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Copyright © 2016 Accreditation Commission for Health Care

ACHC STANDARDS

Program

Date Downloaded:

Services

Hospice

Palliative Care Hospice

[4/3/2017]

ACHC ACCREDITATION STANDARDS The following packet contains the 2016 ACHC Accreditation Standards. Release Date: April 4, 2016 Effective Date: April 4, 2016 ACHC is committed to providing healthcare organizations with relevant, comprehensive standards that facilitate the highest level of performance. In order to ensure each standard is clear, concise, and relevant, ACHC conducts an annual review of all standards by compiling feedback from providers, industry consultants, and regulatory bodies. Based upon the annual review, ACHC has only made one standard change in 2016. Standard HSP4-2C.01 was updated to clarify Tuberculosis (TB) testing and annual screening requirements. The attached Accreditation packet contains: Preliminary Evidence Report (PER) Initial Checklist (if you are applying for ACHC accreditation for the first time)

ACHC Accreditation Standards for Hospice

Hospice Medicare Conditions of Participation Survey Requirements

Glossary of Terms

Glossary of Personnel Qualifications

Preamble for Hospice Service

Revised: 2/14/2017 Page 1 of 2 I achc.org [381] Accreditation Preliminary Evidence Report (PER) Initial Checklist

PRELIMINARY EVIDENCE REPORT (PER) INITIAL CHECKLIST This checklist constitutes the requirements of the PER, which is mandatory for organizations applying for initial Hospice accreditation.

Review and acknowledge that all of the following requirements have been met and submit this signed checklist with the required items listed below.

Verification of the following is required for organizations seeking an initial Medicare Provider Number:

Organization has completed the CMS-855 application and received written confirmation the application has been “processed” and “the application is being forwarded with a recommendation to the state and CMS Regional Office” Submit a copy of the letter from CMS or the Medicare Administrative Contractor (MAC) to your Account Advisor.

This is applicable for companies seeking an initial Medicare Provider Number.

Please follow up with your MAC if the approval letter is greater than 6 months and submit documentation it is still active.

The organization must have provided care to a minimum of 5 patients (not required to be Medicare patients) At least 3 of the required 5 patients should be receiving care at the time of the Initial Medicare Certification Survey If the hospice is located in a medically underserved area, as determined by the CMS Regional Office (RO), please call

ACHC for further guidance The organization can demonstrate they are able to provide all services needed by patients being served and is able to

demonstrate operational capacity of all facets of the organization. The hospice is fully prepared to provide all services necessary to meet the hospice Conditions of Participation (CoPs)

The organization has a full and current license, NOT PROVISIONAL, in the state it is currently doing business, if applicable. Please note: not all states require a license therefore this only pertains to organizations that reside in states that

require a license

Confirmation of the following (initial in spaces provided):

___________ I attest that this organization possesses all policies and procedures as required by the ACHC Accreditation Standards

__________ I acknowledge that this organization was/is/will be in compliance with ACHC Accreditation Standards as of ____________________ date.

Your organization will be placed into scheduling once this document, the Agreement for Accreditation Services and Business Associate Agreement are submitted to your Account Advisor and payments are up-to-date. ACHC will strive to conduct your survey as soon as possible. **PLEASE NOTE: YOUR ORGANIZATION MUST ALWAYS BE IN COMPLIANCE WITH MEDICARE REGULATIONS, CONDITIONS OF PARTICIPATION, AND APPROPRIATE STATE REGULATIONS. I, having the authority to represent this organization, verify that _____________________________________________________________ (organization’s legal name) has met the above requirements for survey. If this organization fails to meet any of the aforementioned

Revised: 2/14/2017 Page 2 of 2 I achc.org [381] Accreditation Preliminary Evidence Report (PER) Initial Checklist

requirements when the ACHC Surveyor arrives on site, the survey performed by ACHC will not be accepted as a legitimate Initial Medicare Certification Survey by CMS. This will result in additional charges to the organization for a subsequent survey to be performed when the organization has notified ACHC it has met all of the above requirements.

_____________________________________________________________________________ _____________________________________________________________________________ (Name) (Title) _____________________________________________________________________________ _____________________________________________________________________________ (Date) (Signature

ACHC ACCREDITATION STANDARDSCustomized for Palliative Care Hospice

Section 1: ORGANIZATION AND ADMINISTRATION

The standards in this section apply to the leadership and organizational structure of the company. All items referring to business licensure including federal, state and local licenses that affect the day-to-day operations of the business should be addressed. This section includes the leadership structure including board of directors, advisory committees, management and employees. Also included is information about leadership responsibilities, conflicts of interest, chain of command, program goals and regulatory compliance.

Standard PC1-A: The provision of palliative care occurs in accordance with professional state and federal laws, regulations and current accepted standards of care. (Guideline 8.3)

Interpretation: The palliative care program is in compliance with federal and state statutes, regulations and laws regarding:

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Disclosure of medical records and health informationMedical decision-makingAdvance care planning and directivesThe roles and responsibilities of surrogate decision-makersAppropriate prescribing of controlled substancesDeath pronouncement and certification processesAutopsy requests, organ and anatomical donationHealth care documentationPalliative care program policies and procedures

Palliative care team members make efforts to understand how patient/family cultural beliefs, perceptions and practices may affect palliative care treatment options, services and the plan of care. The palliative care team is knowledgeable about legal and regulatory aspects of palliative care and has access to legal advice and counsel as needed.

Palliative care practice is modeled on and consistent with existing professional codes of ethics, scopes of practice and standards of care for all relevant disciplines.

Evidence: Patient RecordsEvidence: ObservationEvidence: Personnel FilesEvidence: Response to Interviews

Services applicable: PCHH, PCHSP, PCPD

Page 1 of 15April, 2017 ACHC Accreditation Standards

Section 2: PROGRAM/SERVICE OPERATIONS

The standards in this section apply to the specific programs and services an organization is supplying. This section addresses rights and responsibilities, complaints, protected health information (PHI), cultural diversity, and compliance with fraud and abuse-prevention laws.

Standard PC2-A: Written policies and procedures are established and implemented in regard to the palliative care program coordinating care and collaborating with community resources to ensure continuity of care for the patient and family. (Guideline 1.8)

Interpretation: Written policies and procedures are established and implemented regarding:

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Coordination of care with community resources to ensure continuity of careCommunication and collaboration with hospices and other community service providers involved in the patient’s careReferrals are only made with the patient or appropriate representative's consent Timely and effective sharing of information among healthcare teams while safeguarding privacy

The palliative care program supports and promotes continuity of care throughout the patient’s illness.

Non-hospice palliative care programs have relationships with one or more hospices and other community resources to ensure continuity of care. Non-hospice palliative care programs inform patients and families about hospice and other community resources.

The palliative care team informs the patient’s health care providers of the availability of hospice services and other community resources.

Evidence: Written Policies and ProceduresEvidence: Patient RecordsEvidence: Observation


Standard PC2-B: Written policies and procedures are established and implemented in regard to palliative care services being provided to the patient and family to the extent that their preferences and needs can be met in their physical environment. (Guideline 1.9)

Interpretation: Written policies and procedures are established and implemented that describe the different environments of care available to the patient and family.

The palliative care team provides care in a setting preferred by the patient or family. When care is provided outside of the family’s home, the interdisciplinary team (IDT) collaborates with other service providers to ensure the patient’s safety and sense of control. When possible, the environment provides flexible visiting hours and space for a family visiting area, rest area, eating area, and privacy for the patient and family.

Unique care needs of pediatric/adolescent patients or family members/visitors will be addressed by the palliative care team.

Evidence: Written Policies and ProceduresEvidence: ObservationEvidence: Response to Interviews


Standard PC2-C: Written policies and procedures are established and implemented in regard to the palliative care program providing care/service to patients and families of various of belief systems. (Guideline 6.1)

Interpretation: Written policies and procedures describe the mechanisms the palliative care program uses to provide care for the patients/families of different cultural backgrounds, beliefs and religions.

Palliative care team members make efforts to understand how cultural beliefs, perceptions and practices may affect treatment options, services and the plan of care. Palliative care team members make efforts to understand and accommodate patient/family dietary and ritual practices.

Palliative care team members communicate in a language and manner the patient and family can understand. Options may include:

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Language lineInterpreters Written material in patient’s preferred language


During the assessment process the interdisciplinary team (IDT) elicits and documents the patient/family cultural identification, strengths, concerns and/or needs.

Referrals to culture-specific or culturally based community resources are made as appropriate.



Standard PC2-D: Written policies and procedures are established and implemented in regard to the palliative care program striving to enhance its cultural and linguistic competence. (Guideline 6.2)

Interpretation: The palliative care program has written policies and procedures that describe methods to enhance cultural and linguistic awareness and services.

The palliative care program supports a multicultural work environment. It is an equal opportunity employer and does not discriminate on the basis of race, color, religion, sex, sexual orientation or national origin.

Palliative care staff identify differences in their own beliefs and the patient’s beliefs and find ways to support the patient.

Ongoing education is provided to staff on cultural awareness and cultural competency.

The palliative care program regularly evaluates its services, policies and responsiveness to the multicultural population and makes changes as appropriate.



Standard PC2-E: Written policies and procedures are established and implemented in regard to the palliative care program identifying and assessing complex ethical issues arising in the care of people with life-threatening illnesses. (Guideline 8.2)

Interpretation: Written policies and procedures describe mechanisms for identifying and addressing ethical issues in providing palliative care.

Existing or potential ethical issues are identified by the palliative care team. The palliative care team assesses for possible ethical issues such as withholding or withdrawing treatments, instituting a do not resuscitate (DNR) order, and the use of sedation in palliative care.

Ethical concerns are addressed with the patient or family and are documented in the clinical record.

Referrals are made to ethics consultants or the agency’s ethics committee as appropriate. An ethics committee or consultant may be contacted for guidance on policy development, clinical care issues, conflict resolution and staff education.

Interdisciplinary team (IDT) members have education or training in ethical principles of palliative care.

Evidence: Written Policies and ProceduresEvidence: Patient RecordsEvidence: ObservationEvidence: Personnel Files



Section 4: HUMAN RESOURCE MANAGEMENT

The standards in this section apply to all categories of personnel in the organization unless otherwise specified. Personnel may include, but are not limited to, support personnel, licensed clinical personnel, unlicensed clinical personnel, administrative and/or supervisory employees, contract personnel, independent contractors, volunteers, and students completing clinical internships. This section includes requirements for personnel records including skill assessments and competencies.

Standard PC4-A: Written policies and procedures are established and implemented in regard to the palliative care program option to use volunteers to provide services to the patient and family. (Guideline 1.4)

Interpretation: Written policies and procedures describe the role and practices of volunteers in the palliative care program.

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Volunteers must comply with all personnel policies and procedures, including background checks and training. Volunteers are trained, coordinated and supervised by a palliative care team member. Services provided by volunteers will be included in the plan of care.

Evidence: Written Policies and ProceduresEvidence: Personnel FilesEvidence: Response to Interviews


Standard PC4-B: A written education plan is established and implemented that defines the content and frequency of evaluations as well as the amount of ongoing in-service training. (Guideline 1.5)

Interpretation: The palliative care program has a written education plan.�

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The education plan includes training provided during orientation as well as ongoing in-service education. The palliative care program provides this training directly or arranges for personnel to attend sessions offered by outside sources.The ongoing education plan is a written document that outlines the education to be offered for personnel throughout the year. The plan is based on a reliable and valid assessment of needs relevant to individual job responsibilities. Education activities also include a variety of methods for providing personnel with current, relevant information to assist with their learning needs. These methods include provision of journals, reference materials, books, internet learning, in-house lectures and demonstrations.The palliative care program has an ongoing education plan that includes, but is not limited to:

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The domains of palliative carePain and symptom management Communication skillsMedical ethicsGrief and bereavementFamily and community resourcesHospice care and philosophy as well as eligibilityAdvance care planningCultural considerationsSpiritual beliefs

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The program supports professional development through discipline-specific certifications, mentoring, preceptorships and supervision. There is written documentation confirming attendance at ongoing education programs.Personnel hired for specific positions within the palliative care program meet the minimum qualifications for those positions in accordance with applicable laws or regulations, licensure requirements, and the program's policies/ procedures and job descriptions.

