Hospice: Top 10 Deficiencies for 2023

Join us as we dissect the top 10 hospice deficiencies for 2023 with Keri Culhane, CHAP's Clinical Nurse Educator. Expect to learn about the intricacies of individualized care plans, the critical nature of accurate medication profiles, and the emerging challenges of standard precautions and timely bereavement assessments. We don’t just highlight problems; we also provide actionable strategies to enhance compliance and elevate patient care quality every single day. We also discuss the pivotal role of initial bereavement assessments and an interdisciplinary approach, even when patients opt out of certain disciplines among other essential items. Tune in to find out. 

Click below for:

1. Upcoming Accreditation Intensives 
2. PDF of the Top 10 Hospice Deficiencies for 2023
3. CHAPcast: Home Health Top 10 

Be sure to listen for details on our upcoming micro-learning sessions dedicated to individualized care plan development, designed to help you meet and exceed CHAP standards. 

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Transcript

Speaker 1 0:02

Hi there, I'm Jennifer Kennedy, the lead for quality standards and compliance here at CHAP, and welcome to our CHAPcast.

Speaker 1 0:11

Today we're going to be discussing the top 10 2023 CHAP hospice standard deficiencies and their potential impact in the bigger picture, as well as strategies for success. Again, whether you're new to hospice or whether you've been around the block for a while, today's information is going to help you exceed standards 24-7, 365. So, so I'm so pleased to be talking with my co-worker and friend, carrie Culhane. She is with CHAP as our clinical nurse educator, and this isn't her first round of being at CHAP. She was with CHAP previously as a director of accreditation. Carrie has 18 experience in the post-acute healthcare industry and she's held a number of different positions, from direct patient care clinician as a registered nurse to a chief executive in both home health and hospice organizations. She does have a passion for community-based care and she does a great job because we know she enjoys it of educating others and contributing to not only their growth and development but their overall quality, I'll say as a healthcare professional. So welcome aboard to CHEPCAST, carrie.

Speaker 2 2:11

Thanks, jennifer, I'm glad to be here.

Speaker 1 2:14

Well, we're going to talk about hospice deficiencies and when we're talking about noncompliance with regulations, I think this is one of the most important times in the history of hospice in the United States where compliance is paramount. We now have the hospice special focus program that one of the criteria links to 11 quality of care COPs, and receiving a condition level deficiency in any of these 11 quality of care COPs could be one of the variables in being invited to participate in this special focus program. So I'm really happy. And let's talk about what's topping the list in hospice care and what trends you're seeing in the 2023 data.

Speaker 2 3:37

Well, a few things that are of note for 2023, one of them being our top deficiency has remained the same from 2022 as well, and that has to do with plan of care and the content and elements of the plan of care. And then we have a number two moving up in the ranks in our top 10, and that has to do with a comprehensive assessment of medications and ensuring a complete and accurate med profile. Several of our deficiencies in the top 10 remain in the top 10. Over the last several years, we have some movement in terms of ranking, although we do have two new deficiencies that came into the 2023 top 10 this year, respectively at 9 and number 10, and that has to do with standard precautions, lack of appropriate hand hygiene, as well as completing that initial bereavement assessment, as well as making sure that it's completed in that required timeframe.

Speaker 1 4:36

Wow, so I'm not surprised about number one, I don't think CMS thinks that hospice providers can do an adequate plan of care, but CMS also thinks that CMS the plan of care is the most important document in hospice care. So I think there are a number of variables around why there's deficiency there. But I guess what I am hoping you can do for us is, you know, quickly walk us through what those 10 look like and some of your thoughts about that.

Speaker 2 5:13

Absolutely. So, of course, number one plan of care and Jennifer, you hit the nail on the head. This is one of the most important documents and really what I like to call is ever evolving. It's almost living and breathing, for lack of a better word, because it is constantly changing depending on what is going on with the patient and what that assessment is yielding in terms of findings. So very important that organizations understand the importance of the individualization factor, understand the importance of the individualization factor and biggest thing we see in terms of lack of compliance have to do also with how they're developing those goals and making sure that those goals are what we like to call smart goals, so they are specific, they're measurable, they're achievable, realistic and time-bound. And then also making sure that those interventions that are developed are individualized and that the clinicians have a good understanding of what it means to really develop that plan of care based on what is going on with the patient's needs and not and what they want. What the patient's wishes are right, absolutely, absolutely. And that's a great point because, at the end of the day, we're there to make sure that the patient's goals and the outcomes that they want to achieve we can assist them in meeting those. So absolutely, because this is such an important issue and we see it pop up as a deficiency so often.

