistent with acceptable standards of practice. The following are hospice core services: • Physician services; • Nursing services, (routinely available and/or on call on a 24-hour basis, 7 days a week) provided by or under the supervision of a registered nurse (RN) functioning within a plan of care developed by the hospice (IDG) in consultation with the patient’s attending physician, if the patient has one; • Medical social services by a qualified social worker under the direction of a physician; and • Counseling (including, but not limited to, bereavement, dietary, and spiritual counseling) with respect to care of the terminally ill individual and adjustment to death. The hospice must make bereavement services available to the family and other individuals identified in the bereavement plan of care up to 1 year following the death of the patient. The hospice may contract for physician services as specified in 42 CFR 418.64(a). A hospice may use contracted staff, if necessary, to supplement hospice employees in order to meet the needs of patients under extraordinary or other non-routine circumstances. 2080C.1 - Waiver of Certain Staffing Requirements (Rev. 73, Issued: 12-02-11 Effective: 12-02-11, Implementation: 12-02-11) Hospices are prohibited from contracting with other hospices and non-hospice agencies on a routine basis for the provision of the core services of nursing, medical social services and counseling to hospice patients. A hospice may, however, enter into arrangements with another hospice program or other entity for the provision of these core services in extraordinary, exigent, or other non-routine circumstances. An extraordinary circumstance generally would be a short-term temporary event that was unanticipated. Examples of such circumstances might include unanticipated periods of high patient loads, caused by an unexpectedly large number of patients requiring continuous care simultaneously, temporary staffing shortages due to illness, receiving patients evacuated from a disaster such as a hurricane or a wildfire, or temporary travel of a patient outside the hospice’s service area. The hospice that contracts for services must maintain professional management responsibility for all services provided under arrangement or contract at all times and in all settings. Regulations at 42 CFR 418.100(e) discuss the professional management responsibilities of the hospice for services provided under arrangement. Hospices must maintain evidence of the extraordinary circumstances that required them to contract for the core services and comply with the following: • The hospice must assure that contracted staff is providing care that is consistent with the hospice philosophy and the patient's plan of care and is actively participating in the coordination of all aspects of the patient’s hospice care, and • Hospices may not routinely contract for a specific level of care (e.g., continuous care) or during specific hours of care (e.g., evenings and week-ends). 2080C.2 - Contracting for Highly Specialized Services (Rev. 69, Issued: 12-15-10, Effective: 10-01-10, Implementation: 10-01-10) A hospice may contract for the services of a registered nurse if the services are highly specialized, provided non-routinely, and so infrequently that the provision of such services directly would be impracticable and prohibitively expensive. Highly specialized services are determined by the nature of the service and the nursing skill level required to be proficient in the service. For example, a hospice may need to contract with a pediatric nurse if it cares for pediatric patients infrequently, and employing a pediatric nurse would be impracticable and expensive. Continuous care is not a highly specialized service, because while time intensive, it does not require highly specialized nursing skills. 2080C.3 – Hospice Nursing Shortage Provision (Rev. 69, Issued: 12-15-10, Effective: 10-01-10, Implementation: 10-01-10) CMS has instituted a temporary measure for hospices that are unable to hire a sufficient number of nurses directly due to the nursing shortage. During the time period from October 1, 2010 – September 30, 2012, in order to qualify for an “extraordinary circumstance” exemption, a hospice must notify the state agency (SA) responsible for licensing and certification that it intends to elect an exception under the “extraordinary circumstance” authority. This may be accomplished by providing written notification to the SA when it believes that the nursing shortage has become an “extraordinary circumstance” in its ability to hire nurses directly, and it must estimate the number of nurses it believes it will currently need to employ under contract. Notification may be made prior to September 30, 2012, and should address the following: • An estimate of the number of potential patients that the hospice has not been able to admit during the past --3 months due to the nursing shortage and provide the current and desired patient/nurse ratio for the agency; • Evidence that the hospice has made a good faith effort to hire and retain nurses, including: - Copies of recent advertisements (e.g., in local newspapers, Web sites, etc.,) that demonstrate recruitment efforts; - Copies of reports of telephone contacts with potential hires, professional schools and organizations, recruiting services, etc., and - Job descriptions for nurse employees; • Evidence that salary and benefits are competitive for the area; • Evidence of any other recruiting activities (e.g., recruiting efforts at health fairs, educational institutions, health care facilities, and contacts with nurses at other providers in the area); • Ongoing self-analyses of the hospice’s trends in hiring and retaining qualified staff; and • Evidence that the hospice has a training program in place to ensure that contracted staff are trained in the hospice philosophy, and able to provide palliative