Initial/Comprehensive Assessment
Comprehensive assessments must screen symptoms and their severity. Name 4
Screening for symptoms and their severity:
Pain, Dyspnea, Nausea, Vomiting, Constipation, Restlessness, Anxiety, Sleep Disorders, Skin Integrity, Confusion, Emotional Distress, Spiritual Needs, Support Systems, Family need for Counseling and Education
Complications and risk factors that affect care planning:
Functional status, including the patient’s ability to understand and participate in his or her own care.
Imminence of death
Who oversees the plan of care?
RN
The heart of the CoPs; CMS considers the Plan of Care (POC) the most important document
and concept in hospice care
• Plan of Care of care purpose
• The primary goal of hospice care is to meet the holistic needs of an individual and his/her
caregiver/family for whom curative care is no longer the preferred option.
• To support this goal, the hospice provider develops an individualized plan of care (POC),
established by an Interdisciplinary Group (IDG) and overseen by a Registered Nurse (RN)
coordinator.
• Signatures on plan of care not necessary, but documentation of collaboration must be evident
Review of plan of care needs to occur minimally how many days?
Review of the plan of care
• Minimally every 15 days or as the patient’s condition requires
• All IDT members participate whether actively providing care or not
• Communication with attending may be through phone calls, electronic methods, orders received, or other means
This form must be issued to the beneficiary prior to receiving care that is usually covered by Medicare, but in this particular instance, it is not covered or may not be covered by Medicare
An ABN (Advance Beneficiary Notice)
What department is duties entail:
Organization self assessment, Program scope, Adverse patient events, Program data, Program activities, Performance improvement projects, Executive Responsibilities: Governing body involvement and oversight
Quality
QAPI plan – written, reviewed, updated annually
Program scope
Adverse patient events
Program data
Program activities
Performance improvement projects
Executive Responsibilities: Governing body involvement and oversight
Comprehensive assessment must identify four needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process.
Psychosocial, Emotional, Spiritual ...
Physical
Provide an example of a measurable outcome.
Must have included data elements in assessment that would allow fort he measurement of outcomes:
• Pain
• Dyspnea
• Nausea
• Vomiting
• Constipation
• Emotional distress
• Spiritual needs
Name the "Core Group" required to be at the IDT meeting.
• The IDT must include (Core Group) nursing, medical social work, and pastoral/spiritual counselor.
• Additional team members may include representatives from other therapeutic services (for example, physical therapy and music and art therapy), as well as other care and supportive personnel such as hospice aides and volunteers.
• Hospices are encouraged to include the patient’s primary caregiver as a participant in the IDT
If a termination involves the end of all Medicare covered care and no further care is being delivered, the correct form is.
Notice of Medicare Non-coverage (NOMNC) Form.
What does QAPI stand for?
Quality Assessment and Performance Improvement
Continuous Quality Improvement (CQI)
Patient-focused and outcome (or results) oriented
Data driven performance improvement
Goal
To monitor quality/performance
Find opportunities for improvement – operations/patient care
Focus is on achieving patient/family desired outcomes or results
Drug profile
A review of all the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy.
Effectiveness of drug therapy, Drug therapy currently with laboratory monitoring, Name two more.
Drug side effects.
Actual or potential drug interactions.
Duplicate drug therapy.
Is hospice responsible for needs identified in the comprehensive assess that are not related to terminal illness or related conditions?
• Hospices may identify needs in the comprehensive assessment that are not related to the terminal illness and related conditions.
• The assessment should document that the hospice is aware of these needs and if warranted, note who is addressing them.
• The hospice must ensure that each patient and the primary caregiver(s) receive education and training as appropriate to their responsibilities for the care and services identified in the plan of care.
How long after a person passes do the hospice agency need to offer support to the bereaved family?
•hospice must offer a bereavement POC and supportive services to the caregiver/family for one year after the death of the hospice patient to further support the bereaved family.
This form is used for reductions and terminations due to physician orders and for reductions and terminations for agency reasons.
The HHCCN (Home Health Change of Care Notice) is used for reductions and terminations due to physician orders and for reductions and terminations for agency reasons.