Speaker 2 6:43

We do have a microlearning that I'm putting together related to care planning. That will be available on our education page here very soon and it really will focus in on breaking down care plan development. What is the difference between an intervention and a goal? What does it look like to really individualize those and make them patient specific? So stay tuned for that More to come on that when that's posted, but hopefully that will be a very useful resource for organizations to also then share with their staff on really how to develop those plans of care and individualize them according to the patient's needs. Wow, huzzah, I can't wait to see it it was very fun to the patient's needs.

Speaker 1 7:21

Wow, huzzah, I can't wait to see it.

Speaker 2 7:24

It was very fun to put together, I must say so I hope you would find it as fun as I did putting it together. So then, coming in number two, which I said, this has moved up in the ranks. It was still in the top 10 last year, but now moving into that two spot is the assessment of medications and ensuring that complete and accurate profile. And this also is another area we see, especially when you're out on home visits and observing the staff conduct that medication reconciliation process and really educating your staff on those questions that they can ask to investigate and really be a detective when they're out there and observing what's in the home, what they might see on a nightstand or an end table. Ask those questions to try to compile as accurate of a list as possible and to be conducting that process not only at start of care or, you know, recertification, but also on an ongoing basis, on routine visits, to make sure that that list is as accurate as possible and also making sure that it's matching what is in the record. So not only completing that accurate profile in the home and leaving that there for the patient and family, but then making sure that that is put in the record as well, so that they match and there aren't any discrepancies there.

Speaker 2 8:50

And then three and four I'm going to talk about these together because they both have to do with aid services and coming in at number three is the development of the aid assignment or the aid care plan. And really what we see there is a lack of clear direction on those aid care plans for the aides. You know the aid scope of practice is very limited and it also can vary depending on the state. And so making sure that the nurses are aware of what the scope of practice is for the aides in their state and then providing that clear direction on what the scope of practice is for the aides in their state and then providing that clear direction on what the aide can and cannot do on that assignment sheet and educating them to notify, educating the aides really to notify the RN if there are any issues or if they are unable to complete a task for whatever reason, or if they want to ask permission to do another task that's not on the assignment sheet. And then following that is the aides actually implementing and following what is assigned on their assignment sheet or care plan.

Speaker 2 9:52

That comes in at number four. So really making sure aides understand that they are limited to those tasks that are given to them or assigned to them on that care plan. That they understand that if there is a request from the patient or family to perform maybe a different bathing type, that's ordered they need to call and get permission from the RN before proceeding and completing that task. And then also understanding when they are reporting any changes in condition and whether it's, you know, pain, whether it's maybe a new wound or a new red spot on the patient, that they understand that they are reporting that information to the to the nurse as well.

Speaker 1 10:32

You know, carrie, not that these two aren't important, because they are, but I'm so glad you didn't say the every 14-day supervisory visit. God, that has just been such a theme, at least at the CMS deficiency level, for years on, years on waffles, you know, it just never goes away. So I'm happy to hear that it's not here. But I do think nurses have a bigger responsibility. When they have an aid in, they absolutely have to manage that aid in all aspects, including knowing what's on that care plan at any time, but also updating it and educating the aid. So in a way I feel this is a failure of the nurse working with that aid.

Speaker 2 11:25

And you know, it's also that I think a lot of organizations have are able to maintain compliance with that 14-day requirement because they've instituted the process of every visit. The RN is going to be conducting a supervisory visit.

Speaker 1 11:41

Right.

Speaker 2 11:47

But I also think, and what I've discovered, you know, in my years of surveying, was a lot of nurses didn't understand the true meaning of what it meant to supervise that aid and to really be evaluating their documentation, comparing it to that care plan, making sure they're asking appropriate questions during the supervisory visit of the patient family on how the care is going, what types of services the aide's providing. There's a lot that the nurse can learn by asking those questions and also by really evaluating the documentation component. Yes, consistently right Consistently.

Speaker 1 12:17

Yes, yes, yes, consistently right, consistently.

Speaker 2 12:31

Yes, yes, so you're right, the 14-day one is probably not too far off the top 10 list, I would imagine, but it didn't make it this year.

Speaker 2 12:35

So let's see here.

Speaker 2 12:36

Coming in at number five, we have the patient clinical record containing physician orders.

Speaker 2 12:40

So making sure that when those clinicians are getting orders from the physician they're making sure to document those.

