1. Oregon Hospice Association Professional Practices Exchange
September 24, 2018
Teri-Ann Stofiel, RN
Hospice Surveyor

2. Agenda Agency Overview Survey Process Hospice Impact Act 2014
Emergency Preparedness Rules
Discharge for Cause
Questions & Contact Information

3. Part 1: Oregon Health Authority
OHA Divisions:
External Relations
Fiscal
Agency Operations
Health Policy & Analytics
Health Systems
Office of Equity & Inclusion
Oregon State Hospital
Public Health
Center for Public Health Practice (6 sections)
Center for Prevention & Health Promotion (5 sections)
Center for Health Protection (6 sections)
Fiscal & Business Operations; Program Operations; Policy & Partnerships; Science & Evaluation

4. Overview of OHA Oregon Health Authority 4 Public Health Division
Health Care Regulation & Quality Improvement Section
Health Facility Licensing & Certification Program
Center for Health Protection
Survey and Certification
Facilities Planning and Safety 4

5. Health Facility Licensing & Certification
Recent Changes –
Facilities Planning & Safety and Survey & Certification now have separate managers
Survey & Certification welcomes Anna L. Davis, JD as our new manager

6. Survey & Certification Regulated Entities
Hospitals (CAH, ACU, PSY) including Satellites
Caregiver Registries
Non-Transplanted Anatomical Research Recovery Organizations
Ambulatory Surgical Centers
Outpatient Renal Dialysis Facilities
Freestanding Birth Centers
Hospice Agencies
Hemodialysis Techs
Home Health Agencies
Tissue Bank/Organ Procurement Registry
Rural Health Clinics
Out-Patient Therapy
Special Inpatient Care Facilities
Portable X-ray
Federal Qualified Health Centers
NEW! Extended Stay Centers
In-Home Care Agencies

7. Health Facility Licensing & Certification
Team of:
14 surveyors specializing in one facility type & cross- trained. CMS surveyors are RNs. Surveyors sometimes work in teams.
FPS Administrative assistants also assist Survey & Certification
1 manager
Program Workload:
Fixed: Standard surveys required to satisfy state licensure &/or federal certification requirements
Variable: Federal and state complaint investigations, federal EMTALA reports & immediate jeopardy situations.

8. Part 2: Survey Process Pre-Survey Preparation waivers
Develop survey plan and review facility information including:
waivers
prior surveys & complaints
services provided
on-campus & off-campus satellite locations
licensure & ownership
Survey Day 1
Entrance Activities – Meet with administration to:
Explain purpose & scope of survey
Explain survey process
Discuss logistics (e.g., survey team work space, photocopies, etc.)
Provide “needs list” detailing documents to be provided to surveyor

9. Survey Process Survey Days 1 to ≤ 5 Final Day of Survey
Information Gathering Includes:
On-site observations
Interviews with staff & patients
Administrative document review of policies & procedures, contracts, & personnel records, etc.
Medical record review using representative patient samples
Preliminary Findings
Surveyors use survey tools to quantify information gathered
Final Day of Survey
Exit Conference with Facility Administration
Survey team shares preliminary findings & next steps
Note: Survey closure date will be later if survey team asks provider to submit additional information to clarify outstanding questions

10. Survey Process 10 Business Days Post Survey
Agency Issues Survey Report
Statement of Deficiencies (SOD) documents any deficiencies identified during onsite audit or complaint investigation
Issued to facility leadership
10 Calendar Days After Facility Receives Report
Facility Submits Plan of Corrections (POC)
Written response to each deficiency identified during onsite audit or complaint investigation
POC documents facility’s plan to return to compliance
Revisits
Conditions Out Required; Standard Tags Agency’s Option
Surveyors conduct second survey to assess implementation of provider’s POC & abatement of cited deficiencies

11. Part 3: IMPACT Act of 2014
Hospice Integrity Provisions to Improve & Support Patient Care
New Medicare Survey Intervals: Once every three (3) years (aligns with state licensing standards)
CMS Medical Reviews for “long-stay” hospice patients (care > 180 days)
Standardized Patient Assessment Data Provisions
Inflationary Indexing for Hospice Reimbursements
State Agency Performance Standards
Ensure all Oregon Hospice facilities are surveyed by April 2018 – This was achieved with the help of Federal contracted surveyors
Adhere to new survey intervals going forward
Improving Medicare Post-Acute Care Transformation (IMPACT) Act 11

12. Oregon Hospice Facilities
Hospice Facilities (as of August 2018)
Total: 62
Deemed: 13
Non-Deemed: 38
License Only: 11
New/Vol. Termination: 4/1
Annual Workload
Hospice Recertification / Relicensure Surveys: per year
Hospice Complaint Investigations: varies (8 from Aug Aug 2018)
Hospice initial licensure surveys: varies (3 from Aug Aug 2018) 12