Evidence: Written Policies and ProceduresEvidence: Personnel Files


Standard PC4-C: The palliative care program provides support services to its team members. (Guideline 1.7)

Interpretation: The palliative care program describes the mechanisms of support services available to staff.

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The palliative care program provides regular support meetings for staff and volunteers to encourage discussion of emotional stress/impact when caring for patients and families with serious or life-threatening illnesses. The palliative care program and interdisciplinary team (IDT) implements interventions to promote staff support and sustainability. Opportunities for additional counseling services are available.

Evidence: Response to Interviews


Section 5: PROVISION OF CARE AND RECORD MANAGEMENT

The standards in this section apply to documentation and requirements for the service recipient/client/patient record. These standards also address the specifics surrounding the operational aspects of care/services provided.

Standard PC5-A: Written policies and procedures are established and implemented in regard to an initial evaluation of the patient and family being completed in a timely manner; this assessment forms the basis of the plan of care. (Guideline 1.1)

Interpretation: Written policies and procedures describe the palliative care program’s mechanisms for completing an initial evaluation. Members of the interdisciplinary team (IDT) completes an initial evaluation and subsequent re-evaluations through patient and family interviews; review of medical and other available records; discussion with other providers; and physical exam and assessment. Initial contact occurs within two business days of palliative care referral.

The initial evaluation includes, but is not limited to:

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Assessments of the patient’s current medical status, diagnosis and treatment options, a review of medical history and the patient’s response to past treatments. Assessment includes documentation of the patient’s diagnoses and prognosis, comorbid medical and psychiatric disorders, physical and psychological symptoms, functional status, social, cultural and spiritual needs, advance care planning concerns and patient/family goals for quality of life. Assessment of neonates, children and adolescents must be conducted with consideration of age and stage of neurocognitive development. Assessment of the patient/family perception and understanding of the life-limiting illness, including goals for quality of life and preferences for care.

Needs identified during the initial evaluation are referred to the appropriate IDT member for completion of a comprehensive assessment. Timeframes for completion of the comprehensive assessments are defined in agencies policies and procedures.

The palliative care program has policies in place for prioritizing and responding to referrals as well as responding timely to patient/family crises.

Evidence: Written Policies and ProceduresEvidence: Patient RecordsEvidence: Response to Interviews


Standard PC5-B: Written policies and procedures are established and implemented in regard to patient and family participation in the formation of the plan of care. (Guideline 1.2)

Interpretation: The palliative care program ensures participation by the patient and family in the plan of care. The family is defined by the patient.

The plan of care is developed with professional guidance and support for patient/ family decision-making.

The care plan is based upon ongoing assessments and reflects goals set by the patient/family or surrogate in collaboration with the interdisciplinary team (IDT) and community providers (if applicable).

The care plan is updated as needed based on the evolving needs and presence of the patient and family.

Treatment options and alternatives are communicated to the patient and family to promote informed decision-making.

Complementary and alternative therapies may be included in the plan of care.

The plan of care includes values, goals, and needs that have been expressed by the patient/family.



Standard PC5-C: The interdisciplinary team (IDT) provides services to the patient and family in accordance with the plan of care. (Guideline 1.3)

Interpretation: The palliative care program has mechanisms in place for the IDT to provide services in accordance with the plan of care.


The IDT for the palliative care program consists of spiritual care professionals, nurses, physicians and social workers based on patient and family needs. It may also include other therapeutic disciplines as requested by the patient and family or when a need is identified by IDT members.

The IDT includes palliative care professionals with appropriate education, certifications or training in hospice and/or palliative care to meet the physical, psychological, social and spiritual needs of both the patient and family. If the palliative care program provides services for pediatric or adolescent patients or family members, the IDT members have specialized training in caring for children and or adolescents.

The palliative care program provides services 24 hours a day, seven days a week as necessary to meet patient needs. An on-call coverage system for care/services should be used to provide this coverage during evenings, nights weekends and holidays. If the palliative care program does not provide services 24/7, the IDT will ensure that the patient and family know how to contact the primary care physician for coverage after hours.

The palliative care program may provide respite services to the patient and family.

The IDT communicates frequently to discuss, review or update the patient’s plan of care.

The IDT meets regularly to discuss care provided, staffing issues, policies, clinical practices and quality improvement activities.

Evidence: Patient RecordsEvidence: Personnel FilesEvidence: ObservationEvidence: Response to Interviews


Standard PC5-D: Written policies and procedures are established and implemented in regard to the interdisciplinary team (IDT) assessing and managing the patient's pain and/or other physical symptoms. (Guideline 2.1, 2.2)

Interpretation: Written policies and procedures are established for pain and symptom management. The palliative care program provides individualized care and disease-specific symptom management. Treatment plans for physical symptoms are individualized based on the disease, prognosis, patient functional limitations and patient-centered goals.

Patient/family understanding of the disease, treatment options, symptoms and side effects is assessed by the palliative care team and incorporated in the treatment plan. The goal of pain and symptom management is the safe and timely reduction of physical symptoms to a level acceptable to the patient.

A complete pain and symptom assessment is conducted initially and on an ongoing basis. The assessment includes, but is not limited to: �

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Pain history and interventions��

Pain severityUse of a standardized pain toolUse of an opioid analgesic risk assessment

Shortness of breathNausea FatigueAnorexiaInsomniaRestlessnessConfusion Constipation

The palliative care program develops and uses symptom management tools, treatment policies, standards and guidelines appropriate to the care of patients. The palliative care team regularly documents ongoing assessments of pain and other physical symptoms and functional capacity. Validated symptom assessment tools are used when available. The assessments are appropriate to the patient’s age and diagnoses.

Treatment options for pain, symptom management and side effects include pharmacological, interventional, behavioral and complementary therapies. The program maintains documentation of symptom management in the patient’s health record and communicates interventions and treatments with other health providers as appropriate.

Education regarding use of opioids and misconceptions are discussed with the patient and family members. The palliative care program uses an opioid analgesic risk assessment and management plan consistent with state and federal regulations for patients with chronic pain syndromes. Education regarding safe use of opioids, including driving or operating machinery, storage of medication, inventory and appropriate disposal, are discussed with the patient and family members.

Evidence: Written Policies and ProceduresEvidence: Patient RecordsEvidence: Observation


Evidence: Response to Interviews


Standard PC5-E: Written policies and procedures are established and implemented in regard to the interdisciplinary team (IDT) assessing the psychological and psychiatric aspects of the patient/family coping abilities and quality of life. (Guideline 3.1)

Interpretation: Written policies and procedures are established describing the mechanisms for assessing the psychological and psychiatric aspect of care.

The IDT includes professionals with specialized training in psychological and psychiatric issues such as depression, anxiety, delirium and cognitive impairment.

The IDT completes regular and ongoing assessments of patient/family reactions related to the illness including, but not limited to:

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Level of stressCoping strategies Anticipatory grieving Psychiatric conditionsAge and developmentally appropriate assessments for pediatric patients and/or family members

Whenever possible and appropriate, a validated and context-specific assessment tool is used.

The IDT educates the patient and family on topics including:

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Disease or conditionSymptomsSide effectsTreatmentsCaregiver needsDecision-making capacity Coping strategies

Based on patient and family goals, interventions include assessing psychological needs, treating psychiatric diagnoses, and promoting adjustment to the physical condition or illness. Patient/family psychological stress and/or psychiatric syndromes are treated promptly with pharmacologic, non-pharmacologic and/or complementary therapies.

Patient and family members are informed of treatment options/alternatives. The IDT documents treatment options/alternatives discussed and the patient and/or family’s decision.

Ongoing patient/family assessments regarding response to treatments and treatment efficacy are completed by the palliative care team and documented.

When necessary the IDT refers the patient and/or family members to appropriate healthcare professionals for ongoing psychological or psychiatric treatment.

The agency provides staff education and training in recognition and treatment of common psychological and psychiatric syndromes such as:

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AnxietyDepression Delirium Hopelessness Suicidal ideation Substance withdrawal symptoms Professional coping strategies to manage anticipatory grief and loss

Evidence: Written Policies and ProceduresEvidence: Patient RecordsEvidence: Personnel FilesEvidence: Response to Interviews


Standard PC5-F: The interdisciplinary team (IDT) assesses the social aspects of care to meet and promote patient/family needs and goals and to maximize patient/family strengths and well-being. (Guideline 4.1)

Interpretation: The IDT facilitates and enhances several social aspects of patient/family care, including:


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Patient/family understanding of and coping with illness and griefSupport for patient/family decision-makingDiscussion of patient/family goals for careEmotional and social supportCommunication within the family, between patient/family and with the IDT

The IDT includes a social worker who has a bachelor’s degree and/or graduate degree from an accredited school and experience in hospice and palliative care or a related health care field.

The IDT includes health professionals with expertise in the developmental needs and capacities of pediatric and adolescent patients and/or family members.

Evidence: Patient RecordsEvidence: ObservationEvidence: Personnel Files


Standard PC5-G: Written policies and procedures are established and implemented in regard to the interdisciplinary team (IDT) conducting a social assessment to identify their social strengths, needs and goals based on needs identified during the initial evaluation or subsequent evaluations. (Guideline 4.2)

Interpretation: Written policies and procedures are established and implemented that address the interdisciplinary team (IDT) completing a social assessment.

� The palliative care program completes a social assessment that includes: �

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Family structure and function ��

Roles CommunicationDecision-making patterns

Strengths and vulnerabilities ��

ResiliencySocialSpiritual and cultural supportEffect of illness or injury on intimacy and sexual expression Prior experiences with illness, disability and lossRisk of abuse, neglect or exploitation

Changes in family members' activities��

Schooling Employment or vocational roles Recreational activitiesEconomic security

Patient/family living environment and/or living arrangementPatient/family perceptions about care giving needs, availability and capacityNeeds for adaptive equipment, home modifications or transportationAccess to medications and nutritional productsAccess to community resources, financial support and respite careAdvance care planning and legal concerns

The IDT develops a social care plan that reflects patient/family culture, values, strengths, goals and preferences.

The IDT implements interventions such as education and family meetings to maximize social well-being and coping skills of both the patient and family.

The IDT refers the patient and family to appropriate resources and services as needed.



Standard PC5-H: Written policies and procedures are established and implemented in regard to the interdisciplinary team (IDT) conducting a spiritual assessment to identify religious or spiritual/existential background, preferences and related beliefs;rituals and practices of the patient and family; and symptoms such as spiritual distress and/or pain, guilt, resentment, despair and hopelessness based on needs identified during the initial evaluation or subsequent evaluations. (Guideline 5.1, 5.2)


Interpretation: Written policies and procedures are established and implemented in regard to the IDT conducting a spiritual assessment that includes spiritual and existential concerns recognizing spirituality as a fundamental aspect of compassionate patient and family-centered care.

The IDT documents spiritual themes including but not limited to:

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Life reviewAssessment of hopes, values and fearsMeaning, purpose and beliefs about afterlifeSpiritual or religious practicesCultural norms and beliefsCoping, guilt, forgiveness and life-completion tasks Whenever possible, a standard instrument is used

The patient’s resources of spiritual strength are supported and documented. Spiritual/existential care needs, goals and concerns identified by patients, family members, IDT members or spiritual care professionals are documented and addressed in the IDT care plan.

The IDT re-evaluates spiritual/existential interventions and updates them as needed.

The IDT includes spiritual care professionals who have documented education and training in spirituality and existential issues, or other experience based on agency policies and/or job description.

All palliative care team members are respectful of patient/family religious and spiritual beliefs, rituals and practices.

The IDT refers the patient to appropriate community resources (pastoral counselor, spiritual director or spiritual care professional) when requested.