Speaker 2 12:46

You know, being in the field and in patients' homes so much we do a lot of verbal communication with the physicians and get those verbal orders and it's just really important that staff understand how important it is to document those and capture those in the record as well, that staff understand how important it is to document those and capture those in the record as well. And then coming in at number six is completing that initial comprehensive assessment within that five calendar day window after the election of hospice care and so making sure that you know those disciplines are reaching out there and if they're not able to get out there or if they're refused for one reason or another, that the, the RN, is really key in collecting that data and documenting that in the assessment. And one thing that I always like to, you know, educate organizations on is it if a discipline is is refused or the patient does not want them in the home. That doesn't mean that they're not still participating and providing input, especially during the IDG process.

Speaker 1 13:46

Absolutely.

Speaker 2 13:48

And the RN can be communicating that with the team and that chaplain or social worker can be providing some input or guidance to the RN if they are, you know, refused and they don't want that discipline out there. So it doesn't mean that they get a pass and they're hands off. It just means that they have to do a little bit of more work with that nurse in within the team setting and really work together still to meet those patient and family needs.

Speaker 1 14:12

Yeah, thanks for saying that it's. It's so important. I think and I, I, I wholly agree it's not a vacation because you're not in there. You know you're still in there, you know, mentoring your team members on what they can do on the social worker, spiritual care counselor behalf.

Speaker 2 14:33

So yeah, for sure.

Speaker 2 14:36

And then coming in at number seven, we have, if the patient revokes the hospice benefit or is discharged, the hospice is forwarding a copy of that discharge summary to the attending physician and making sure that that summary is comprehensive in its elements.

Speaker 2 14:52

So organizations need to make sure there's a process in place to make sure that summary is being completed and forwarded, to make sure that summary is being completed and forwarded to the attending and making sure that that summary is indeed a summary of the patient's stay and what transpired throughout their certification periods, however long that may be. And then coming in at number eight is making sure that services and the care that's being provided are following the individualized plan of care. And here we do see a little bit of more of an issue related to visit frequency. So making sure that that visit frequency, the disciplines are identifying in the plan are being met and followed according to the plan of care. And, if not, making sure there's documentation to indicate why, why a visit might have been missed or what the case may be. So making sure that the record is painting that picture and providing that evidence of why that standard might not be compliant.

Speaker 1 15:55

And again, the scope of practice and the frequency is per the patient and family's needs, not per your staffing issues. Right, absolutely so. I know it's tough out there. I understand that some hospices and home health or they're trying to do more with less, but we have to make sure that the patient's we have to have somebody out there doing it.

Speaker 2 16:28

Absolutely, and what I love to see is a fluctuation in visit frequencies as the certification period's going on, based on what the patient's needs are and what's transpiring. You know, again, I mentioned earlier it really is a living and breathing thing that plan of care. So seeing that movement in the documentation and at the ebb and flow really does reflect individualization and focusing in on what the patient's wants are and what their needs are.

Speaker 1 16:56

Absolutely.

Improving Hospice Compliance Through Education

Speaker 2 16:57

And then we have our last two. Again, these are new for the top 10 this year, for 2023. And number nine is following accepted standards of practice to prevent transmission of infection. So standard precautions and appropriate hand hygiene. Again, this is so important out there. It is such a basic function in terms of your hand hygiene processes, but it is a challenge when you think about the environments that the hospice staff are going into, whether that's a patient home that may be, you know, not the most clean, or maybe has a lot of stuff, like we like to call it. You know where they're having to figure out where they might be able to place their bag, if they have access to a sink and be able to wash their hands, etc. So really important that organizations are observing their staff in the field, seeing how they can adapt to those situations in the environment in order to still maintain appropriate infection control practices.

Speaker 1 17:59

And ongoing yeah, go ahead. I was just going to say, as you're talking, I'm thinking back to my days out there of challenging household situations. But I would but you know, I would have thought after COVID things would have gotten better with some of these basic things like standard precautions and hand washing.

Speaker 2 18:21

You would have thought that you know there was so much education and training going on during the public health emergency, but what I also saw surveying during that time was a lot of inappropriate glove use, which there was a lot of individuals that started wearing gloves due to the pandemic and concerns about their own safety, but there was a misconception on what that meant in terms of when they have to perform hand hygiene, you know when those gloves should be changed.

Speaker 2 18:53

It was kind of this mentality of you know gloves are on, I'm safe, I can pretty much do anything because I've got gloves on. So there's a lot of education related to appropriate glove use and I think that I think the more staff get into a routine and the more they just they really have to be self-starters. The way I look at it is they really have to be mindful when they're out in the home and really develop their own routine so that it just flows naturally for them. And when they're being observed or when they're in a new environment, they have really adopted a routine for themselves that works and they can just, you know, seamlessly hopefully implement that, you know, from home to home depending on the situation. But lots of ongoing education and training we say. You know, repetition is the key to adult learning. So the more that they're seeing and visualizing or practicing these type of skills, the more it hopefully will stick and become a part of the routine processes going forward.

