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HCFA rule ties it with Medicare funding
With the Health Care Financing Administration (HCFA) granting deemed status to a few accrediting organizations, the once-voluntary process of seeking that accreditation can now be tied to HCFA certification, giving new importance to preparations for that scrutiny.
In 1999, HCFA granted "deemed status" to the Community Health Accreditation Program (CHAP) in New York City and the Joint Commission on Accreditation of Health Care Organizations (JCAHO) in Oakbrook Terrace, IL. The move allows these accrediting organizations to not only perform their own accreditation surveys, but also certification surveys that determine whether a hospice is complying with Medicare regulations. And gaining that certification is a prerequisite for receiving Medicare reimbursement.
When it comes to accreditation review, most hospice providers dread the microscopic inspection. They spend months preparing and breathe a sigh of relief after the reviewer has left. What if, however, the visit is tied to certification? While the stakes are greater and the anxiety heightened, the preparation strategy is similar: identifying areas of weakness and making necessary improvements.
Hospices could use some tweaking
Most hospices need a little tweaking when it comes to policies and procedures that reflect on quality and administration, says Jerald Cohen, MA, RN, president of CHAP.
In the past, the JCAHO has said the five following accreditation standards garnered the most Type I recommendations:
• Standard LD.7 — defining hospice services in written contracts;
• Standard IM.9.20 — documenting medication and medication allergies and sensitivities;
• Standard TX.2 — obtaining and updating physician orders;
• Standard HR.6 — assessing, maintaining, and improving the competence of staff members;
• Standard IM.9.13 — maintaining proper documentation of care planning activities in the patient record.
JCAHO declined to release its most recent list of frequent Type I recommendations prior to the release of the accreditation organization’s own publication this month. CHAP, on the other hand, cites the following areas in which it finds hospices are in need of improvement:
• Supervision of nursing aides. Nursing aides should be supervised once every two weeks, including written documentation in the patient record.
• Plan of care does not reflect physician orders. The plan of care should be updated with each change made by the interdisciplinary team and agreed upon by the patient’s physician.
• Lack of bereavement care plan. Documentation often does not reflect a thorough plan, one that begins before the patient dies in which each family member’s need for counseling is assessed.
• Unclear or poorly written agreements with contractors. Some contracts with outside providers do not include clear language stating the responsibilities of contractors and those of the hospice, such as medical management of the patient.
CHAP standards are based on four principles, says Cohen: Structure and function; quality; resources (human, financial and physical); and long-term viability (planning, risk management, and innovation).
"Most problems are in the quality area," says Cohen. "To get through a CHAP review, you have to have more than just policies in place. You can have the most beautiful policies and procedures manual, but if you’re not doing what your policies say you’re supposed to do, you’re not going to get a good review."
A common theme among these trouble areas is documentation, or, more specifically, the lack of it. It is important to remember that, as far as the reviewer is concerned, if there isn’t a written record, the tasks were never performed. From the broader quality perspective, proper documentation allows for better interdisciplinary communication and helps avoid unnecessary mistakes.
The top documentation issue, according to the joint commission, is the keeping of medication information. Nearly 27% of hospice organizations surveyed last year scored 3, 4, or 5 on Standard IM.9.20. Each standard is scored on a five-point scale, 1 being the best and 5 being the worst.
For a hospice to score a 1 or 2, its nurses must question patients and family about medication the patient is taking, both prescription and over the counter, and check the home for other drugs the patient or family may have forgotten to mention. When there are changes in physician orders, nurses should note the update in prescribed medication and dosage. Yet, the observations and changes communicated to the nurse often fail to find their way to the patient record.
Experts blame noncompliance on the volume of data that nurses must collect, which is made more difficult because they are working with a hand-written system. Documentation should be looked at as a chain of accountability. Using patient medication documentation as an example, the chain begins with the nurse who must ask the patient and caregiver about medications and prescription compliance. The next link in the accountability chain is a clinical manager who needs to monitor nurse behavior diligently and offer remedies for those who consistently fail to meet documentation standards.
Keep updated physician orders
Another common documentation problem is failing to update physician orders. Physician orders change regularly, as doctors react to the changing condition of the dying patient. These changes often are made verbally, with a written order expected to follow.
However, in the course of treating the patient, nurses often forget to follow up with the physician and get a written order. Or, perhaps, the written order is received but not placed in the patient record.
Both accuracy and timeliness are issues providers must be concerned with in dealing with physician orders. Across the hospice industry, providers are having difficulty getting their nurses not only to keep a complete collection of physician orders, but also to update the orders in a timely fashion.
The same problems are also seen in clinical staff’s documentation of care planning activities, which include communication with physicians and interdisciplinary meetings or discussions regarding patient care planning. The best way to ensure compliance is to perform routine audits of patient charts and to provide routine inservice training to stress the importance of this task.