What does Medicare require to qualify for a GIP stay?
Uncontrolled symptoms management that cannot be controlled in an alternative setting?
How long do you have to complete the initial assessment after signing the Notice of Election?
48 hours from the effective date of the notice of election
Completed by an RN
Not a “meet and greet” visit
Must be completed in the location where the hospice services are being delivered
RN begins to develop the plan of care
Focus is on meeting immediate needs of patient/ family
Are PRN visits acceptable to be a standalone visit?
No - PRN visits acceptable as an accompaniment to an established visit frequency but may not be a standalone visit frequency
Medicare requirements for POC
1. Interventions to manage pain and symptoms
2. A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs such as visit frequency
Standing orders must be individualized and signed by patient’s physician
3. Measurable outcomes anticipated from implementing and coordinating the POC Outcomes should be a measurable result of the implementation of the plan of care
Data elements should be used as part of the plan of care to see if they are meeting the goals of care
4. Drugs and treatments necessary to meet the needs of the patient
5. Medical supplies and appliances necessary to meet the needs of the patient
6. The IDG documentation of the patient’s or representative’s level of understanding, involvement, and agreement with the POC, in accordance with the hospice’s own policies, in the clinical record
How often does a Home Health Aide require supervision?
•A registered nurse must make an on-site visit to the patient’s home:
•No less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs
•The hospice aide does not have to be present during this visit
•A registered nurse must make an on-site visit to the patient’s home:
•The hospice aide does not have to be present during this visit
Is a NOMNC required when the patient refuses all further services or when patient goes from Medicare Home Health to Medicare Hospice benefit?
NOT required
For a inpatient stay it is the hospice responsibility to assure that the facility has enough nursing personnel present on all shifts to guarantee the adequate safety measure are in place for the patient, and that the routine, special and emergency needs of all patients are met at all times.
Yes - see last section
• Inpatient care must be available for pain control, symptom management, and respite purposes, and must be provided in a participating Medicare or Medicaid facility.
Respite
• The facility providing respite care must provide 24-hour nursing services that meet the nursing needs of all patients and are furnished in accordance with each patient’s plan of care. Each patient must receive all nursing services as prescribed and must be kept comfortable, clean, well-groomed, and protected from accident, injury, and infection.
• If the patient needs 24-hour nursing services, then the facility must be able to provide it
• The hospice must assure that the inpatient facility has enough nursing personnel present on all shifts to guarantee that adequate safety measures are in place for the patients, and that the routine, special, and emergency needs of all patients are met at all times.
How long do you have to complete the comprehensive assessment?
No more than 5 calendar days after the effective date of the election of hospice care (Masonicare/best practice NOE is signed and Initial/Comprehensive assessment is completed on same day)
Plan of care is not formed by RN alone POC development requires Interdisciplinary Team participation with attending physician input
When is the plan of care initially developed?
At start of care by the registered nurse and patient/family. It is adjusted and reviewed during IDT.
How often does the written Home Health Aide care plans left in the patients home have to be updated?
60 days
REMINDERS: Hospice aide written instructions:
• Hospice aides are assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group
• Written patient care instructions for a hospice aide must be prepared by a registered nurse who is responsible for the supervision of a hospice aide
Written by the RN (RN is responsible for the supervision of the aide)
Must be patient specific and not genetic
• Aide notes for a visit should match aide care instructions for the patient
• Update Hospice aide care plan as patient’s needs change
You must wait until the last two days of service to provide a NOMNC (Notice of Medicare NonCoverage)?
No - but Masonicare request that you do not provide on a Friday or weekend. Please plan to provide form when appeals will not be provided on weekend.
6 of top 10 survey deficiencies in CY 2021 were related to what?
• 6 of top 10 survey deficiencies in CY 2021 were related to plan of care
• Plans of care were not individualized
• Hospice staff missed direct-care visits
• Documentation of visits did not meet requirements (for example, wound care)
• POCs were incomplete (for example, not inclusive of all needed services)
• IDG meetings were inconsistent, with plans of care not being updated