Between Medicare Hospice CoPs and DPH State Hospice ...

[Pages:55]Crosswalk

between

Medicare Hospice CoPs and DPH State Hospice Licensure Regulations

Reference Websites

April 2009

CoPs 2008 Medicare Conditions of Participation for Hospice Care 42 CFR418 (2008)



State Operations Manual CMS State Operations Manual; Interpretive Guidelines, Hospice, Interim Version 1.1 (01/09)



Mass DPH State Licensure Regulations Mass. Department of Public Health, Chapter 141.000: Licensure of Hospice Programs (2003)

Mass Health Mass Division of Medical Assistance, Hospice Provider Manual , 8/1/1998

NHPCO National Hospice and Palliative Care Organization



Hospice & Palliative Care Federation of Massachusetts

1420 Providence Highway, Suite 277, Norwood, MA 02062-4662

phone - 781.255.7077 fax - 781.255.7078

e-mail- hospicefed@

website -

H&PCFM thanks VNA Hospice Care's Executive Director Diane Bergeron and Quality/Regulatory Compliance Specialist Julia Anne Walsh for sharing this crosswalk with Federation members

Regulatory Crosswalk

State Ops Manual, Ver 1.1

Mass. DPH Regulations Mass Health Key Differences

Medicare CoP's 2008

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

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

418.21

Duration of hospice care coverage--Election periods

(a) Subject to the conditions set

forth in this part,

(1) An initial 90-day period;

an individual may elect to receive

hospice care during one or more of the following

(2) A subsequent 90-day period; or

election periods

(3) An unlimited number of subsequent 60-day periods.

418.22

Certification of terminal illness a) Timing of certification

(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:

(c) Sources 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) Exception. 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 (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. (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

(d) Maintenance of records. Hospice staff must--

(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 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.

141.207

141.208 (A) (3) 437.411

141.207 C(3)

State Ops Manual, Ver 1.1

Mass. DPH Regulations Mass Health Key Differences

Medicare CoP's 2008

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. 418.30) may file the election statement

1) Identification of the particular hospice that will provide care to the individual.

(b) Content of election statement. 2) The individual's or representative's acknowledgement that he or she has been given a full

The election statement must

understanding of the palliative rather than curative nature of hospice care, as it relates to the

include the following:

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

1) Remains in the care of a hospice, and (c) Duration of election. An election to receive hospice care (2) Does not revoke the election under the provisions of Sec.418.28 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

(d) Waiver of other benefits. For the duration of an election of

(1) Hospice care provided by a hospice other than the hospice designated by the individual (unless provided under arrangements made by the designated hospice

hospice care, an individual waives

all rights to Medicare payments for

the following services:

(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

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

141.205 (A) (B)

437.412 450.105

State Ops Manual, Ver 1.1

Mass. DPH Regulations Mass Health Key Differences

Medicare CoP's 2008

(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 nay time file an election, in accordance with this section, for any other election period that is still available to the individual

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 1) Diagnosis of the terminal condition of the patient that the patient is terminally ill, the hospice medical director must consider at least the following information:

2) Other health conditions, whether related or unrelated to the terminal condition

3) Current clinically relevant information supporting all diagnoses

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 b y 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

L 682

141.208

437.411 DPH has specific language regarding 437.112 admission policies and procedures

141.207 141.209

Code of Federal Regulations 624 (b) (2)

State Ops Manual, Ver 1.1

Mass. DPH Regulations Mass Health Key Differences

Medicare CoP's 2008

(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

(1) Is no longer covered under Medicare for hospice care;

individual, upon discharge from

the hospice during a particular (2) Resumes Medicare coverage of the benefits waived under 418.24(d); and election period for reasons other

than immediate transfer to another

hospice -

(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

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

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

representative must file a

statement with the hospice that

includes the following information: 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. 41824(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

L 683

141.209

437.412 (C) (2)

State Ops Manual, Ver 1.1

Mass. DPH Regulations Mass Health Key Differences

Medicare CoP's 2008

418.30 Change of the designated hospice

a) An individual of representative my change, once in each election period, the designation of the particular hospice from which hospice 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

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

the hospice from which care has

been received and with the newly

designated hospice, a statement

that includes the following

information:

141.207 C(3) 141.209

L682

437.412 (C) (3)

418.52 Patient's rights

The patient has the right to be informed of his or her rights, and the hospice must protect and promote the exercise of these rights.