Evidence: Written Policies and ProceduresEvidence: Patient RecordsEvidence: Response to InterviewsEvidence: Personnel FilesEvidence: Observation


Standard PC5-I: Written policies and procedures are established and implemented in regard to the palliative care program facilitating religious, spiritual and/or cultural services as requested by the patient or family at and after the time of death. (Guideline 5.3)

Interpretation: Written policies and procedures are established and implemented by the palliative care program in regard to providing spiritual care services at and after the time of death.

The palliative care program provides spiritual counseling and services in accordance with patient/family acceptance of these services and with their beliefs and desires. This may include:

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Performing religious ritualsAssisting with funerals and memorial services

The patient and family are supported in their desires to display and use their own religious, spiritual and/or cultural symbols.

The spiritual team facilitates communication with spiritual/religious communities or individuals as desired by the patient and/or family.

The palliative care team follows up post death with phone calls, home visits or attendance at the funeral or wake to offer support, identify any additional needs/referrals and to assist the family with bereavement.

Evidence: Written Policies and ProceduresEvidence: Patient RecordsEvidence: ObservationsEvidence: Response to Interviews


Standard PC5-J: Written policies and procedures are established and implemented in regard to a core component of the palliative care program being the provision of grief and bereavement services for patients and families, based on assessment of needs. (Guideline 3.2)

Interpretation: Written policies and procedures are established and implemented by the palliative care program for the provision of


bereavement services.

Bereavement counseling services must be available to the patient and family to assist in minimizing the stress and problems that arise from living with a serious or life-threatening illness.

Bereavement services must be an organized program with services provided by qualified professionals who have experience and education in grief, loss and bereavement. Bereavement services may be provided by members of the interdisciplinary team (IDT) or through referrals to community resources.

An initial grief and bereavement assessment is completed upon admission to the palliative care program. The assessment shall include an evaluation of patient/family risks for complicated grief, bereavement and comorbid complications.

Information on loss, grief and the availability of bereavement services that are culturally appropriate and in a language the patient/family can understand is communicated to the family before and after death. Information on community services including support groups, counselors, collaborated partnerships with hospices and other community resources is also provided.

Patients/families who have been identified as at risk for complicated grief and bereavement shall receive intensive psychological support and prompt referrals to appropriate professionals.

Ongoing bereavement assessments and reassessments are completed by the palliative care team during the continuum of the patient’s illness.

The IDT provides grief support and interventions appropriately determined by the cultural, spiritual and developmental needs and expectations of the patient and family.

Bereavement services and follow-up are recommended for the family for a minimum of 12 months after the death of the patient.

The palliative care program provides staff and volunteers with ongoing education, supervision and support in coping with their own grief as well as guidelines for effectively responding to patient/family grief.

Evidence: Written Policies and ProceduresEvidence: Patient and Bereavement RecordsEvidence: ObservationEvidence: Personnel Files


Standard PC5-K: Written policies and procedures are established and implemented in regard to the interdisciplinary team (IDT) providing a continuum of care for the patient and family through the transition of dying to the time of death and bereavementfollow-up. (Guideline 7.1)

Interpretation: Written policies and procedures describe the types of services and mechanisms the palliative care program uses to provide care for the patient at the end of life to meet the physical, psychosocial, spiritual, social and cultural needs of patients and families.

The palliative care team identifies the needs of the patient and family during end-of-life care. The care of the patient is divided into three phases: pre-death, peri-death and post-death.

The palliative care team provides support and ongoing care of the patient and family during the end of life. The IDT addresses:

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ConcernsHopesFears and expectations about the dying processSymptom management and pain management

Care is provided with respect for the patient and family values, preferences, beliefs, culture and religion.

The IDT educates the family on signs and symptoms of imminent death and provides emotional support.



Standard PC5-L: Written policies and procedures are established and implemented in regard to the palliative care team presenting the patient and family with an end-of-life plan of care that addresses the dying process, treatments, symptom management, family preferences and other requests. (Guideline 7.2)


Interpretation: Written policies and procedures are established and implemented in regard to providing care at the time of death.

The palliative care team assesses the patient for symptoms and prepares family and other caregivers on the dying process and the management of symptoms. The plan of care during the dying process is discussed and updated as needed to meet the needs of thepatient and family. Any discussion prior to the patient’s death about an autopsy, organ or tissue donation, or other anatomical gifts is documented. Any inability to honor the patient/family expressed wishes for care during the dying process and at the time of death is documented in the clinical record.

The palliative care team will have an appropriately timed discussion with the patient/family regarding hospice services that adhere to patient/family preferences.

Evidence: Written Policies and ProceduresEvidence: Patient Records


Standard PC5-M: Written policies and procedures are established and implemented in regard to the provision of post-death care based on care setting. (Guideline 7.3)

Interpretation: Written policies and procedures are established and implemented in regard to the palliative care program providing post-death care in a respectful manner that honors patient/family cultural and religious practices. The policies and procedures include, but are not limited to:

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Post-death care is provided in a respectful manner.Cultural and religious practices are honored in accordance with institutional practices, local laws and state regulations. Family has sufficient time with the patient after death.Preparation and disposition of the body in accordance with applicable law and regulations, taking into account patient/family wishes

Evidence: Written Policies and ProceduresEvidence: Patient Records


Standard PC5-N: The palliative care program implements the bereavement plan post death. (Guideline 7.4)

Interpretation: Bereavement services for the patient’s family are implemented post death by the interdisciplinary team (IDT). The bereavement plan is based on a social, cultural and spiritual grief assessment.

A palliative care team member is assigned to support the family and assist with religious practices, funeral arrangements, burial planning and emotional/grief support as appropriate.

Evidence: Patient RecordsEvidence: Bereavement Records


Standard PC5-O: Written policies and procedures are established and implemented in regard to the palliative care program respecting the patient's or surrogate’s goals, preferences and choices for care within the limits of applicable state and federal laws, current accepted standards of medical care, and professional standards of practice. (Guideline 8.1)

Interpretation: Written policies and procedures are established and implemented in regard to ethical and legal principles in providing palliative care.

The interdisciplinary team (IDT) includes the patient's or surrogate’s goals, preferences and choices in the development of the plan of care. The IDT discusses achievable goals for care in regard to the patient's or surrogate’s desires and preferences and addresses advance directives. Patient and family members are encouraged to seek professional help with updating or completing legal and financial documents. A palliative care team member assists with completing advance directives as appropriate, communicates to other team members the patient’s or surrogate’s wishes, and documents the advance directives in the clinical record.

The IDT assesses the ability of the patient and family in the decision-making process. For care of pediatric patients, the child’s views and preferences are documented and discussed with the patient and family as appropriate. The IDT advocates for the patient’s wishes and preferences. In the absence of advance directives and if the patient is unable to communicate, the IDT will assess whether the patient previously expressed any wishes, values or preferences in regard to care. The IDT will support and assist the surrogate with decision-making concerns, questions, and legal or ethical issues in determining to honor the patient’s preferences or wishes.


Failure to honor the patient’s or surrogate’s preferences is documented and addressed by the IDT.

The IDT includes professionals with knowledge and skill in ethical, legal and regulatory aspects of medical decision-making.




Section 6: QUALITY OUTCOMES/PERFORMANCE IMPROVEMENT

The standards in this section apply to the organization’s plan and implementation of a Performance Improvement (PI) program. Items addressed in these standards include who is responsible for the program, activities being monitored, how data is compiled and corrective measures being developed from the data and outcomes.

Standard PC6-A: The palliative care program develops, implements and maintains an effective, ongoing Quality Assessmentand Performance Improvement (QAPI) program. The program measures, analyzes and tracks quality indicators and other aspects of performance that enable the program to assess processes of care, services and palliative care outcomes. (Guideline 1.6)

Interpretation: Written policies and procedures are established and implemented that describe the palliative care program’s QAPI plan.

The palliative care program designates someone to coordinate and implement a QAPI program.

The QAPI program measures, analyzes and tracks quality indicators and other aspects of performance that enable the palliative care program to assess processes of care and operations.

Quality care follows the National Quality Strategy set forth by the U.S. Department of Health and Human Services described in the following provisions in the Affordable Care Act. These include, but are not limited to:

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Making care safer by reducing harm caused in the delivery of careEnsuring patients and families are engaged as partners in carePromoting effective communication and coordination of carePromoting the most effective treatment practices for the leading cause of mortalityMaking quality care more affordable

The QAPI program reviews all of the palliative care domains including organizational structure, education, team utilization and assessment. The review includes the effectiveness of physical, psychological, psychiatric, social, spiritual, cultural and ethical assessment and interventions to manage these aspects of care. CMS quality reporting requirements will be included in the review.

Quality improvement processes may include the development and testing of screening, history and assessment tools, protocols for diagnoses and interventions. Examples include:

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Structure and processesPhysical aspects of carePsychological and psychiatric aspects of careSocial aspects of careSpiritual, religious and existential aspects of careCultural aspects of careCare of the patient at the end of lifeEthical and legal aspects of care

Quality improvement activities for clinical services are collaborative, interdisciplinary, and focused on meeting patient/family goals.

The QAPI program must be ongoing and have a written plan of implementation. Ongoing means that there is a continuous and periodic collection and assessment of data. Opportunities to improve care should be applied on a program-wide basis, when appropriate. The program must at least be capable of showing measurable improvement in indicators related to improved palliative outcomes and hospice services.

From the QAPI process, the palliative care program establishes quality improvement policies and procedures.

The QAPI program includes evaluations of the palliative care program from patients, families, staff and the community.

Evidence: Written Policies and Procedures/QAPI Implementation PlanEvidence: QAPI Reports and DocumentationEvidence: ObservationEvidence: Response to Interviews



Appendix A: Reference Guide for Required Documents, Policies and ProceduresCustomized for: PCHSP

Standard # Documents, Policies and Procedures Agency Notes

PC2-A Written Policies and Procedures

PC2-B Written Policies and Procedures

PC2-C Written Policies and Procedures

PC2-D Written Policies and Procedures

PC2-E Written Policies and Procedures





PC5-D Written Policies and Procedures

PC5-E Written Policies and Procedures

PC5-G Written Policies and Procedures

PC5-H Written Policies and Procedures

PC5-I Written Policies and Procedures

PC5-J Written Policies and Procedures

PC5-K Written Policies and Procedures

PC5-L Written Policies and Procedures

PC5-M Written Policies and Procedures

PC5-O Written Policies and Procedures

PC6-A Written Policies and Procedures/QAPI Implementation Plan


MEDICARE CONDITIONS OF PARTICIPATION SURVEY REQUIREMENTS

HOSPICE

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The ACHC Accreditation Standards are developed in conjunction with the Medicare Conditions of Participation (CoPs). This checklist will assist a provider in auditing and preparing the hospice agency for accreditation. Non-compliance with a minimum of one condition-level CoP will require another on-site survey at the organization’s expense. Following this checklist does not guarantee approval of accreditation by the Accreditation Commission for Health Care (ACHC). Agencies should refer to the State Operations Manual, Appendix M-Guidance to Surveyors: Hospice Agencies, for further information regarding Medicare CoPs. This document only reviews the Medicare CoPs; please refer to the ACHC Accreditation Standards for additional ACHC requirements.

How to use this pre-evaluation checklist:Review each Medicare CoP and the associated L-tags in the State Operations Manual. If in compliance, score the Ltag as a “Yes”. If not in compliance, score the Ltag as a “No.” Multiple “No” answers under an individual CoP could put the agency at risk for a condition-level deficiency, and therefore should be a priority in correcting.

YES NO L Tag

Are you in compliance with the Medicare Condition of Participation pertaining to Patient’s Rights (reference CFR 418.52)?

L501 Is there evidence the patient was informed and the hospice promoted and protected patient rights?

L502 Is there evidence the agency provided the patient with verbal and written notice of rights in advance of care?

L503 Is there evidence the agency informed and distributed advance directive information?

L504 Is there evidence the agency obtained a signature confirming receipt of rights and responsibilities?

L505 Is there evidence the agency allows the patient to exercise his or her rights, agency demonstrates respect for property/person and allows the patient to voice grievances?