care prior to patient contact; Contracted nurses may only be used to supplement the hospice nurses employed directly and should not be used solely to provide the continuous nursing level of care or on call service. The hospice is expected to continue its recruitment efforts during the period that it is contracting for nurses. No approval action is required on the SA’s part when it receives written notification from a hospice for an exemption, as long as the hospice provides the appropriate information. The SA will maintain copies of each exception notification and validate the hospice’s stated need for an exemption during complaint and re-certification surveys. Of particular importance will be the extent to which the hospice nurses have been trained in the hospice philosophy and are able to effectively provide care to the patients consistent with the patient specific plan of care established by the IDG. NOTE: CMS has instituted a temporary measure to allow individual hospices to contract for nurses until September 30, 2012, if the hospice can demonstrate that the nursing shortage is creating an extraordinary circumstance that prevents it from hiring an adequate number of nurses. 2080D - Hospice Required Services (Rev. 73, Issued: 12-02-11 Effective: 12-02-11, Implementation: 12-02-11) Requirement for 24-Hour Services The hospice is required by the CoPs at 42 CFR 418.100 to make nursing services, physician services, drugs, and biologicals routinely available on a 24-hour basis, 7 days a week. It also has to make all other covered services available on a 24-hour basis, 7 days a week, when reasonable and necessary to meet the needs of the patient and family. In addition to the hospice core services (physician services, nursing services, medical social services, and counseling), the following services must be provided by the hospice, either directly or under arrangements, to meet the needs of the patient and family: • Physical and occupational therapy and speech-language pathology services; • Hospice aide services A hospice aide employed by a hospice, either directly or under contract, must meet the qualifications required by Section1891(a)(3) of the Act and implemented at 42 CFR 418.76; • Homemaker services; • Volunteers; • Medical supplies (including drugs and biologicals on a 24-hour basis) and the use of medical appliances related to the terminal diagnosis and related conditions; • Short-term inpatient care (including respite care and interventions necessary for pain control and acute and chronic symptom management) in a Medicare/Medicaid participating facility; and • Continuous home care provided during a period of crisis. Nursing care may be covered on a continuous basis for as much as 24 hours a day during periods of crisis, as necessary to maintain the patient at home. 42 CFR 418.204(a) defines a crisis as the period in which an individual requires continuous care for as much as 24 hours to achieve palliation or management of acute medical symptoms. The care provided must require at least 8 hours of care in a 24 hour period, and the care must be provided predominantly by a licensed nurse (RN, LVN, LPN). Homemaker or hospice aide services or both may also be covered if needed. Section 1861(dd)(5) of the Act allows CMS to permit certain waivers of the requirements that the hospice make physical therapy, occupational therapy, speech language pathology services, and dietary counseling available (as needed) on a 24-hour basis. CMS is also allowed to waive the requirement that hospices provide dietary counseling directly. These waivers are available only to an agency or organization that is located in an area which is not an urbanized area (as defined by the Bureau of Census) and that can demonstrate to CMS that it has been unable, despite diligent efforts, to recruit appropriate personnel. These waivers are codified at 42 CFR 418.74. 2080D.1 - Hospice Interdisciplinary Group (IDG) (Rev. 69, Issued: 12-15-10, Effective: 10-01-10, Implementation: 10-01-10) Hospices participating in the Medicare program must use an interdisciplinary approach to assessing and meeting the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. The hospice IDG members include, but are not limited to, the hospice physician (doctor of medicine or osteopathy) who must be an employee of or under contract with the hospice, registered nurse, social worker, and pastoral or other counselor. The IDG is required to conduct a comprehensive assessment of the patient and update the assessment at required time points. In addition, the group, in consultation with the patient's attending physician, if the patient has one, must prepare a written plan of care for each patient that reflects patient and family goals and interventions based on the needs identified in the initial, comprehensive, and updated assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. The attending physician may either be a doctor of medicine or osteopathy or a nurse practitioner. This person is identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual’s medical care. In the event that a beneficiary’s attending physician is a nurse practitioner, the hospice medical director and/or physician designee must certify or re-certify the terminal illness. Nurse practitioners cannot certify a terminal diagnosis or the prognosis of 6 months or less, if the illness or disease runs its normal course, or re- certify a terminal diagnosis or prognosis. The hospice IDG is responsible for developing and maintaining a system of communication, coordination, and integration of services that ensures that the plan of care is reviewed and updated no less frequently than every 15 calendar days. It is not permissible for either the attending physician or the hospice medical director to provide the sole guidance for the plan of care. The law and regulations require that it be the combined work of the IDG.