Hospice Survey Process Presentation to Georgia Hospice and
- Slides: 15
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 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 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 time schedule for survey completion
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
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: 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, 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: 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 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 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 and Regulations can be found under Healthcare Facility Regulation Division.
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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
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