L506 If the patient is incompetent, is there evidence the rights are exercised by person appointed to act on patient’s behalf?

L507 If a patient is not incompetent, is there evidence of legal representative designated by patient if the patient desires a representative?

L508 Is there evidence all alleged violations are reported immediately?

L509 Is there evidence all alleged violations are immediately investigated to prevent further violations?

L510 Is there evidence of appropriate corrective action for verified violations was initiated?

L511 Is there evidence of verified violations were reported within 5 working days?

L512 Is there evidence the patient has the right to receive effective pain management and symptom control?

L513 Is there evidence the patient has the right to be involved in developing the plan of care?

L514 Is there evidence the patient has the right to refuse care or treatment?

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YES NO L Tag

L515 Is there evidence the patient has the right to choose their attending physician?

L516 Is there evidence the patient has the right to a confidential clinical record?

L517 Is there evidence the patient has the right to be free from mistreatment, neglect, or mental, sexual and physical abuse, injuries unknown source, misappropriation of property?

L518 Is there evidence the patient has the right to receive information about hospice benefit covered services?

L519 Is there evidence the patient has the right to receive information on services that will be provided?

Are you in compliance with the Medicare Condition of Participation pertaining to Initial and Comprehensive Assessment of the Patient (reference CFR 418.54)?

L521 Is there evidence of a documented patient specific comprehensive assessment?

L522 Is there evidence an RN completed the initial assessment within 48 hours of election?

L523 Is there evidence the IDG and attending physician complete the comprehensive assessment no later than 5 calendar days after election?

L524 Does the comprehensive assessment identify the physical, psychosocial, emotional and spiritual needs related to the terminal illness?

L525 Does the comprehensive assessment consider the nature and condition causing admission?

L526 Does the comprehensive assessment consider complications and risk factors?

L527 Does the comprehensive assessment consider the functional status, including the patient’s ability to understand and participate in his or her own care?

L528 Does the comprehensive assessment consider the imminence of death?

L529 Does the comprehensive assessment consider the severity of symptoms?

L530 Does the comprehensive assessment include a drug profile?

L531 Does the comprehensive assessment include a bereavement assessment?

L532 Does the comprehensive assessment consider the need for referrals to other health professionals?

L533 Is there evidence the comprehensive assessment is updated at least every 15 days?

L534 Does the comprehensive assessment include data elements for measurement of outcomes?

L535 Is there evidence the data elements are an integral part of the comprehensive assessment?

Are you in compliance with the Medicare Condition of Participation pertaining to Initial and Comprehensive Assessment of the Interdisciplinary Group, Care Planning, and Coordination of Services (reference CFR 418.56)?

L537 Is there evidence the IDG/attending physician prepared a written plan of care?

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YES NO L Tag

L538 Does the plan of care specify the care/services needs of patient and family as identified in comprehensive assessment?

L539 Is there evidence of a designated IDG to meet the needs of the patient and family?

L540 Is there evidence of an RN assigned to coordinate care?

L541 Does the IDG include a MD/OD, RN, SW and a pastoral or other counselor?

L542 Is there evidence an IDG has been identified to establish the day-to-day polices governing the provision of hospice services?

L543 Is there evidence that care follows an individualized plan of care?

L544 Is there evidence of education and training provided to the patient/caregiver?

L545 Has an individualized plan of care been developed for each patient?

L546 Does the plan of care include interventions to manage pain and symptoms?

L547 Does the plan of care include a detailed statement of scope and frequency of services for all disciplines including volunteers?

L548 Does the plan of care include the measurable outcomes anticipated?

L549 Does the plan of care include the necessary drugs and treatments to meet the patient’s needs?

L550 Does the plan of care include the medical supplies/appliances to meet the needs of the patient?

L551 Is there evidence of the patient’s/representative’s involvement with the plan of care?

L552 Is there evidence the IDG reviews and revises the plan of care as necessary but no less frequently than every 15 days?

L553 Does the revised plan of care include information from the updated assessments and identify the progress towards outcomes and goals?

L554 Is there evidence the IDG maintains responsibility for the care and services provided?

L555 Is there evidence the IDG ensures the care and services are provided in accordance with the plan of care?

L556 Is there evidence the IDG ensures the care and services provided are based on all assessments?

L557 Is there evidence of the sharing of information between all disciplines providing care?

L558 Is there evidence of the sharing of information with non-hospice providers providing care?

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HOSPICE

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YES NO L TagAre you in compliance with the Medicare Condition of Participation pertaining to Quality Assessment and Performance Improvement (reference CFR 418.58)?

L560 Is there evidence of a hospice wide data-driven quality assessment performance improvement program?

L561 Is the program capable of showing measurable improvement in indicators related to improved palliative outcomes and hospice services?

L562 Does the program measure, analyze and track quality indicators?

L563 Does the program use quality indicators including patient care & other relevant data?

L564 Does the program use the data to monitor the effectiveness and safety of services and identify opportunities for improvement?

L565 Is there evidence of the governing body’s approval of the frequency and detail of the data collected?

L566 Does the program focus on high risk, high volume or problem-prone areas?

L567 Does the program consider incidence, prevalence and severity of problems in these areas?

L568 Does the program affect palliative outcomes, patient safety and quality of care?

L569 Does the program track and analyze adverse events and implement preventive actions?

L570 Does the hospice measure its success and track performance to ensure improvements are maintained?

L571 Is the hospice implementing performance improvement projects?

L572 Does the scope of the performance improvement projects reflect the complexity of the hospice agency?

L573 Is there documented evidence of the performance improvement projects?

L574 Is there evidence the governing body ensures an ongoing program is defined, implemented, maintained and evaluated annually?

L575 Is there evidence that the program addresses priorities and improvement activities and is evaluated for effectiveness?

L576 Is there evidence of a designated individual(s) responsible for the QAPI program?

Are you in compliance with the Medicare Condition of Participation pertaining to Infection Control (reference CFR 418.60)?

L578 Is there evidence of a documented infection control program?

L579 Are accepted standards of practice established and followed to prevent the transmission of infections?

L580 Is there evidence the hospice maintains an agency-wide program for surveillance, identification, prevention, control and investigation of infections and it is part of QAPI?

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YES NO L Tag

L581 Does the infection control plan include methods to identify problems and implement actions for prevention?

L582 Is there evidence that education is provided to staff, contract providers, caregivers and patients?

Are you in compliance with the Medicare Condition of Participation pertaining to Licensed Professional Services (reference CFR 418.62)?

L584 Is there evidence that staff (employees and under arrangement) are qualified and services are delivered and supervised appropriately?

L585 Is there evidence staff actively participate in the coordination of all aspects of care?

L586 Is there evidence staff participate in the QAPI program and in-service training?

Are you in compliance with the Medicare Condition of Participation pertaining to Core Services (reference CFR 418.64)?

L588Is there evidence routinely all core services are provided directly by employees of the hospice (Physician, Nursing, Medical Social Services [MSS], bereavement counseling, dietary counseling, and spiritual counseling services)?

L589 If contracted staff are used to provide core services, is there evidence of a written agreement with another Medicare certified hospice?

L590 Is there evidence of the hospice medical director accepting responsibility for the palliation and management of the terminal illness and conditions related to the terminal illness?

L591 Is there evidence of nursing services being provided by or under the supervision of a RN?

L592 Is there evidence the agency is following state law regarding the ability of nurses to see, treat and write orders for patients?

L593 Is there evidence of highly specialized nursing services needing to be provided under contract due to the infrequency of the service?

L594 Are medical social services being provided by a qualified social worker?

L595 Are counseling services available to the patient and family?

L596

Is there evidence of the agency having organized bereavement services available to the family and others up to 1 year following the death of the patient being provided by qualified individuals along with a bereavement plan of care that is developed to define the kind of bereavement services offered and the frequency of services?

L597 Is dietary counseling being provided by a qualified individual?

L598 Is there evidence of spiritual counseling being offered in accordance with the patient’s and family’s acceptance of this service?

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HOSPICE

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YES NO L TagAre you in compliance with the Medicare Condition of Participation pertaining to Nursing Services Waiver Of Requirement That Substantially All Nursing Services Be Routinely Provided Directly By A Hospice (reference CFR 418.66)?

L600 Is there evidence that the agency is not able to provide nursing services directly, and if so, has the agency applied for a waiver from CMS and been excluded from this requirement?

Are you in compliance with the Medicare Condition of Participation pertaining to Furnishing of Non-core Services (reference 418.70)?

L602 Is there evidence all clinical staff members, direct and contractual, are providing care in a manner consistent with current standards of practice?

Are you in compliance with the Medicare Condition of Participation pertaining to Physical Therapy, Occupational Therapy, and Speech-Language Pathology (reference CFR 418.72)?

L604 Is there evidence therapy services are available and, when provided, offered in a manner consistent with accepted standards of practice?

Are you in compliance with the Medicare Condition of Participation pertaining to Waiver of Requirement- Physical Therapy, Occupational Therapy, Speech Language Pathology and Dietary Counseling (reference CFR 418.74)?

L606 Is there evidence that the agency is not able to provide therapy and dietary counseling, and if so, has the agency applied for a waiver from CMS and been excluded from this requirement?

Are you in compliance with the Medicare Condition of Participation pertaining to Hospice Aide and Homemaker Services (reference CFR 418.76)?

L608 Are all staff who provide aide services qualified?

L609 Is there documentation that all aides have completed the required training /competency/licensure program?

L610 Is there evidence that all aides providing care have not exceeded a period of 24 months or greater without providing care?

L611 Is there evidence for all aides who have received training to become an aide received at least 75 hours of classroom/supervised training?

L612Is there evidence for all aides who have received training to become an aide have received at least a minimum of 16 classroom hours prior to receiving a minimum of 16 hours of supervised practical training?

L613 Is there evidence the aide training program addresses the required subject areas?

L614 Is there documentation demonstrating the required training has been accomplished?

L615 Is there evidence for all aides who have completed a competency evaluation program that the required subject areas have been addressed?

L616 Is there evidence that any organization that is offering a Hospice Aide Competency Program has not been cited for a condition-level deficiency in the past two years?

L617 Is there evidence the competency evaluation was completed by a RN in consultation with other professionals as appropriate?

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YES NO L Tag

L618 Is there evidence that all hospice aides have been determined competent for all tasks in which they are performing independently?

L619 Is there documentation demonstrating the competency requirements have been completed?

L620 Are all hospice aides receiving at least 12 hours of in-service training annually?

L621 Is the in-service training supervised by an RN?

L622 Is there documented evidence of the in-service training having been completed for each aide?

L623 Is the instructor conducting the classroom training and supervised practical training appropriately qualified?

L624 Does the agency offer/provide a Hospice Aide Competency Evaluation Program that within the past two years it has not been cited for a Condition Level deficiency?

L625 Are there written patient care instructions, prepared by an RN, that are specific in nature to the patient care tasks to be performed?

L626 Is the aide performing services as ordered by the IDG, included in the plan of care and appropriate for the aide to perform?

L627Is the aide performing duties that include hands on personal care, simple procedures as an extension of nursing or therapy services, assistance in ambulation and/or assistance with medication administration for medications ordinarily self-administered?

L628 Is there documentation the aide has reported any changes related to the need to alter the plan of care?

L629 Is there evidence of the RN supervisory visit no less frequently than every 14 days?

L630 Is there evidence of any areas of concern regarding the aide providing care, the hospice has made an on-site visits with the aide present to address the areas of concern?

L631 Is there evidence of any areas of concern that are validated by the on-site visit, the aide has completed a competency evaluation?

L632 Is there evidence a RN has made an annual on-site visit, with the aide present, for all aides providing care?

L633 Is there evidence the RN assesses the initial and continued satisfactory performance in the required topics?

L634 Is there evidence of the Medicaid Personal Care Services-only aides appropriately qualified?

L635 Is there evidence of services under the PCS benefit are only being used to the extent the hospice would routinely use the services of the family?

