Every regulatory scheme seems to hinge on provider policies and procedures. The revised Medicare Conditions of Participation (COPs) for hospice providers are no different. In last month’s inaugural issue of Hospice Endnotes, we wrote about contract considerations under the COPs. This month we discuss policies and procedures required by the COPs.

The revised COPs require hospices to have in place certain designated policies and procedures. The list below includes those policies and procedures that are specifically required under the Final Rule, and that will likely be requested and reviewed by surveyors during annual recertification and/or complaint surveys. This list is not necessarily exhaustive since providers may choose to have other policies and procedures, based on operational issues or other considerations. But the list below identifies those that are specifically called for by the revised COPs:
 

• 418.52(a)(2)    Policies on advance directives.
• 418.52(b)(4)(ii)    Policies on investigating allegations of abuse, neglect and misappropriation of property.
• 418.56(a)(2)    Policies governing the day-to-day provision of hospice care and services.
• 418.56(c)(6)    Policies governing the documentation of the patient’s or representative’s understanding of, involvement in and agreement with the plan of care.
• 418.56(e)    Policies concerning the hospice’s system for communication and integration of services including the IDG coordination and supervision of care and services, the provision of care and services in accordance with the plan of care and based on assessments of the patient and family, sharing of information between all disciplines in all settings, and sharing of information with non-hospice providers furnishing services unrelated to the hospice diagnosis.
• 418.62(a)   Licensed professional services must be provided by professionals who practice under hospice policies and procedures.
• 418.76(g)(4)   Policies concerning hospice aide documentation and record keeping requirements.
• 418.76(h)(3)(iv)   Infection control policies. (See also 18.60.)
• 418.100(g)(3)   Policies describing methods of assessment of competency
• 418.104(b)   Policies describing authentication of medical records.
• 418.104(d)   Policies regarding record retention and storage if the hospice ceases to operate.
• 418.106(a)(1)    Policies addressing IDG consultation with an individual with education and training in drug management.
• 418.106(c)(2)(i)    Policies that promote dispensing accuracy in hospice inpatient facilities.
• 418.106(e)(2)    Policies for the management and disposal of controlled drugs in the patient’s home.
• 418.106(e)(2)(ii)    Policies for the management and disposal of controlled drugs in the hospice inpatient facility.
• 418.106(f)(1)    Policies regarding repair and maintenance of equipment (in the absence of manufacturer’s guidelines).
• 418.110(c)(1)(ii)    Hospices that provide inpatient care directly must have a written disaster plan.
• 418.110(c)(2)    Policies for controlling the reliability and quality of storage and disposal of trash and medical waste; light, temperature and ventilation control; emergency gas and water supply; and scheduled and emergency equipment maintenance and repair (inpatient facilities).
• 418.110(m)(3)(ii)    Policies for safe and appropriate restraint and seclusion techniques (inpatient facilities).
• 418.110(m)(4)    Policies to authorize physicians to order restraints or seclusion (inpatient facilities). 
• 418.110(m)(7)(ii)    Policies for restraint renewal for nonviolent patients (inpatient facilities).
• 418.110(m)(9)    Policies for monitoring the condition of the restrained or secluded patient (inpatient facilities).
• 418.110(m)(10)    Policies for physician training requirements for restraints (inpatient facilities).
• 418.110(n)(1)(iii)    Policies for restraint training intervals (inpatient facilities).
• 418.110(n)(2)(vi)    Policies for monitoring the restrained patient’s condition associated with the one-hour face-to-face evaluations (inpatient facilities).
• 418.112(f)    Policies regarding methods of comfort, pain control and symptom management.
  

All certified hospice providers should review their existing policies and procedures to determine if they are sufficient under the revised COPs. In some cases, providers may need to develop additional policies and/or revise existing ones. In doing that, remember that the policies should be a) clear; b) comprehensive; and c) something agency employees can follow day in and day out. Overly complex policies and procedures create confusion and become sources of liability for providers in terms of both regulatory noncompliance and civil lawsuits. Failure to follow your own policies is often a key component in both types of legal proceedings.

It is also important to demonstrate to the surveyors that your staff is aware of, and has been trained on, your policies and procedures. You should maintain a written description of the in-service training that has been provided during at least the previous twelve months. We also suggest that in-service records be kept from the date of your last survey, and for at least a rolling twelve-month period after that. Your in-service records should include a detailed description of the content, the names and signatures of those in attendance, the name(s) and qualifications of the trainer(s), and the date of the in-service training. You should also revisit your HIPAA policies and procedures since the revised COPs require hospices to comply with the provisions of the HIPAA Privacy and Security Rule.

Finally, remember that policies and procedures are not the same thing as a training manual. Overloading agency policies with information that is more appropriate for staff training manuals makes them overly complex and difficult to apply and follow. In most cases, the regulations tell you what should be addressed in your policies and procedures. Other information that may be really helpful to your staff should be placed in training manuals and materials.