|§483.70(o) Hospice services.|
§483.70(o)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.
§483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.
§483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.
§483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24.
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two of 30 residents reviewed (Residents 7, 56).
The facility's policy regarding hospice (end-of-life) services, dated January 21, 2021, revealed that for a resident to qualify for the hospice benefit under Medicare there must be a certification of terminal illness, and the facility was responsible for communication with the hospice provider and documention to ensure that the needs of the resident were met twenty-four hours a day.
Physician's orders and a care plan for Resident 7, dated November 26, 2020, revealed that the resident was to receive a hospice evaluation and treatment. A comprehensive, significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated December 4, 2020, indicated that the resident was severely cognitively impaired, had diagnoses that included Parkinson's disease (a disease that affects the brain and movement) and COVID-19, and received hospice services during the assessment period.
There was no documented evidence that information about hospice visits/services provided from November 26, 2020, to March 16, 2021, were a part of the resident's clinical record.
Interview with the Nursing Home Administrator on March 17, 2021, at 4:20 p.m. confirmed that hospice notes were to be kept in a binder or scanned into the resident's electronic record, and there were no hospice notes that were currently part of Resident 7's records.
Physician's orders for Resident 56, dated March 1, 2021, included an order for a hospice consultation. A comprehensive, significant change MDS assessment, dated March 9, 2021, indicated that the resident was severely cognitively impaired, and received hospice services during the assessment period.
There was no documented evidence that a physician's certification of terminal illness was obtained and was part of Resident 56's clinical record.
Interview with the Director of Nursing on March 18, 2021, at 10:47 a.m. confirmed that there was no documented evidence that a physician's certification of terminal illness was obtained and on record for Resident 56.
28 Pa. Code 211.12(d)(1)(3) Nursing services.
| ||Plan of Correction - To be completed: 05/07/2021|
1. Hospice documentation for services provided from November 26,2020 through March 16, 2021 were filed in R7's medical record.
The physician's certification of terminal illness was filed in the R56's medical record.
2. Records of current hospice residents will be reviewed to validate documentation of hospice visits/services provided and physician certification of terminal illness are present and current.
3. The Interdisciplinary team will be re-educated on the responsibilities outlined in the regulatory requirements, including but not limited to: hospice collaboration, communication and documentation requirements.
4. Hospice documentation will be uploaded to the electronic medical record. Medical Records/Designee will be responsible to receive and upload documentation in the resident electronic record.
5. Social Service/Designee will monitor 20% of hospice resident records to validate hospice documentation is current and physician certification of terminal illness is present, weekly x 4 weeks, the monthly x 3 months.
6. Audit results will be reported and reviewed by the Quality Assurance Process Improvement Committee monthly x 3, for further review and recommendation.