L636 Is there evidence of the coordination of the PCS services with the hospice aide/homemaker services?

L637 Are staff that are performing homemaker services qualified?

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HOSPICE

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YES NO L Tag

L638 Are homemaker service coordinated and supervised by a member of the IDG?

L639 Are the instructions for the homemaker prepared by a member of the IDG?

L640 Is there evidence of homemakers reporting concerns about the patient and family to a member of the IDG?

Are you in compliance with the Medicare Condition of Participation pertaining to Volunteers (reference CFR 418.78)?

L642 Is the hospice utilizing volunteers in defined roles under the supervision of a designate hospice employee?

L643 Is there evidence of volunteer orientation and training consistent with hospice industry standards?

L644 Are volunteers used in administrative and/or patient care roles?

L645 Is there evidence the hospice demonstrated ongoing efforts to recruit and retain volunteers?

L646 Is there evidence of the cost savings due to the utilization of volunteers?

L647 Is there evidence the utilization of volunteers is equal to or greater than 5% of the total patient care hours for all paid hospice employees and contract staff?

Are you in compliance with the Medicare Condition of Participation pertaining to Organization and Administration of Services (reference CFR 418.100)?

L649 Is there evidence the hospice organizes, manages and administers its resources to provide care?

L650 Is there evidence the care provided to the patient and family meets the needs and goals of the patient and family?

L651 Is there a governing body that assumes full legal authority and has appointed a qualified administrator?

L652 Is there evidence the hospice is primarily engaged in providing the specified hospice services?

L653 Are nursing services, physician services and drugs/biologicals routinely available 24/7?

L654 Is the hospice providing care to Medicare/Medicaid beneficiaries regardless of their ability to pay?

L655 Is there a written agreement for all services provided under arrangement?

L656 If the hospice has multiple locations, have all locations been approved by CMS prior to providing care and services to Medicare patients?

L657 Is there evidence of the appropriate supervision of all locations issued a Medicare certification number?

L658 Are the lines of authority and professional and administrative control clearly defined?

L659 Does the multiple location meet the definition of a multiple location as set forth in 498.3?

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HOSPICE

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YES NO L Tag

L660 Is there evidence the hospice monitors and manages all services provided at all locations?

L661 Is there evidence of orientation provided to all employees and contract staff who have patient and family contact?

L662 Is there evidence of each employee receiving an orientation that addresses the employee’s specific job duties?

L663 Is there evidence that hospice has assessed the skills and competence of all individuals furnishing care, including volunteers?

Are you in compliance with the Medicare Condition of Participation pertaining to Medical Director (reference CFR 418.102)?

L665 Has a physician been designated to serve as the medical director?

L666 Is the medical director a self-employed physician or employed by a professional entity if not an employee of the hospice?

L667 Has the medical director or physician designee provided written certification regarding the patient’s anticipated life expectancy at the time of the initial certification?

L668 Has the medical director or physician designee provided written certification regarding the patients anticipated life expectancy before each recertification period?

L669 Is there evidence the medical director or designee has accepted the responsibility of the medical component of the patient care aspects of the hospice program?

Are you in compliance with the Medicare Condition of Participation pertaining to Clinical Records (reference CFR 418.104)?

L671 Is there a clinical record for all patients served by the hospice that contains the appropriate clinical information?

L672 Does the clinical record contain the initial and updated plans of care/assessments and clinical notes?

L673 Does the clinical record contain signed copies of the notice of patient rights and the election statement?

L674 Does the clinical record contain the patient’s response to medications, symptom management, treatments and services?

L675 Does the clinical record contain outcome measure data elements?

L676 Does the clinical record contain the initial certification and recertifications?

L677 Does the clinical record contain advance directives, if the patient has advance directives?

L678 Does the clinical record contain physician orders?

L679 Are all entries legible, clear, complete and appropriately authenticated and dated?

L680 Are all clinical records and the information contained in them protected against loss or unauthorized use?

L681 Are all clinical records maintained for at least 6 years after the death or discharge of the patient?

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HOSPICE

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YES NO L Tag

L682 If the patient was transferred to another Medicare/Medicaid certified facility, was a copy of the discharge summary sent to the facility as well as the medical record, if requested?

L683 If the patient revoked services or was discharged, was the attending physician sent a copy of the discharge summary as well as the medical record, if requested?

L684 Does the discharge summary address the required elements?

L685 Is the medical record readily available upon request of the appropriate authority?

Are you in compliance with the Medicare Condition of Participation pertaining to Drugs and Biologicals, Medical Supplies and Durable Medical Equipment (reference CFR 418.106)?

L687 Are drugs and biologicals, related to the palliation and management of the terminal condition provided by the hospice?

L688 Is there evidence the hospice confers with an individual regarding drug management?

L689 If the hospice provides in-patient care in its own facility; do they provide pharmacy services under the direction of a qualified licensed pharmacist?

L690 Are drugs only ordered by the appropriately qualified individuals?

L691 Are drugs and biologicals obtained only from community or institutional pharmacist or from their stock drugs and biologicals?

L692 Is there evidence the hospice is determining the ability of the patient and/or family to safely self-administer drugs and biologicals?

L693 Are all drugs and biologicals correctly labeled in accordance with currently accepted professional practice?

L694 Is there evidence of the safe use and disposal of controlled drugs in the patient’s home?

L695 Is there evidence that patients are provided with the agency’s written policies and procedures on the management and disposal of controlled drugs?

L696 Is there evidence of the discussion of the hospice’s policies and procedures for the management and safe use and disposal of controlled drugs?

L697 Is there documentation in the clinical record that the policies and procedures for managing controlled drugs was provided and discussed?

L698 If the hospice provides inpatient care, is there evidence of the proper disposal of controlled drugs?

L699 If the hospice provides inpatient care is the hospice properly storing drugs and biologicals?

L700 Are any discrepancies in the acquisition, storage, dispensing, administration or disposal of controlled drugs properly investigated?

L701 Is there evidence the hospice ensures the safe use of DME and that manufacturer maintenance recommendations are followed?

L702 Is there evidence the patient/family/caregiver received instructions on the safe use of DME and supplies?

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YES NO L Tag

L703 Is the hospice contracted with a DME supplier that meets Medicare DMEPOS Supplier Quality and Accreditation Standards?

Are you in compliance with the Medicare Condition of Participation pertaining to Short-term Inpatient Care (reference CFR 418.108)?

L705 Is there evidence short-term inpatient care is available for pain control, symptom management, and respite purposes?

L706 Is short-term inpatient care provided in a Medicare-certified hospice?

L707 Is short-term inpatient care provided in a Medicare-certified hospital or a skilled nursing facility?

L708 Is short-term inpatient care available for respite purposes in a Medicare-certified hospice, Medicare-certified hospital or a skilled nursing facility?

L709 Is short-term inpatient care available for respite purposes in a Medicare or Medicaid certified facility per 418.110?

L710 Is there evidence the facility that provides respite care is able to provide 24 hour nursing services?

L711If the hospice provides inpatient care under arrangement, is there a written agreement that specifies the requirements to include at a minimum; the hospice supplies the inpatient facility a copy of the plan of care.

L712 The inpatient facility has established policies and procedures consistent with palliative care protocols.

L713 The inpatient record includes all the required components.

L714 There is an identified individual within the facility who is responsible for the implementation of the agreement.

L715 The hospice retains responsibility for the training of inpatient facility personnel.

L716 Is there a method to verify these requirements are met?

L717 Is there evidence that the hospice has not exceeded the 20% of the total number of hospice days consumed in total by this group of beneficiaries?

L718 Is this an agency that began operations before January 1, 1975 and therefore exempt from L-717?

Are you in compliance with the Medicare Condition of Participation pertaining to Hospices that Provide Inpatient Care Directly (reference CFR 418.110)?

L720 Is there evidence the inpatient care facility is in compliance with all of the following standards?

L721 Is the inpatient facility able to provide the appropriate staffing based on the volume of patient, level of acuity and intensity of service needs.

L722 Is the inpatient facility able to provide 24 hour nursing services.

L723 If at least one patient is receiving general inpatient care, is there an RN available to provide direct patient care each shift?

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YES NO L Tag

L724 Is the inpatient facility able to maintain a safe environment?

L725 Is the inpatient facility able to address real or potential threats to the health and safety of patients?

L726 Does the inpatient facility have a written disaster preparedness plan?

L727Does the inpatient facility have procedures for controlling the reliability of proper waste management, light and ventilation, emergency gas, and water, and the scheduled and emergency maintenance and repair of all equipment?

L728 Is the inpatient facility in compliance with Life Safety Code?

L729 Does the inpatient facility provide a home-like atmosphere?

L730 Do the patient rooms meet the requirements?

L731 Is each patient room equipped with or conveniently located near toileting and bathing facilities?

L732 Is there an adequate supply of hot water at all times?

L733 Does the inpatient facility maintain an infection control program that protects patients, staff, and others?

L734 Is the inpatient facility providing care in a sanitary environment?

L735 Does the inpatient facility have available a supply of clean linen for patient care?

L736 Is the inpatient facility able to provide the meal services as required?

L737 Are all patients free from physical or mental abuse and corporal punishment?

L738 If restraints or seclusions are being utilized, is the least restrictive intervention being used?

L739 If restraints or seclusions are being utilized, is the least restrictive intervention being used to protect the patient, staff or others from harm?

L740 If restraints are being utilized are they being used in accordance with a written plan of care and implement in accordance with safe and appropriate restraint and seclusion techniques?

L741 If restraints are being utilized are they in accordance with the order of an appropriately authorized physician?

L742 If restraints are being utilized, are the orders individualized and the use of PRN or standing orders are not used?

L743 If restraints are being utilized and the attending physician did not order the restraint, is the medical director consulted?

L744 If restraints are being utilized are the orders being renewed in accordance with the following time frames?

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YES NO L Tag

L745 If restraints are being utilized are they being discontinued at the earliest possible date?

L746 If restraints are being utilized properly monitored by a physician or properly trained staff?

L747 If the inpatient utilizes restraints does the agency have policies regarding the usage of restraints?

L748 If restraints are being utilized to manage violent behavior has the patient had a face-to-face within 1 hour of the intervention?

L749 If the restraints are more restrictive than required by the L tags, are they meeting the state restraint requirement?

L750 After the face-to-face meeting is the properly trained RN consulting with the medical director?

L751 If simultaneous restraints are being used are they following the specified requirements?

L752 Is there proper documentation when restraints or seclusion are being utilized?

L753 If restraints are being utilized are staff properly trained?

L754 Are the training intervals met?

L755 Does the training meet the required content?

L756 Is the trainer properly trained?

L757 Is the training documented?

L758 If any death has been associated with the use of restraints or seclusion, has it been properly reported?

Are you in compliance with the Medicare Condition of Participation pertaining to Hospices that Provide Hospice Care to Residents of a SNF/NF or ICF/IID (reference CFR 418.112)?

L760 If the hospice is providing care to residents of a SNF/NF or ICF/IID are the requirements met?

L761 Does the patient meet the Medicare hospice eligibility requirements?

L762 Is there evidence the hospice assumes the responsibility for the professional management of the patient’s hospice services provided?

L763 Is there a written agreement between the hospice and the facility?

L764 Does the written agreement ensure communication and documentation of communication to ensure the patient’s needs are being met?

L765 Does the agreement outline when the hospice must be notified immediately to the specifications of this standard?

L766 Does the agreement state the hospice will assume responsibility for determining the appropriate hospice care?

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YES NO L Tag

L767 Does the agreement specify that the SNF/NF or ICF/IID will continue to furnish 24 hour room and board, meeting the personal care and nursing needs?

L768 Does the agreement specify the hospice will continue to provide service at the same level as if that patient were in his/her own home?

L769 Does the agreement identify how the hospice and the facility will ensure that all needed hospice services and benefits, based on the needs of the patient, will be provided to the patient?

L770 Does the agreement specify the use of the facility’s nursing personnel to provide care will be to the extent the family would have been utilized in the home?

