HCFA Informational
Releases: #2000-12, Questions and Answers regarding Hospices
#2000-16, Change of Ownership, Merger, and Termination Procedures
Affecting HHAs and OASIS Requirements
PDF Version of BQA 00-050
- (PDF, 21 KB)
Date: July 17, 2000 -- DSL-BQA-00-050
To: Home Health Agencies HHA 16,
Hospices HSPCE 19 From: Otis Woods, Section Chief, Health Services Section
via: Susan Schroeder, Director, Bureau of Quality Assurance
Attached [see below] are two informational releases from HCFA, sent to the
Bureau of Quality Assurance (BQA) as Electronic Regional Program Letters. BQA is
forwarding them to you for your information.
If you have further questions about #2000-12, Question and
Answers regarding Hospices, you may contact:
- Barbara Woodford, Nurse Consultant, Provider Regulation and Quality
Improvement Section (PRQI) (replaced by Marianne
Missfeldt, (715) 836-4036).
- Juan Flores, Supervisor, Southern Team, Health Services Section (HSS) (replaced by Cremear Mims, (414) 227-4556.
- Jane Walters, Supervisor, Northern Team, Health Services Section (HSS) (replaced by Jan Heimbruch, (608) 243-2086).
If you have further questions about #2000-16, Change of
Ownership, Merger, and Termination Procedures Affecting Home Health Agencies (HHAs) and
Outcome and Assessment Information Set (OASIS) Requirements, you may contact:
Karen Turnure, PRQI Licensing/Certfication Leadworker, at (608)
266-7782.
Andrea Henrich, OASIS Education Coordinator, PRQI, at (608) 267-3807.
HEALTH CARE FINANCING ADMINISTRATION
Chicago Regional Office, Midwest Consortium
Electronic Regional Program Letter #2000-12
DATE: April 26, 2000
FROM: HCFA, Chicago Regional Office, Division of Survey and Certification
SUBJECT: Questions and Answers regarding Hospices - INFORMATION
TO: State Survey Agency Directors
The purpose of this memorandum is to inform you that HCFA recently provided the
following answers in response to questions submitted from the Hospice Association of
America at the National Association for Home Care’s Policy Conference on April 3rd.
We are including them for your files.
1. Q. Have there been any changes in the Skilled Nursing Facility/Nursing Facility
(SNF/NF) regulations this year or current problems that hospice programs should be aware
of in providing hospice services to residents of long term care ( LTC) facilities?
1. A. There have been no changes to the SNF/NF requirements at 42 CFR 483(ff) this
year. However, we remain concerned about the care that some residents who elect the
hospice benefit are receiving.
We added guidance to surveyors of LTC facilities several years ago that mirrors the
guidance we have for hospice surveyors. Specifically, the State Operations
Manual (SOM) for LTC surveyors states that surveyors will review the care of a resident receiving
hospice care. When a facility resident has elected the Medicare hospice benefit, the
hospice and the nursing facility must communicate, establish, and agree upon a coordinated
plan of care for both providers which reflects the hospice philosophy, and is based on an
assessment of the individual’s needs and unique living situation in the facility.
Surveyor’s major concerns with hospice care in the LTC facility include the
following:
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The provision of care and services which does not reflect the hospice
philosophy.
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Problems with the coordination, delivery and review of the plan of care
between the hospice and the LTC facility.
-
Ineffective systems in place to monitor/assure that the plan of care is meeting the
resident’s needs in the area of pain management and symptom control.
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Poor communication between the hospice and nursing home staff:
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nursing home staff are often not aware of the hospice philosophy;
-
plan
of care does not reflect the hospice philosophy or adequately address pain management and
symptom control; and
-
hospice and LTC staff do not communicate problems encountered with the pain management
assessments and make needed revisions to the plan of care in an effective and timely
manner.
2. Q. If a hospice program has adopted the National Hospice Organization’s
(NHO) standards of care, which state that the hospice social worker is an MSW and the
hospice program has employed a BSW, can the hospice be cited?
2. A. We expect that hospices will develop their policies and procedures, and we expect
that they will follow them. The Federal requirement for a social worker is for a BSW,
which is less stringent than the NHO standards. So the hospice is in compliance with the
Federal requirement for social work, but the larger issue surrounds the hospice’s
failure to follow its own policies/standards. If the hospice tells the surveyor that their
policy follows the NHO standards for an MSW and the surveyor discovers that this is not
true, it is a finding.
Surveyors will look at the total picture during a survey and observe the hospice’s
total operations. They will also review their survey "findings." This particular
finding could in fact lead to a citation under the governing body--which is charged with
assuming responsibility for determining, implementing and monitoring the hospice’s
policies.