13. Most Common Tags 8/2015 to 8/2018 State OARs (Chapter 333 Division 35)
Criminal Background Checks: Required prior to employment and every 3 years (includes volunteers)
Criminal Background Checks Written Policies: Policies must include description of convictions that disqualify an individual
Federal (42 CFR CoP for Hospice Part 418)
L565 - Program Data: QAPI data collection must be approved by governing body
L548 - Content of Plan of Care: Must have measurable outcomes anticipated from implementing and coordinating the plan of care 13

14. Most Common Tags 8/2015 to 8/2018 Federal 14
L547 - Content of Plan of Care: Must include detailed statement of the scope and frequency of services
L573 - Performance Improvement Projects: Must document what PIPs are being conducted, the reason, and measurable progress
L580 - Control: Infection control program must be integral part of QAPI
L663 - Training: Must assess competency and provide in-service training for those giving care (including volunteers) and must have P & Ps and maintain documentation of both 14

15. Most Common Tags 8/2015 to 8/2018 Federal 15
L531 - Content of Comprehensive Assessment: Must include initial bereavement assessment
L629 - Supervision of Hospice Aides: Must provide supervisory visit every 14 days
L643 - Training: Must maintain, document and provide volunteer orientation and training consistent with hospice industry standard
L545 - Content of Plan of Care: Must reflect patient and family goals and interventions and must include all services necessary for the palliation and management of terminal illness and related conditions 15

16. Part 4: Emergency Preparedness
New Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers
Overview: One additional Condition of Participation (CoP) / Condition for Coverage (CfC) that is required to participate in Medicare.
Purpose: To establish national emergency preparedness requirements that ensure adequate planning for natural and manmade disasters, and coordination with federal, state, tribal, regional and local emergency preparedness systems.
Application: All 17 provider and supplier types:
Hospitals;
Comprehensive Outpatient Rehabilitation Facilities (CORFs)
Religious Nonmedical Health Care Institutions (RNHCIs);
Critical Access Hospitals (CAHs)
Ambulatory Surgical Centers (ASCs);
Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services
Hospices;
Psychiatric Residential Treatment Facilities (PRTFs);
All-Inclusive Care for the Elderly (PACE);
Community Mental Health Centers (CMHCs)
Transplant Centers;
Organ Procurement Organizations (OPOs)
Long-Term Care (LTC) Facilities;
Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID);
End-Stage Renal Disease (ESRD) Facilities
Home Health Agencies (HHAs)
Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers 16

17. Emergency Preparedness
(4) Enforcement Date: started on November 15, 2017
(5) Substantive Requirements: Each provider/supplier has dedicated EP regulations incorporated into its CoPs / CfC requirements.
Some vary by provider/supplier (e.g. Hospice required to track and inform officials of patients in need of evacuation, address power outages)
(6) Emergency Preparedness Program Shared Elements:
Risk Assessment and Planning – Develop emergency plan based on risk assessment, use “all hazards” approach, focus on capacities and capabilities, update annually
Policies and Procedures – Develop P&Ps based on emergency plan, ensure that P&Ps address range of issues, update annually
Communication Plan – Develop communications plan that meets state and federal standards and coordinates care within facility, across providers, with state/local public health departments and emergency management systems, update annually
Training and Testing – Develop training & testing programs, P&Ps, conduct drills & exercises, document analysis of drills and exercises
(7) Resources: CMS website downloads; SOM Appendix Z
(8) Note: EP requirements do apply to license only facilities
(9) Note: EP citations result in 3 SODs
Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers 17

18. Most Common Tags Emergency Preparedness
E016 - Hospice Follow up for Staff: P & Ps must include procedures to follow up with on duty staff and patients and must notify local officials of those they are unable to contact
E019 - Homebound HHA/Hospice Inform EP Officials: P & Ps must include procedure for notifying officials of patients needing assistance with evacuation from their residences
E032 - Primary/Alternate Means for Communication: Must include staff and Federal, State, tribal, regional, and local emergency management officials
E039 - EP Testing Requirements: Must have one full-scale and additional full-scale or tabletop exercise and must include analysis of response to exercises and whether changes to emergency plan were made or needed

19. Part 5: Discharge for Cause
Required before discharge:
Advise patient discharge for cause is being considered
Make a serious effort to resolve the problem
Document the problem and efforts to resolve in the clinical record
Obtain a physician’s order; consult attending physician if there is one involved
Consider notification of other agencies
Notification of State Agency:
Written notification that includes: patient name, date patient was notified discharge was being considered, summary of problem and efforts to resolve, date of discharge
Fax: or 19

20. Part 6: Questions & Contact Information
Program Information: General Inquiries
(971)
Additional Resources: Teri-Ann Stofiel, RN
Hospice Surveyor
(971)
John Pilmer, RN
Lead Surveyor
(971)
Anna L. Davis, JD
Survey & Certification Manager
(971)
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