What can hospice providers expect from Medicare deemed status surveys?

Joint Commission and CHAP officials give preview

About 1,000 hospices soon will be offered an opportunity to have their accreditation survey combined with a Medicare survey. The country’s two largest accreditation organizations are expected to receive Medicare deemed status within the next two months. The question on everyone’s mind now is: How will this change the survey process?

About 950 hospices are accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL. For these hospices, the chief difference between an accreditation survey and a combined Joint Commission and Medicare survey is that the survey will be unannounced, says Maryanne Popovich, RN, MPH, executive director of the home care program.

Presently, Joint Commission surveys are announced. Since the Medicare survey would be combined with the regular survey, both would be unannounced. Agencies no longer would have the luxury of scheduling survey dates. Instead, they will have to apply for accreditation when they are prepared for a survey, Popovich says.

The Joint Commission expects to receive a decision on its deemed status application by the Baltimore-based Health Care Financing Administration (HCFA) in January.

Surveys will pose problems for hospices

If a hospice chooses to have a combined accreditation and Medicare survey, the Medicare survey would be conducted, followed by the Joint Commission survey Popovich says.

The Community Health Accreditation Program (CHAP) in New York City, should hear an answer on its hospice deemed status application by February, says Kathleen Egan, senior vice president of the organization which surveys about 50 hospices.

CHAP already holds unannounced surveys, which means that aspect will not change under Medicare surveys, Egan says.

However, CHAP-accredited hospices may not have been surveyed, according to Medicare’s Conditions of Participation (COPs) prior to 1997, Egan says. "We re-did the standards in 1997 and included COPs because we were preparing to apply for deemed status in 1998."

An extensive Medicare survey could be a big change for many hospices, because they have been low priorities in many states, Egan suggests. "The biggest problem is going to be within the hospice industry; there has not been regular standard-level HCFA surveys for the last six to seven years."

As a result, the hospice industry has not had the same benefit as other providers, such as home care agencies, and regular surveys where HCFA surveyors provide ongoing education, Egan adds.

Guidelines for survey preparation

Agencies that undergo a deemed status survey will know exactly what type of compliance measures are expected of them. This is important education, since the hospice industry may soon face the same kind of fraud and abuse scrutiny in recent years that has faced home care agencies under Operation Restore Trust, Egan says.

"Because of deemed status surveys, home care agencies learned when they were in compliance and not in compliance, they could correct things in an ongoing sort of way," Egan adds.

Hospices have a third accreditation alternative with the Accreditation Commission for Home Care (ACHC) in Raleigh, NC, which began accrediting hospices a year ago. However, the organization has not yet applied for deemed status, says Tom Cesar, president of the 13-year-old organization.

Whether a hospice prepares for a deemed status survey or a single accreditation survey, there are some basic steps to follow.

Popovich, Egan, and Cesar offer these guidelines for survey preparation:

1. Do your homework.

All three accreditation organizations have manuals that carefully spell out every requirement and expectation. Successful hospices have their staffs study them carefully — point by point. (See advice from three hospices that passed their surveys, p. 3.)

"We list the kinds of evidence that surveyors are going to be looking for to verify compliance," Cesar says of ACHC’s manual. "Our standards are very explicit."

ACHC encourages agencies to copy its standards manual and distribute it to allow staff to focus on different areas."That way, you have an ownership of the process; and two, if you cut up the pie and have more people working on it, they can be thorough," Cesar says.

The CHAP accreditation model looks at four areas:

• structure and function;

• quality;

• resources;

• viability in the long term.

CHAP surveyors will want answers to the following questions:

• What does the structure and function of an organization look like?

• Is it set up to do the task or business of its hospice?

• What does the governing body look like?

• How are they set up financially?

• What are the systems they utilize in terms of quality assurance?

• What is the quality of the level of personnel they bring in to do the job, and do they have specific standards addressing that?

• How do they set up their personnel department?

• How do they track quality-of-care to clients and client satisfaction?

• What kind of data are they collecting, tracking, and analyzing?

• What outcomes measures have they been studying? "We expect to see at least two per program," Egan says. "We ask them to collect meaningful outcome data that has some applicability to their everyday practice; and that is an area that hospices struggle with the most."

2. Pay attention to your contracts.

Hospices need to attend to all of their contracts, including those with pharmaceutical organizations and home medical equipment organizations, Popovich advises."Make sure those contracts specify who does what. This is very important."

Some agencies use contracts with general language that doesn’t identify who performs which tasks or roles. For example, a contract with a medical equipment company might not specify who is supposed to deliver equipment to the patient’s home and exactly what kind of equipment will be provided, Popovich explains.

Even if the hospice employees know the answers to these questions, it should be spelled out in the contract.

3. Complete all necessary staff competency evaluations.

Organizations should make sure their competency tests match employees’ job descriptions, Popovich says. For example, a hospice shouldn’t say that all RNs must be competency-assessed on venipuncture draws if they have some RNs who never do venipuncture draws.

"I might suggest that venipuncture draws should not be high on a list of competency assessments for hospice nurses," Popovich says. "In hospice, you might want to see an RN have good assessment skills in pain management; and if that’s what you want, then you should be testing for them."

The point is, hospices should require competency testing for all staff, including volunteers, who provide direct patient care; and they should do this with a thoughtful approach that considers exactly what their skills should be, Popovich says.

4. Focus on infection control.

Infection control is a common problem area, and it probably always will be, Popovich says."This is real basic in terms of whether something is supposed to be sterile; how do you make sure the sterility is maintained?"

Suppose a nurse is taking care of a patient’s central line, and one of the tasks is to flush the central line. The needle must remain sterile. Yet, Joint Commission surveyors have seen nurses cause a break in sterility and keep on going. "I think there’s a tendency in home care of thinking that the patient’s germs are the patient’s germs," Popovich says.

Dressing changes are another common problem area. The dressing is supposed to remain sterile. When a nurse opens a new four-by-four package, he or she should open it in a way that keeps the package on the bottom so the sterile bandage does not touch the bed linens. "We’ve seen some nurses dump the dressing on linens and then put it on the wound," Popovich says. "We’re seeing some real breaks in sterile technique, and I hope it’s not because hospice nurses think these patients are dying anyway."

Popovich suggests hospices give nurses a refresher course on infection control before the surveys.

5. Do what your policies say.

Surveyors from all three organizations will carefully study each hospice’s rules and standards. Then, they compare the standards to hospice staff’s actions to make sure everyone is in compliance.

"Our surveyors are looking at an organization’s policies and overlapping them with our standards," Cesar says. "Are they doing what they say they’re doing; and are they incorporating our standards within their policies?"


• Tom Cesar, President, Accreditation Commission for Home Care, 3325 Executive Drive, Suite 150, Raleigh, NC 27609. Telephone: (919) 872-8609. Fax: (919) 872-5048. Web site: www.achc.org.

• Kathleen Egan, Senior Vice President, Community Health Accreditation Program, 61 Broadway, New York, NY 10006. Telephone: (800) 669-1656 or (212) 363-5555, ext. 242. Fax: (212) 812-0394. Web site: www.chapinc.org.

• Maryanne Popovich, RN, MPH, Executive Director of Home Care Program, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 916-5742. Web site: www.jcaho.org.