3. Q. What are the top ten survey problems?
3. A. The ten most frequently cited tags include regulations pertaining to the
development and updating of the plan of care and required records:
- L137 - Plan states scope and frequency of services needed - 16.18%
- L136 - Plan
includes assessment of individual needs - 14.07%
- L135 - Plan is reviewed and updated at intervals - 12.01%
- L134 - Plan established prior to providing care - 10.74%
- L210 - RN visits the home site at least every 2 weeks - 9.07%
- L133 - Written plan of care established - 8.94%
- L200 - Plan of care for bereavement service - 7.67%
- L209 - Home health aide and homemaker services available - 6.97%
- L211 - RN prepares written instructions for home health aide - 6.40%
- L185 - Record contains documentation of all services - 6.36%
4. Q. A hospice program is admitting patients and awaiting their initial survey.
Should the hospice program have these patients sign a Medicare benefit election statement
during the admission process even though the hospice is not certified to offer the
Medicare benefit at that time?
4. A. No. The Medicare beneficiary can only elect hospice from a Medicare approved
hospice. A hospice awaiting its initial survey is not Medicare approved.
5. Q. During an initial hospice survey the hospice program was told that "your
program is responsible for paying for all of the medications for the hospice
patients". Is that correct?
5. A. Until a hospice is Medicare approved; it would not be expected to pay for the
required drugs for Medicare beneficiaries. We would also like to note that the condition
of participation at 42 CFR 418.56 requires the Medicare approved hospice to maintain
professional management responsibility for the services it provides under arrangement. The
standard at 42 CFR 418.56(d) requires the hospice to retain responsibility for payment for
those services. A Medicare approved hospice is reimbursed for all covered services it
provides, whether directly or under arrangement. It is the responsibility of the hospice
to pay for those services provided to Medicare beneficiaries under arrangement. When a
hospice provides services under arrangements to non-Medicare beneficiaries, the hospice is
responsible for establishing how payment for those services will occur, but the standard
does not require the hospice to pay for those services directly or to pay for services for
which there is no reimbursement or for which another insurer is obligated to pay.
6. Q. A three program agency (HHA/hospice/ private pay) provides services in a several
hundred square mile rural area. Can this agency share its staff to cover on-call service
for all three programs?
6. A. If the staff are all employed by one corporation or organization, and that
organization is responsible for issuing the W2 form on their behalf, employees could
divide work time between the parent organization and the hospice or HHA if they were also
appropriately trained to do the work. The hospice and the HHA need to maintain a record of
the individual's assigned time to each program. However, if these "corporate"
employees provide services to the HHA or hospice outside of their own usual working hours
or shifts (i.e., "moonlight" as HHA or hospice employees, as opposed to working
overtime for the corporation,) they would be considered contract employees and would not
meet the core service requirement for hospice or the direct service requirement for HHAs.
7. Q. Can an HHA and hospice use contract nurses to staff the agency’s on-call
needs if the contract nurse is functioning in the role of "answering service
only" for hospice calls?
7. A. A hospice cannot use a contract nurse unless it is to meet the needs of patients
during periods of peak patient loads or under extraordinary circumstances (e.g., half the
nursing staff is out with the flu.) These circumstances are unexpected and for a finite
period of time.
An HHA may use contract nurses if nursing is not the one service that it provides in
its entirety directly by its own employees.
8. Q. A Medicare hospice patient is receiving support service through the State's home
and community-based care (HCBC) program. The services are for home health aides for
personal care and related support. Currently, the state HCBC programs nurses are approving
the delivery of this care, through the waiver program. Is this double-dipping?
8. A. States have often argued that providing personal care services is duplicative to
the home health aide and homemaker services that must be provided under the hospice
benefit. The hospice is required by federal regulation to provide the home health aide and
homemaker services in an amount that is adequate to meet the needs of the patient. These
needs are determined by the hospice interdisciplinary team and should be noted and a part
of the plan of care provided by the hospice.
To prevent duplication of services, it is up to the State to define the Medicaid
personal care services option benefit and to determine if the benefit is more extensive
than the homemaker/ home health aide benefit provided under the Medicare hospice benefit.
If the personal care benefit is more extensive than what is offered under the Medicaid
hospice benefit, then the State must pay for these services when a need for such services
is indicated in the hospice patient’s plan of care.
9. Q. Over the years a variety of clarification memos have been released, how and where
can a new hospice program access this information so they can provide the correct
information when issues arise during a survey.
9. A. We have developed a web site specifically for hospice material related to survey
and certification issues. This site contains our recent memos, frequently asked questions,
as well as links to the regulations and State Operations Manual. This web site can be
accessed at www.hcfa.gov/medicaid/hospice/hospice.htm
(exit DHFS) [address updated].
If you have any questions about this, please contact your Principal Program
Representative.