L771Does the agreement specify that the hospice must report all alleged violations by anyone unrelated to the hospice to the SNF/ICF or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged violation?

L772 Does the agreement delineate the provision of bereavement services to SNF/NF or ICF/IID staff?

L773 Is there evidence the written plan of care was developed in consultation with SNF/NF or ICF/IID representatives?

L774 Does the written plan of care specifically identify which provider is responsible for performing the respective function on the written plan of care?

L775 Is there evidence the written plan of care reflects the participation of the hospice, the SNF/NF or ICF/IID and patient and family to the extent possible?

L776 Is there evidence that any changes in the plan of care were discussed with the representatives of the SNF/NF or ICF/IID, patient or family and approved by the hospice prior to implementation?

L777 Is there evidence of a designated member from the IDG that is responsible for hospice patients in a SNF/NF or ICF/IID and that designated member is responsible for:

L778 The overall coordination of hospice care

L779 Communicating with the SNF/NF or ICF/IID representative regarding the provision of hospice care

L780 Ensuring the communication with the representatives of the SNF/NF or ICF/IID and other involved in the care of the patient

L781 Are all of the proper documents provided to the SNF/NF or ICF/IID?

L782 Is there evidence of orientation of SNF/NF or ICF/IID staff in the hospice philosophy?

Are you in compliance with the Medicare Condition of Participation pertaining to Personnel Qualifications (reference CFR 418.114)?

L784 Is there evidence all professionals who furnish services directly must be legally authorized in accordance with applicable federal, state and local laws?

L785 Is there evidence that physicians are properly qualified?

L786 Is there evidence that hospice aides are properly qualified?

L787 Is there evidence that the social workers are properly qualified?

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HOSPICE

855-YES-ACHC (855-937-2242) achc.org

YES NO L Tag

L788 Is there evidence that the speech language pathologists are properly qualified?

L789 Is there evidence that the occupational therapists are properly qualified?

L790 Is there evidence that the occupational therapist assistants are properly qualified?

L791 Is there evidence that the physical therapists are properly qualified?

L792 Is there evidence that the physical therapy assistants are properly qualified?

L793 Is there evidence the RNs are properly qualified?

L794 Is there evidence the LPNs are properly qualified?

L795 Has a criminal background check been completed for all who have direct patient contact or access to patient records?

L796Have criminal background checks been completed according to state regulations, if state regulations exists, and if not, have the criminal background checks been obtained according to the time frames specified in this standard?

Are you in compliance with Federal, State and Local Laws and Regulations Related to the Health and Safety of Patients (reference CFR 418.116)?

L798 Is there evidence all services are furnished in compliance with all applicable federal, state and local laws and regulations?

L799 If there are multiple locations, is there evidence they have been approved by Medicare and are licensed in accordance with state licensure laws?

L800 Is there evidence of a CLIA waiver/certificate if the hospice is performing testing?

L801 If the hospice chooses to refer to a reference laboratory for laboratory testing, does the hospice have a copy of the laboratory’s CLIA waiver/certificate?

15 of 15[333] Revised: 07/06/2015

Revised: 03/31/2017 Page 1 of 2I achc.org [257] Glossary of Terms Hospice

GLOSSARY OF TERMS Bereavement Counseling: Emotional, psychosocial, and spiritual support and services provided before and after the death of the patient to assist with issues related to grief, loss, and adjustment.

Bylaws: A set of rules adopted by a hospice agency for governing the agency's operation.

Cap Period (Medicare-Certified Hospice Agency): The 12-month period ending October 31 used in the application of the cap on overall hospice reimbursement specified in §418.309.

Clinical Note (Medicare-Certified Hospice Agency): A notation of a contact with the patient and/or the family that is written and dated by any person providing services and that describes signs and symptoms, treatments and medications administered and the patient's reaction and/or response, and any changes in physical, emotional, psychosocial, or spiritual condition during a given period of time.

Comprehensive Assessment: A thorough evaluation of the patient’s physical, psychosocial, emotional, and spiritual status related to the terminal illness and related conditions. This includes a thorough evaluation of the caregiver’s and family’s willingness and capability to care for the patient.

Core Services: Hospice must routinely provide substantially all core services directly by hospice employees. These services must be provided in a manner consistent with acceptable standards of practice. These services include nursing services, medical social services, and counseling.

Dietary Counseling (Medicare-Certified Hospice Agency): Education and interventions provided to the patient and family regarding appropriate nutritional intake as the patient’s condition progresses. Dietary counseling is provided by qualified individuals, which may include a Registered Nurse, dietitian, or nutritionist, when identified in the patient’s plan of care.

Employee (Medicare-Certified Hospice Agency): A person who: (1) works for the hospice and for whom the hospice is required to issue a W-2 form; or (2) if the hospice is a subdivision of an agency or organization, an employee of the agency or organization who is assigned to the hospice; or (3) is a volunteer under the jurisdiction of the hospice.

Hospice: A public agency or private organization or subdivision of either of these that is primarily engaged in providing care to terminally ill individuals.

Hospice Care: A comprehensive set of services described in Section 1861(dd)(1) of the Social Security Act, identified and coordinated by an Interdisciplinary Group (IDG)/Interdisciplinary Team (IDT)to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care.

Initial Assessment: An evaluation of the patient’s physical, psychosocial, and emotional status related to the terminal illness and related conditions to determine the patient’s immediate care and support needs.

Interdisciplinary Group (Medicare-Certified Hospice Agency)/ Interdisciplinary Team: The Interdisciplinary Group (IDG)/ Interdisciplinary Team (IDT) is composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of hospice patients and families facing terminal illness and bereavement.

Revised: 03/31/2017 Page 2 of 2I achc.org [257] Glossary of Terms Hospice

Multiple Location (Medicare-Certified Hospice Agency): A Medicare-approved location from which the hospice provides the same full range of hospice care and services that is required of the hospice issued the certification number. A multiple location must meet all of the Conditions of Participation applicable to hospices.

Nonprofit Agency: An agency exempt from federal income taxation under section 501 of the Internal Revenue Code of 1954.

Palliative Care: 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.

Progress Note: A written notation dated and signed by a member of the health team that summarizes facts about care furnished and the patient's response during a given period of time.

Proprietary Agency: A private, profit-making agency licensed by the state.

Public Agency: An agency operated by a state or local government.

Representative (Medicare-Certified Hospice Agency): An individual who has the authority under state law (whether by statute or pursuant to an appointment by the courts of the state) to authorize or terminate medical care or to elect or revoke the election of hospice care on behalf of a terminally ill patient who is mentally or physically incapacitated. This may include a legal guardian.

Restraint (Medicare-Certified Hospice Agency): 1. Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability

of a patient to move his or her arms, legs, body, or head freely, not including devices such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort); or

2. A drug or medication that, when used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement, is not a standard treatment or dosage for the patient’s condition.

Seclusion (Medicare-Certified Hospice Agency): The involuntary confinement of a patient alone in a room or an area from which the patient is physically prevented from leaving.

Summary Report: The compilation of the pertinent factors of a patient's clinical notes and progress notes that is submitted to the patient's physician.

Terminally Ill (Medicare-Certified Hospice Agency): Classification of a patient whose diagnosis puts life expectancy at six months or less if the illness runs its normal course.

Revised: 04/01/2015 Page 1 of 6I achc.org [253] Glossary of Personnel Qualifications Hospice

GLOSSARY OF PERSONNEL QUALIFICATIONS

Allied Health Personnel: Licensed Practical Nurses (LPN), Physical Therapy Assistants (PTA), Occupational Therapy Assistants (COTA), Speech Therapy Assistants, or other health professionals as defined in occupational licensure laws that are subject to supervision by a health professional.

Attending Physician (Medicare Certified Hospice Agency): 1. Doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he or

she performs that function or action; or 2. Nurse Practitioner who meets the training, education, and experience requirements as described in §410.75 (b) of

this chapter 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.

Chief Executive Officer: The person who heads an organization and has the authority and responsibility, as delegated by the governing body, to accomplish program-specific goals and objectives, implement program policy, and manage personnel and resources.

Experienced Professional: A professional with at least one year of work experience.

Health Professional: A licensed health care provider authorized to supervise other personnel as defined in applicable occupational licensure laws and regulations.

Home Health Aide (Medicare Certified Hospice Agency): A qualified hospice aide is a person who has successfully completed one of the following:

1. A training program and competency evaluation as specified in paragraphs (b) and (c) of 418.76 2. A competency evaluation program that meets the requirements of paragraph (c) of 418.76 3. A nurse aide training and competency evaluation program approved by the State as meeting the requirements

of 483.151 through 483.154 and is currently listed in good standing on the State nurse aide registry 4. A State licensure program that meets the requirements of paragraphs (b) and (c) of 418.76

A hospice aide is not considered to have completed a program as specified in paragraph (a)(1) of 418.76, if, since the individual's most recent completion of the program(s), there has been a continuous period of 24 consecutive months during which none of the services furnished by the individual as described in 409.40 were for compensation. If there has been a 24-month lapse in furnishing services, the individual must complete another program, as specified in paragraph (a)(1) of this section, before providing services.

Licensed Practical/Vocational Nurse (LPN/LVN): A person who is licensed as a Practical/Vocational Nurse by the State in which practicing.

Licensed professional: Means a person licensed to provide patient care services by the State in which services are delivered.


Occupational Therapist (OT): A person who: A.

1. Is licensed or otherwise regulated, if applicable, as an Occupational Therapist by the State in which practicing, unless licensure does not apply;

2. Graduated after successful completion of an Occupational Therapist education program accredited by the Accreditation Council for Occupational Therapy Education (ACOTE) of the American Occupational Therapy Association, Inc. (AOTA), or successor organizations of ACOTE; and

3. Is eligible to take, or has successfully completed the entry-level certification examination for Occupational Therapists developed and administered by the National Board for Certification in Occupational Therapy, Inc. (NBCOT)

B. On or before December 31, 2009: 1. Is licensed or otherwise regulated, if applicable, as an Occupational Therapist by the State in which practicing;

or 2. When licensure or other regulation does not apply

i. Graduated after successful completion of an Occupational Therapist education program accredited by the Accreditation Council for Occupational Therapy Education (ACOTE) of the American Occupational Therapy Association, Inc. (AOTA) or successor organizations of ACOTE; and

ii. Is eligible to take, or has successfully completed the entry-level certification examination for Occupational Therapists developed and administered by the National Board for Certification in Occupational Therapy, Inc., (NBCOT)

C. On or before January 1, 2008: 1. Graduated after successful completion of an occupational therapy program accredited jointly by the

committee on Allied Health Education and Accreditation of the American Medical Association and the American Occupational Therapy Association; or

2. Is eligible for the National Registration Examination of the American Occupational Therapy Association or the National Board for Certification in Occupational Therapy

D. On or before December 31, 1977: 1. Had 2 years of appropriate experience as an Occupational Therapist; and 2. Had achieved a satisfactory grade on an Occupational Therapist proficiency examination conducted,

approved, or sponsored by the U.S. Public Health Service

E. If educated outside the United States, must meet all of the following: 1. Graduated after successful completion of an Occupational Therapist education program accredited as

substantially equivalent to Occupational Therapist entry level education in the United States by one of the following: i. The Accreditation Council for Occupational Therapy Education (ACOTE) ii. Successor organizations of ACOTE iii. The World Federation of Occupational Therapists iv. A credentialing body approved by the American Occupational Therapy Association

2. Successfully completed the entry-level certification examination for Occupational Therapists developed and administered by the National Board for Certification in Occupational Therapy, Inc. (NBCOT)

3. On or before December 31, 2009, is licensed or otherwise regulated, if applicable, as an Occupational Therapist by the State in which practicing

Occupational Therapy Assistant (COTA): A person who: A. Meets all of the following:

1. Is licensed, unless licensure does not apply, or otherwise regulated, if applicable, as an Occupational Therapy Assistant by the State in which practicing


2. Graduated after successful completion of an Occupational Therapy Assistant education program accredited by the Accreditation Council for Occupational Therapy Education, (ACOTE) of the American Occupational Therapy Association, Inc. (AOTA) or its successor organizations