a) Notice of rights and

1) During the initial assessment visit in advance of furnishing care the hospice must provide the

responsibilities

patient or representative with verbal (meaning spoken) and written notice of the patient's rights and

responsibilities in a language and manner that the patient understands

L500-L519 L 501

141.205

141.205 141.207 (C)(10)

L 502

141.205; 141.206

Omnibus Budget Reconcilliation Act (OBRA) 1990 - PL 101 - 508

Civil Rights Act, Title VI, Section 601, 1964 45 CFR 80.3 (b) (2) HHS Tile VI Guidance of Limited English Proficiency - 68 FR 48311 (8/2003) Medicare Claims Processing Manual, Chapter 30- Financial Liability Protections (Rev) CMSTransmittal R1587CP, Change Request 6135, 09/05/09, Revised Form CMS-R-131 Advance Beneficiary Notice of Non-coverage, Effective date 03/03/08, Implementation date 03/01/09 Social Security Act - Section 1879 Limitation on Liability Provisions NHPCO Advance Beneficiary Notice Form (CMS-R-131) Tip Sheet

State Ops Manual, Ver 1.1

Mass. DPH Regulations Mass Health Key Differences

Medicare CoP's 2008

2) The hospice must comply with the requirements of subpart 1 of part 489 of this chapter regarding advance directives. The hospice must inform and distribute written information to the patient concerning its policies on advance directives, including a description of applicable State law

3) The hospice must obtain the patient's or representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities

b) Exercise of rights and respect for property and person

1) The patient has the right:

i) To exercise his or her rights as a patient of the hospice

ii) To have his or her property and person treated with respect iii) To voice grievances regarding treatment or care that is (or fails to be furnished and the lack of respect for property by anyone who is furnishing services on behalf of the hospice; and

iv) To not be subjected to discrimination or reprisal for exercising his or her rights 2) If a patient has been adjudged incompetent under state law by a court of proper jurisdiction, the rights of the patient are exercised by the person appointed pursuant to state law to act on the patient's behalf

3) If a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law

4) The hospice must:

i) Ensue that all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of the hospice, are reported immediately by hospice employees and contracted staff to the hospice administrator;

L503

L504 L505

L506 L507 L508

141.205 141.201 F 141.201 (G)

141.201 F, G 141.204 (F)

155.000

ii) Immediately investigate all alleged violations involving anyone furnishing services on behalf of the hospice and immediately take action to prevent further potential violations while the alleged violation is being verified. Investigations and/or documentation of all alleged violations must be conducted in accordance with established procedures;

L509

iii) take appropriate corrective action in accordance with state law if the alleged violation is verified by the hospice administration or an outside body having jurisdiction, such as the State survey agency or local law enforcement agency; and

L510

Clarification from CMS IG - If the hospice has a policy not to certify staff for CPR and the patient does not have a DNR order, the patient must be informed of what procedure will be occur should resuscitation be needed Patient Self Determination Act 1995 489.102 Mass Health Care Proxy/Care and Comfort Legislation - 201 B, D Mass Health Legislation for Health Care Proxy - 130 CMR 501

Clarification of CMS IG - Violations of patients rights must immediately be

State Ops Manual, Ver 1.1

Mass. DPH Regulations Mass Health Key Differences

Medicare CoP's 2008

c) Rights of the patient

iv) Ensure that verified violations are reported to State and local bodies having jurisdiction (including to the State survey and certification agency) within five (5) working days of becoming aware of the violation The patient has a right to the following : 1) Receive effective pain management and symptom control from the hospice for conditions related to the terminal illness;

2) Be involved in developing his or her hospice plan of care;

L511 L512

L513

141.205

141.203 141.205 (A)(4) 141.206 (C)(6)

3) Refuse care or treatment;

4) Choose his or her attending physician;

5) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164 6) Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property;

7) Receive information about the services covered under the hospice benefit

8) Receive information about the scope of services that the hospice will provide and specific limitations on those services

L514 L515 L516

L517 L518

L519

141.205 (A)(3)

141.205 (A)(2) 141.209 (F) 141,201(F) 141.205(A)(1) 141.205 (A)(1),(B), (D)

418.54

Initial & Comprehensive Assessment of the Patient

The hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patient's need for hospice care and services, and the patient's need for physical, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions.

L520 L521

141.202

patients rights must immediately be investigated and reported to the hospice administrator and if verified, be reported to state and local authorities with five (5) days

Clarification of CMS IG - If one discipline, e.g. chaplain or volunteer, is consistently refused, the surveyor may look at how the services are presented to the patient and family.

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