/s/ -- Charles Bennett, Branch Manager,
Survey and Certification Program,
Coordination and Improvement
HEALTH CARE FINANCING ADMINISTRATION
Chicago Regional Office, Midwest Consortium
Electronic Regional Program Letter #2000-16
DATE: June 5, 2000
FROM: HCFA, Chicago Regional Office, Division of Survey and Certification
SUBJECT: Change of Ownership, Merger, and Termination Procedures Affecting Home
Health Agencies (HHAs) and Outcome and Assessment Information Set (OASIS) Requirements
-INFORMATION
TO: State Survey Agency Directors
The purpose of this regional letter is to provide oversight guidance for OASIS
implementation in three situations: where an HHA undergoes a change of ownership with a
merger of two or more agencies; where there is a change of ownership with and without
assignment of the seller’s provider agreement; and where there is termination of the
provider agreement.
As part of Health Care Financing Administration’s (HCFA) effort to achieve
broad-based improvements in quality of care furnished by HHAs through Federal programs,
OASIS is one of the most important aspects of the HHA’s quality assessment and
quality improvement efforts. The OASIS will assist agencies in improving their performance
through quality of care determinations which are expected to be provided in Outcome-based
Quality Improvement (OBQI) reports currently under development. As the individual patient
assessments are linked to the individual HHA by their provider number, the OBQI reports
will also be linked to the individual HHA by the provider number.
It is imperative that the provider number be accurately reported on the OASIS
assessments in all reports, including when HHAs undergo change of ownership, merger, or
termination.
Change of Ownership - Mergers
In accordance with 42 CFR Part 489.18 and SOM 3210, the merger of a provider
corporation into another corporation constitutes a change of ownership. In the case of the
merger of Agency A into Agency B, Agency A’s provider agreement and its associated
provider number are terminated. Agency B retains its existing provider agreement and
provider number.
Agency A should provide the OASIS discharge comprehensive assessment for each
discharged patient prior to or at the effective date of the merger. The surviving HHA
(Agency B) should provide a Start of Care (SOC) comprehensive assessment for all persons
it admits after the merger at the next skilled visit after the official merger date. The
SOC assessment will allow eligibility for the home health benefit to be verified and care
planning for the individual to proceed under Agency B. Subsequently, the assessments for
all individuals being accepted for care by Agency B will be linked to the correct provider
number to enable the agency to engage in quality improvement efforts with accurate OBQI
reports.
Change of Ownership with Assignment
In accordance with 42 CFR Part 489.18 and SOM 3210, when there is a change in ownership
and the new owner accepts assignment of the existing provider agreement, the new owner is
subject to all the terms and conditions under which the existing agreement was issued,
including compliance with the comprehensive assessment of patients condition of
participation. The provider number remains the same if the new HHA owner accepts
assignment of the existing provider agreement. The new owner is responsible for continuing
to complete updates to the comprehensive assessment at the next scheduled time points.
Change of Ownership without Assignment
In accordance with 42 CFR Part 489.18 and SOM 3210, when there is change of ownership
and the new owner rejects this assignment of the provider agreement, the provider
agreement and provider number of the former owner should be terminated. The HHA that is
terminating its provider agreement and provider number should provide an OASIS discharge
comprehensive assessment for each patient subject to OASIS standards prior to the
effective date of the termination, according to 42 CFR 484. The new HHA will not be able
to participate in the Medicare program without going through the same process as any new
provider, which includes an initial survey. The HHA should meet all the Federal
requirements, including applicable OASIS requirements as specified in the regulations, for
all persons it accepts for care in order to participate in the Medicare program. This
means that the HHA should provide a new SOC comprehensive assessment at the first skilled
visit once it becomes Medicare-approved. In addition, updates to the comprehensive
assessment should be provided at the other OASIS time points, in accordance with 42 CFR
Part 484, for all patients of the former owner it accepts for care.
Voluntary Terminations
In accordance with 42 CFR Part 489.52 and SOM 3046, a Medicare approved HHA may
voluntarily terminate its provider agreement by filing a written notice of its intention
to the State Agency who, in turn, notifies the Regional Office. HCFA recommends the HHA
that is terminating its provider agreement should provide a discharge comprehensive
assessment for each patient prior to the effective date of the termination.
Involuntary Terminations
The Regional Office may terminate an agreement with an HHA, in accordance with 42 CFR
489.53. HCFA will work with the HHA on a case-by-case basis to provide for the safe and
orderly transfer of patients to another Medicare-approved HHA if appropriate.
The agency to whom the patients are transferred should provide a new SOC comprehensive
assessment as well as updates to the comprehensive assessment at the other OASIS time
points.
The guidance and recommendations provided in this memorandum apply to all accredited
HHAs that participate in Medicare and to HHAs that are required to meet the Medicare
Conditions of Participation, including Medicaid HHAs.
If you have any questions or concerns about this regional program letter, please
contact me.
/s/ -- Charles Bennett, Branch Manager,
Survey and Certification Program,
Coordination and Improvement
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