3. Is eligible to take or successfully completed the entry-level certification examination for Occupational Therapy Assistants developed and administered by the National Board for Certification in Occupational Therapy, Inc. (NBCOT)

B. On or before December 31, 2009: 1. Is licensed or otherwise regulated as an Occupational Therapy Assistant, if applicable, by the State in which

practicing; or any qualifications defined by the State in which practicing, unless licensure does not apply; or 2. Must meet both of the following:

i. Completed certification requirements to practice as an Occupational Therapy Assistant established by a credentialing organization approved by the American Occupational Therapy Association

ii. After January 1, 2010, meets the requirements in paragraph (A) of this section

C. After December 31, 1977 and on or before December 31, 2007: 1. Completed certification requirements to practice as an Occupational Therapy Assistant established by a

credentialing organization approved by the American Occupational Therapy Association; or 2. Completed the requirements to practice as an Occupational Therapy Assistant applicable in the State in which

practicing

D. On or before December 31, 1977: 1. Had 2 years of appropriate experience as an Occupational Therapy Assistant; and 2. Had achieved a satisfactory grade on an Occupational Therapy Assistant proficiency examination conducted,

approved, or sponsored by the U.S. Public Health Service

E. If educated outside the United States, on or after January 1, 2008: 1. Graduated after successful completion of an Occupational Therapy Assistant education program that is

accredited as substantially equivalent to Occupational Therapist assistant entry level education in the United States by: i. The Accreditation Council for Occupational Therapy Education (ACOTE) ii. Its successor organizations iii. The World Federation of Occupational Therapists iv. By a credentialing body approved by the American Occupational Therapy Association; and

2. Successfully completed the entry-level certification examination for Occupational Therapy Assistants developed and administered by the National Board for Certification in Occupational Therapy, Inc. (NBCOT)

Physical Therapist (PT): A person who is licensed, if applicable, by the State in which practicing, unless licensure does not apply and meets one of the following requirements: A.

1. Graduated after successful completion of a Physical Therapist education program approved by one of the following: i. The Commission on Accreditation in Physical Therapy Education (CAPTE) ii. Successor organizations of CAPTE iii. An education program outside the United States determined to be substantially equivalent to Physical

Therapist entry-level education in the United States by a credentials evaluation organization approved by the American Physical Therapy Association or an organization identified in 8 CFR 212.15(e) as it relates to Physical Therapists; and

2. Passed an examination for Physical Therapists approved by the State in which physical therapy services are provided.

B. On or before December 31, 2009:


1. Graduated after successful completion of a physical therapy curriculum approved by the Commission on Accreditation in Physical Therapy Education (CAPTE); or

2. Must meet both of the following: i. Graduated after successful completion of an education program determined to be substantially

equivalent to Physical Therapist entry level education in the United States by a credentials evaluation organization approved by the American Physical Therapy Association or identified in 8 CFR 212.15(e) as it relates to Physical Therapists

ii. Passed an examination for Physical Therapists approved by the State in which physical therapy services are provided

C. Before January 1, 2008: 1. Graduated from a physical therapy curriculum approved by one of the following:

i. The American Physical Therapy Association ii. The Committee on Allied Health Education and Accreditation of the American Medical Association iii. The Council on Medical Education of the American Medical Association and the American Physical

Therapy Association

D. On or before December 31, 1977 was licensed or qualified as a Physical Therapist and meets both of the following: 1. Has 2 years of appropriate experience as a Physical Therapist 2. Has achieved a satisfactory grade on a proficiency examination conducted, approved, or sponsored by the U.S.

Public Health Service

E. Before January 1, 1966: 1. Was admitted to membership by the American Physical Therapy Association; or 2. Was admitted to registration by the American Registry of Physical Therapists; or 3. Has graduated from a physical therapy curriculum in a 4-year college or university approved by a State

department of education

F. Before January 1, 1966 was licensed or registered, and before January 1, 1970, had 15 years of full-time experience in the treatment of illness or injury through the practice of physical therapy in which services were rendered under the order and direction of attending and referring doctors of medicine or osteopathy.

G. If trained outside the United States before January 1, 2008, meets the following requirements: 1. Was graduated since 1928 from a physical therapy curriculum approved in the country in which the curriculum

was located and in which there is a member organization of the World Confederation for Physical Therapy 2. Meets the requirements for membership in a member organization of the World Confederation for Physical

Therapy

Physical Therapist Assistant (PTA): A person who is licensed, unless licensure does not apply, registered, or certified as a Physical Therapist Assistant, if applicable, by the State in which practicing, and meets one of the following requirements: A.

1. Graduated from a Physical Therapist Assistant curriculum approved by the Commission on Accreditation in Physical Therapy Education of the American Physical Therapy Association; or if educated outside the United States or trained in the United States military, graduated from an education program determined to be substantially equivalent to Physical Therapist Assistant entry level education in the United States by a credentials evaluation organization approved by the American Physical Therapy Association or identified at 8 CFR 212.15(e); and

2. Passed a national examination for Physical Therapist Assistants

B. On or before December 31, 2009, meets one of the following: 1. Is licensed, or otherwise regulated in the State in which practicing


2. In States where licensure or other regulations do not apply, graduated on or before December 31, 2009, from a 2-year college-level program approved by the American Physical Therapy Association and, effective January 1, 2010 meets the requirements of paragraph (a) of this definition

C. Before January 1, 2008, where licensure or other regulation does not apply, graduated from a 2-year college-level program approved by the American Physical Therapy Association.

D. On or before December 31, 1977, was licensed or qualified as a Physical Therapist Assistant and has achieved a satisfactory grade on a proficiency examination conducted, approved, or sponsored by the U.S.

Paraprofessional: A trained Aide who assists a professional person (i.e. Home Care Aide, Nursing Assistant).

Pharmacist: A person licensed to prepare and dispense drugs and medicines who is licensed as a Registered Pharmacist by the State in which practicing.

Pharmacy Technician: An individual that compounds and maintains medication and supply inventory under the direction of a Registered Pharmacist. Certification preferred

Physician for a Medicare Certified Hospice Agency: An individual who meets the qualifications and conditions as defined in Section 1861(r) of the Act and implemented at §410.20 of this chapter.

Physician designee for a Medicare Certified Hospice Agency: A doctor of medicine or osteopathy designated by the hospice who assumes the same responsibilities and obligations as the medical director when the medical director is not available.

Registered Nurse (RN): A graduate of an approved school of professional nursing, who is licensed as a Registered Nurse by the State in which practicing.

Professional: Refers to a licensed Registered Nurse, Licensed Registered Pharmacist, Licensed Respiratory Care Practitioner, Licensed Physical Therapist, Licensed Speech Therapist, Certified Occupational Therapist, or a person with a bachelor's degree in social work, home economics or closely related helping profession.

Qualified Staff: An individual that has had appropriate training and experience for the position held with evidence of education and training in accordance with applicable laws or regulations.

Qualified Supervisor: Employed directly or through contract and possesses:

1. Evidence of verification of education and training requirements in accordance with applicable laws or regulations, and the organization's policy, and

2. Evidence that clinical and supervisory knowledge and experience are appropriate to his/her assigned supervision responsibilities.

Social Worker (Medicare Certified Hospice Agency): A person who:

1. Has a Master of Social Work (MSW) degree from a school of social work accredited by the Council on Social Work Education; or

2. Has a baccalaureate degree in social work from an institution accredited by the Council on Social Work Education; or

3. A baccalaureate degree in psychology, sociology, or other field related to social work and is supervised by an MSW as described in paragraph (b)(3)(i)(A) of CFR 418.114

In addition to the above requirements, the Social Worker has 1 year of social work experience in a healthcare setting.


If the Social Worker has a baccalaureate degree from a school of social work accredited by the Council on Social Work Education, and was employed by the hospice before December 2, 2008, then the Social Worker is not required to be supervised by an MSW.

Speech-Language Pathologist (S-LP) (Medicare Certified Hospice Agency): A person who meets either of the following requirements:

1. The education and experience requirements for a Certificate of Clinical Competence in speech-language pathology granted by the American Speech-Language-Hearing Association

2. The educational requirements for certification and is in the process of accumulating the supervised experience required for certification

Unlicensed Assistive Personnel (UAP): Non-licensed health care personnel that provide services to clients under the direction of a licensed health care professional.

Revised: 01/03/2014 Page 1 of 6I achc.org [259] Preamble for Hospice Service

PREAMBLE FOR HOSPICE SERVICE

Eligibility, Election and Duration of Benefits

The eligibility, election and duration of benefits for Hospice Services is defined in the Medicare Conditions of

Participation as listed below.

42 CFR 418.20 Eligibility requirements

In order to be eligible to elect hospice care under Medicare, an individual must be— (a) Entitled to Part A of Medicare; and

(b) Certified as being terminally ill in accordance with Sec. 418.22

42 CFR 418.21 Duration of hospice care coverage — Election periods

(a) Subject to the conditions set forth in this part, an individual may elect to receive hospice care during one or more of the following election periods:

(i) An initial 90-day period; (ii) A subsequent 90-day period; or (iii) An unlimited number of subsequent 60-day periods

42 CFR 418.22 Certification of terminal illness

(a) Timing of certification — (1) General rule. The hospice must obtain written certification of terminal illness for each of the periods listed in §

418.21, even if a single election continues in effect for an unlimited number of periods, as provided in § 418.24(c). (2) Basic requirement. Except as provided in paragraph (a) (3) of this section, the hospice must obtain the written

certification before it submits a claim for payment. (3) Exceptions:

(i) If the hospice cannot obtain the written certification within 2 calendar days, after a period begins, it must obtain an oral certification within 2 calendar days and the written certification before it submits a claim for payment

(ii) Certifications may be completed no more than 15 calendar days prior to the effective date of election (iii) Recertification’s may be completed no more than 15 calendar days prior to the start of the subsequent

benefit period (4) Face-to-face encounter. As of January 1, 2011, a hospice physician or hospice nurse practitioner must have a

face-to-face encounter with each hospice patient, whose total stay across all hospices is anticipated to reach the 3rd benefit period, no more than 30 days prior to the 3rd benefit period recertification, and must have a face-to-face encounter with that patient no more than 30 calendar days prior to every recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care.

(b) Content of certification. Certification will be based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness. The certification must conform to the following requirements: (1) The certification must specify that the individual’s prognosis is for a life expectancy of 6 months or less if the

terminal illness runs its normal course. (2) Clinical information and other documentation that support the medical prognosis must accompany the

certification and must be filed in the medical record with the written certification as set forth in paragraph (d)(2) of this section. Initially, the clinical information may be provided verbally, and must be documented in the medical record and included as part of the hospice’s eligibility assessment.


(3) The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms.

(i) If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician’s signature

(ii) If the narrative exists as an addendum to the certification or recertification form, in addition to the physician’s signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum

(iii) The narrative shall include a statement directly above the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient’s medical record or, if applicable, his or her examination of the patient

(iv) The narrative must reflect the patient’s individual clinical circumstances and cannot contain check boxes or standard language used for all patients

(v) The narrative associated with the 3rd benefit period recertification and every subsequent recertification must include an explanation of why the clinical findings of the face-to-face encounter support a life expectancy of 6 months or less

(4) The physician or nurse practitioner who performs the face-to-face encounter with the patient described in (a) (4), must attest in writing that he or she had a face-to-face encounter with the patient, including the date of that visit. The attestation of the nurse practitioner shall state that the clinical findings of that visit were provided to the certifying physician, for use in determining whether the patient continues to have a life expectancy of 6 months or less, should the illness run its normal course. The attestation, its accompanying signature, and the date signed, must be a separate and distinct section of, or an addendum to, the recertification form, and must be clearly titled.

(5) All certifications and recertification’s must be signed and dated by the physician(s), and must include the benefit period dates to which the certification or recertification applies.

