Hospice Survey Process Presentation to Georgia Hospice and

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Hospice Survey Process Presentation to: Georgia Hospice and Palliative Care Organization Presented by: Bunice

Hospice Survey Process Presentation to: Georgia Hospice and Palliative Care Organization Presented by: Bunice L. Wilson, RN Hospice Nurse Surveyor Date: June 6,

Learning Objectives • Explain the purpose of the hospice survey • Describe the survey

Learning Objectives • Explain the purpose of the hospice survey • Describe the survey process • Identify the most frequently cited state and federal deficiencies • Discuss the role of hospice staff in avoiding deficiencies

Why Do A Hospice Survey? • Protect hospice patients • Assure hospice agencies are

Why Do A Hospice Survey? • Protect hospice patients • Assure hospice agencies are meeting minimum health and safety requirements – Federal Conditions of Participation – State Rules and Regulations

Survey Process Entrance Conference • Purpose of survey • Request needed documents • Estimated

Survey Process Entrance Conference • Purpose of survey • Request needed documents • Estimated time schedule for survey completion

Survey Process Data collection • • Clinical record review Personnel record review Contracts Quality

Survey Process Data collection • • Clinical record review Personnel record review Contracts Quality assessment activity Volunteer activity On-call log Grievance/complaint process Home visits

Survey Process Exit Conference • Findings • Deficiencies

Survey Process Exit Conference • Findings • Deficiencies

Most Frequently Cited Deficiencies Condition of Participation (Co. P) 418. 56 (a) Approach to

Most Frequently Cited Deficiencies Condition of Participation (Co. P) 418. 56 (a) Approach to service delivery • L 539: Designation of interdisciplinary group to provide care and services offered by the hospice, and the group, in its entirety, supervise the care and services – Non-compliance due to multi-disciplinary approach to care instead of interdisciplinary approach to care

Most Frequently Cited Deficiencies 418. 56 (a) Approach to service delivery • L 545:

Most Frequently Cited Deficiencies 418. 56 (a) Approach to service delivery • L 545: Individualized plan of care – Non-compliance due to plans of care that are not individualized and patient-specific. – The plan of care lacks the designation of disciplines responsible for each intervention.

Most Frequently Cited Deficiencies 418. 58 (d): Performance improvement project • L 571: Develop,

Most Frequently Cited Deficiencies 418. 58 (d): Performance improvement project • L 571: Develop, implement and evaluate performance improvement projects • L 573: Document projects being conducted, reason and measurable progress achieved 418. 64: Core services • L 597: Dietary counseling

Most Frequently Cited Deficiencies 418. 76 Hospice aide and homemaker services • L 615:

Most Frequently Cited Deficiencies 418. 76 Hospice aide and homemaker services • L 615: Successful completion of competency evaluation that must address each subject. 418. 106: Drugs/Biologicals/Medical Supplies/DME • L 695 and L 697: Provide copy of hospice police and procedure for controlled drugs

Most Frequently Cited Deficiencies 418. 112: Hospices that provide hospice care to residents of

Most Frequently Cited Deficiencies 418. 112: Hospices that provide hospice care to residents of a SNF/NF or ICF/MR (facility) • L 774: Hospice plan of care must identify care/services and provider responsible. 418. 114: Personnel qualifications • L 795: Hospice contracts must require that all contracted entities obtain criminal background checks on contracted employees who have direct patient contact or access to

How to avoid deficiencies ü Become familiar with State and Federal regulations ü Conduct

How to avoid deficiencies ü Become familiar with State and Federal regulations ü Conduct quality assessment monitoring activities to assess overall compliance ü In-service staff regarding regulatory requirements

Reference • www. dch. ga. gov – Department of Community Heath Website. Hospice Rules

Reference • www. dch. ga. gov – Department of Community Heath Website. Hospice Rules and Regulations can be found under Healthcare Facility Regulation Division.

Evaluation Your feedback is important to us! Please follow the link below to complete

Evaluation Your feedback is important to us! Please follow the link below to complete your evaluation form http: //www. surveymonkey. com/s/HOSPICE 2 Thank you, HFRD Training Staff

Contact Information Bunice L. Wilson, Nurse Surveyor Department of Community Healthcare Facility Regulation Division

Contact Information Bunice L. Wilson, Nurse Surveyor Department of Community Healthcare Facility Regulation Division 2 Peachtree St. , NW, Suite 31 Atlanta, GA 30303 404 -558 -3930 blwilson@dhr. state. ga. us