Speaker 2 19:54

And then, last but not least, is the initial bereavement assessment and making sure that that is completed as part of the initial comprehensive assessment. And it's also important to note that if the other disciplines are refused, I know a lot of organizations have policies where typically maybe the chaplain or social worker may be conducting that bereavement assessment. But keeping in mind that if those disciplines are refused or are unable to get out there within the appropriate time frame, that that RN also can be conducting that bereavement assessment as well and making sure that they're also sharing that with the team, getting input from the team if those disciplines are indeed refused. But again, it is a team approach to the care for that patient. So the nurse can definitely be obtaining that information and completing that assessment as part of the comprehensive assessment.

Speaker 1 20:46

Yeah, absolutely, I know that it's you know. Yeah, absolutely, I know that it's. You know, depending on the patient, they may not want certain disciplines, so it may end up that a nurse has to do that. And even if the basic assessment is completed for bereavement, depending on the outcome, an expanded assessment may be required.

Speaker 2 21:18

So you know ties back to you don't get a pass from the IDG table if you're not actually hands-on in the house, for sure, yes, absolutely.

Speaker 1 21:21

So you've given us a lot of good information as you've reviewed the deficiencies, but are there any other overarching practices or measures that a hospice provider could take to meet our standards and hopefully exceed them as it relates to their performance?

Speaker 2 21:49

Now, I think, two areas that really I think about when I think about trying to exceed expectations and really focusing on quality patient care, and one would be making sure you've got dedicated education and training for your staff. I think when we talk about these deficiencies and those ways to come into compliance, a lot of what we say is ongoing education and training, and that is so important that staff understand you know we'll take care planning, for example. You know how that process is supposed to be developed and providing them with the tools needed to develop that individualized plan of care. You know giving them specific education related to reconciliation and how to really compile a comprehensive medication list. And then again, with you know basics as hand hygiene and you know bag technique processes, making sure that they are receiving just ongoing education, training, real-time observations so that they are prepared. So that's one area I would say is definite education and training and investing in your staff and providing them the tools and resources necessary to be successful.

Speaker 2 22:57

And then a second thing I really would focus in on is making sure that an organization has a robust, comprehensive quality improvement program where they're really looking at a variety of indicators, doing their audit processes, collecting that data, honing in on those areas that they've identified, either through their own internal processes, or taking some of these top deficiencies and really looking at them internally and where their compliance level is with these in terms of their own processes, and then developing projects If they're finding those deficiencies, identifying opportunities where they can really come together, develop a project to make improvements in that area and demonstrate that improvement and sustain improvement. I think one of the areas organizations struggle with is they may get to that goal, but then how do they maintain that compliance on a long-term basis and not let it you know, for lack of a better word fall off the radar and something that they're not keeping up on? So making sure that they've got those ongoing monitoring processes in place, you know, to keep things where they need to be in terms of compliance.

Speaker 1 24:10

Wow, those are great tips and it's so been really great chatting with you about all this. You know, I think one of our calls to action for our listeners out there today is to not only look at the list of top 10 deficiencies that we'll include with our episode notes, but we do have what we call CHAP accreditation intensives, and I know you just happened to teach those. So can you give me a couple of points about the hospice intensive?

Speaker 2 24:46

Absolutely so.

Speaker 2 24:47

We conduct our intensive several times throughout the year.

Speaker 2 24:51

In fact, we have our next one coming up, I believe, towards the end of August, and we really focus in on each chapter of the hospice standards and break it down on the more granular level what each of the standards mean, what guidance is related to interpretation of those standards, what are the top deficiencies as it relates to that specific chapter, and providing organizations with tips for success on how to bring those areas into compliance and demonstrate compliance. Moving forward, we strive to make these sessions very interactive and engaging. There's a lot of discussion amongst groups, there are breakout activities that we focus in on, and the goal is really to not only have them learn from us as instructors but also their peers that are attending the intensive with them. You know people have been in the. Those that have been in the industry for a long time have a lot of valuable lessons learned and things they can share, where others can glean from that as well, especially if we have newer ones attending that might just be getting started in the hospice industry, so they can be a very valuable resource.

Speaker 1 26:02

Well, this sounds great and I think it sounds like a do not miss for our hospice provider listeners out there. Well, Carrie, thanks again so much for spending time with me to talk about this important topic today.

Speaker 2 26:17

Thanks for having me, jennifer, it was a pleasure.

Speaker 1 26:20

And thank you to all of you out there for taking a few minutes out of your day to listen to our podcast From me and the entire CHAP staff. Keep your quality needle surging forward, stay safe and well, and thanks for all you do. Thank you.