(c) Sources of certification. (1) For the initial 90-day period, the hospice must obtain written certification statements (and oral certification

statements if required under paragraph (a)(3) of this section) from-- (i) The medical director of the hospice or the physician member of the hospice interdisciplinary group; and (ii) The individual's attending physician if the individual has an attending physician

(2) For subsequent periods, the only requirement is certification by one of the physicians listed in paragraph (c)(1)(i) of this section.

(d) Maintenance of records. Hospice staff must-- (1) Make an appropriate entry in the patient's medical record as soon as they receive an oral certification; and (2) File written certifications in the medical record.

42 CFR 418.24 Election of hospice care

(a) Filing an election statement. An individual who meets the eligibility requirement of Sec. 418.20 may file an election statement with a particular hospice. If the individual is physically or mentally incapacitated, his or her representative (as defined in Sec. 418.3) may file the election statement.

(b) Content of election statement. The election statement must include the following: (1) Identification of the particular hospice that will provide care to the individual. (2) The individual's or representative's acknowledgement that he or she has been given a full understanding of the

palliative rather than curative nature of hospice care, as it relates to the individual's terminal illness. (3) Acknowledgement that certain Medicare services, as set forth in paragraph (d) of this section, are waived by

the election. (4) The effective date of the election, which may be the first day of hospice care or a later date, but may be no

earlier than the date of the election statement. (5) The signature of the individual or representative.


(c) Duration of election. An election to receive hospice care will be considered to continue through the initial election period and through the subsequent election periods without a break in care as long as the individual-- (1) Remains in the care of a hospice; and (2) Does not revoke the election under the provisions of Sec. 418.26. (3) Is not discharged from the hospice under the provisions 418.26

(d) Waiver of other benefits. For the duration of an election of hospice care, an individual waives all rights to Medicare payments for the following services: (1) Hospice care provided by a hospice other than the hospice designated by the individual (unless provided under

arrangements made by the designated hospice). (2) Any Medicare services that are related to the treatment of the terminal condition for which hospice care was

elected or a related condition or that are equivalent to hospice care except for services— (i) Provided by the designated hospice (ii) Provided by another hospice under arrangements made by the designated hospice; and (iii) Provided by the individual's attending physician if that physician is not an employee of the designated

hospice or receiving compensation from the hospice for those services.

(e) Re-election of hospice benefits. If an election has been revoked in accordance with Sec. 418.28, the individual (or his or her representative if the individual is mentally or physically incapacitated) may at any time file an election, in accordance with this section, for any other election period that is still available to the individual.

42 CFR 418.25 Admission to hospice care

(a) The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient’s attending physician (if any).

(b) In reaching a decision to certify that the patient is terminally ill, the hospice medical director must consider at least the following information: (1) Diagnosis of the terminal condition of the patient. (2) Other health conditions, whether related or unrelated to the terminal condition. (3) Current clinically relevant information supporting all diagnoses.

42 CFR 418.26 Discharge from hospice care

(a) Reasons for discharge. A hospice may discharge a patient if— (1) The patient moves out of the hospice’s service area or transfers to another hospice; (2) The hospice determines that the patient is no longer terminally ill; or (3) The hospice determines, under a policy set by the hospice for the purpose of addressing discharge for cause

that meets the requirements of paragraphs (a)(3)(i) through (a)(3)(iv) of this section, that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired. The hospice must do the following before it seeks to discharge a patient for cause:

(i) Advise the patient that a discharge for cause is being considered; (ii) Make a serious effort to resolve the problem(s) presented by the patient’s behavior or situation; (iii) Ascertain that the patient’s proposed discharge is not due to the patient’s use of necessary hospice

services; and (iv) Document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its

medical records

(b) Discharge order. Prior to discharging a patient for any reason listed in paragraph (a) of this section, the hospice must obtain a written physician’s discharge order from the hospice medical director. If a patient has an attending physician involved in his or her care, this physician should be consulted before discharge and his or her review and decision included in the discharge note.

(c) Effect of discharge. An individual, upon discharge from the hospice during a particular election period for reasons other than immediate transfer to another hospice— (1) Is no longer covered under Medicare for hospice care;


(2) Resumes Medicare coverage of the benefits waived under § 418.24(d); and (3) May at any time elect to receive hospice care if he or she is again eligible to receive the benefit.

(d) Discharge planning. (1) The hospice must have in place a discharge planning process that takes into account the prospect that a

patient’s condition might stabilize or otherwise change such that the patient cannot continue to be certified as terminally ill.

(2) The discharge planning process must include planning for any necessary family counseling, patient education, or other services before the patient is discharged because he or she is no longer terminally ill.

42 CFR 418.28 Revoking the election of hospice care

(a) An individual or representative may revoke the individual's election of hospice care at any time during an election period.

(b) To revoke the election of hospice care, the individual or representative must file a statement with the hospice that includes the following information: (1) A signed statement that the individual or representative revokes the individual's election for Medicare

coverage of hospice care for the remainder of that election period. (2) The date that the revocation is to be effective. (An individual or representative may not designate an effective

date earlier than the date that the revocation is made).

(c) An individual, upon revocation of the election of Medicare coverage of hospice care for a particular election period-- (1) Is no longer covered under Medicare for hospice care; (2) Resumes Medicare coverage of the benefits waived under Sec. 418.24(e)(2); and (3) May at any time elect to receive hospice coverage for any other hospice election periods that he or she is

eligible to receive.

42 CFR 418.30 Change of the designated hospice

(a) An individual or representative may change, once in each election period, the designation of the particular hospice from which hospice care will be received.

(b) The change of the designated hospice is not a revocation of the election for the period in which it is made.

(c) To change the designation of hospice programs, the individual or representative must file, with the hospice from which care has been received and with the newly designated hospice, a statement that includes the following information: (1) The name of the hospice from which the individual has received care and the name of the hospice from which he

or she plans to receive care. (2) The date the change is to be effective.

Hospice Coverage Requirements

The coverage requirements for Hospice Services is defined in the Medicare Conditions of Participation as listed below.

42 CFR 418.200 Requirements for coverage

To be covered, hospice services must meet the following requirements. They must be reasonable and necessary for the palliation or management of the terminal illness as well as related conditions. The individual must elect hospice care in accordance with Sec. 418.24. A plan of care must be established and periodically reviewed by the attending physician, the medical director, and the interdisciplinary group of the hospice program as set forth in Sec. 418.56. That plan of care must be established before hospice care is provided. The services must be consistent with the plan of care. A certification that the individual is terminally ill must be completed as set forth in Sec. 418.22.


42 CFR 418.202 Covered services

All services must be performed by appropriately qualified personnel, but it is the nature of the service, rather than the qualification of the person who provides it, that determines the coverage category of the service. The following services are covered hospice services:

(a) Nursing care provided by or under the supervision of a registered nurse.

(b) Medical social services provided by a social worker under the direction of a physician.

(c) Physicians' services performed by a physician as defined in Sec. 410.20 of this chapter except that the services of the hospice medical director or the physician member of the interdisciplinary group must be performed by a doctor of medicine or osteopathy.

(d) Counseling services provided to the terminally ill individual and the family members or other persons caring for the individual at home. Counseling, including dietary counseling, may be provided both for the purpose of training the individual's family or other caregiver to provide care, and for the purpose of helping the individual and those caring for him or her to adjust to the individual's approaching death.

(e) Short-term inpatient care provided in a participating hospice inpatient unit, or a participating hospital or SNF, that additionally meets the standards in Sec. §418.202 (a) and (e) regarding staffing and patient areas. Services provided in an inpatient setting must conform to the written plan of care. Inpatient care may be required for procedures necessary for pain control or acute or chronic symptom management. Inpatient care may also be furnished as a means of providing respite for the individual's family or other persons caring for the individual at home. Respite care must be furnished as specified in Sec. ‘§ 418.108(b). Payment for inpatient care will be made at the rate appropriate to the level of care as specified in Sec. 418.302.

(f) Medical appliances and supplies, including drugs and biologicals. Only drugs as defined in section 1861(t) of the Act and which are used primarily for the relief of pain and symptom control related to the individual's terminal illness are covered. Appliances may include covered durable medical equipment as described in §410.38 of this chapter as well as other self-help and personal comfort items related to the palliation or management of the patient's terminal illness. Equipment is provided by the hospice for use in the patient's home while he or she is under hospice care. Medical supplies include those that are part of the written plan of care and that are for the palliation and management of the terminal or related conditions.

(g) Home health aide services furnished by qualified aides as designated in Sec. § 418.76 and homemaker services. Home health aides (also known as hospice aides) may provide personal care services as defined in §409.45(b) of this chapter. Aides may perform household services to maintain a safe and sanitary environment in areas of the home used by the patient, such as changing bed linens or light cleaning and laundering essential to the comfort and cleanliness of the patient. Aide services may include assistance in the maintenance of a safe and healthy environment and services to enable the individual to carry out the treatment plan. Homemaker services may include assistance in maintenance of a safe and healthy environment and services to enable the individual to carry out the treatment plan.

(h) Physical therapy, occupational therapy and speech-language pathology services in addition to the services described in Sec. 409.33 (b) and (c) of this chapter provided for purposes of symptom control or to enable the patient to maintain activities of daily living and basic functional skills.

(i) Effective April 1, 1998, any other service that is specified in the patient’s plan of care as reasonable and necessary for the palliation and management of the patient’s terminal illness and related conditions and for which payment may otherwise be made under Medicare.

42 CFR 418.204 Special coverage requirements

(a) Periods 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 an individual at home. Either homemaker or home health aide (also known as hospice aide) services or both may be covered on a 24-hour continuous basis during periods of crisis but care during these periods must be predominantly nursing care. A period of crisis is a period in which the individual requires continuous care to achieve palliation or management of acute medical symptoms.


(b) Respite care. (1) Respite care is short-term inpatient care provided to the individual only when necessary to relieve the family members or other persons caring for the individual.(2) Respite care may be provided only on an occasional basis and may not be reimbursed for more than five consecutive days at a time.

(c) Bereavement counseling. Bereavement counseling is a required hospice service but it is not reimbursable.

42 CFR 418.205 Special requirements for hospice pre-election evaluation and counseling services

(a) Definition. As used in this section the following definition applies. Terminal illness has the same meaning as defined in CFR 418.3.

(b) General. Effective January 1, 2005, payment for hospice pre-election evaluation and counseling services as specified in §418.304(d) may be made to a hospice on behalf of a Medicare beneficiary if the requirements of this section are met. (1) The beneficiary. The beneficiary:

(i) Has been diagnosed as having a terminal illness as defined in §418.3 (ii) Has not made a hospice election (iii) Has not previously received hospice pre-election evaluation and consultation services specified under this

section (2) Services provided. The hospice pre-election services include an evaluation of an individual's need for pain and

symptom management and counseling regarding hospice and other care options. In addition, the services may include advising the individual regarding advanced care planning.

(3) Provision of pre-election hospice services. (i) The services must be furnished by a physician (ii) The physician furnishing these services must be an employee or medical director of the hospice billing for

this service (iii) The services cannot be furnished by hospice personnel other than employed physicians, such as but not

limited to nurse practitioners, nurses, or social workers, physicians under contractual arrangements with the hospice or by the beneficiary's physician, if that physician is not an employee of the hospice

(iv) If the beneficiary's attending physician is also the medical director or a physician employee of the hospice, the attending physician may not provide nor may the hospice bill for this service because that physician already possesses the expertise necessary to furnish end-of-life evaluation and management, and counseling services

(4) Documentation. (i) If the individual's physician initiates the request for services of the hospice medical director or physician,

appropriate documentation is required (ii) The request or referral must be in writing, and the hospice medical director or physician employee is

expected to provide a written note on the patient's medical record (iii) The hospice agency employing the physician providing these services is required to maintain a written

record of the services furnished (iv) If the services are initiated by the beneficiary, the hospice agency is required to maintain a record of the

services and documentation that communication between the hospice medical director or physician and the beneficiary's physician occurs, with the beneficiary's permission, to the extent necessary to ensure continuity of care