The hospice industry is no stranger to regulatory and compliance matters but lately they have become more stringent.
As hospice professionals, we work diligently to exceed the regulations outlined in the Hospice Conditions of Participation, yet when we evaluate the compliance of our organizations, we can find new opportunities for improvement.
Analysis of industry-wide deficiency patterns and activities of the Office of Inspector General (OIG) may provide valuable insights into how the past is informing the future of hospice care.
Introducing New Enforcement Remedies
Following a 2019 report that revealed major areas of improvement in the hospice industry, the OIG has been influential in the development of new survey regulations per the Hospice Conditions of Participation with the goal of gaining back public trust, addressing inconsistencies between survey agencies and accrediting organizations and ensuring accountability through consistent survey requirements.
If you have worked in long-term care, you are most likely familiar with enforcement remedies. However, all hospice organizations need to be familiar with the newly-enacted enforcement remedies that come with survey deficiencies.
Factors to be Considered in Selecting Enforcement Remedies
Here are the considerations federal regulators gauge when imposing enforcement remedies:
- Extent of Immediate Jeopardy (IJ): How bad was the Immediate Jeopardy to patient health and safety?
- Nature, incidence, manner, degree and duration: This is how we evaluate the extent of the Immediate Jeopardy and other deficiencies they identify.
- Repeat deficiencies: They are going to look at whether every three years your organization will receive a pretty significant deficiency for patient care, patient concerns, a plan of care, your comprehensive assessment, your patient’s rights and those kinds of things.
- Compliance history for location and additional locations
- Failure to provide quality patient care
- Larger organization: If your location is part of a larger organization, they will look at the larger organization as well to see if there is a pattern. Is there something at the corporate level that is lending itself to these deficiencies?
- System-wide failure: Is it affecting the care of patients? Make sure that your policies and procedures reflect the care that you are providing and also reflect the needs of your organization, the larger organization and are aligned with the goals and desires of the board of directors.
Where to Start in Preparing for the New Survey Requirements
The easiest and most beneficial way to prepare your organization is to start keeping track of your incidents and complaints. Track their nature, incidence, manner, degree and duration.
How many people were affected? Who is affected now? Who could be affected?
What are you going to put in place to ensure that it does not happen again? What did you do immediately for the people who were affected?
Understanding where there are opportunities for improvement, using the information contained in the incident and complaint logs, will support the quality assurance performance improvement, patient care and organizational environment survey domains.
These changes affect organizations of all sizes and will require hospice professionals to have a new perspective on surveys and how to prepare for them. Register for this in-depth webinar to understand the changes made to the survey process, receive survey preparation tips and strategies and pinpoint factors that will affect your next survey.
Axxess Hospice, a cloud-based hospice and palliative care software, prepares organizations for upcoming surveys through a HIPAA-compliant automatic workflow to ensure information is present and accurate.
