Hospice Forum July 2008
Highlights of Final Hospice CoPs: Implementation Expected in Early December
On May 27, the Centers for Medicare & Medicaid Services (CMS) alerted the National
Association for Home Care & Hospice (NAHC) that the long-awaited Hospice
Conditions of Participation (CoPs) were available publicly. CMS had requested (and
received) a brief extension (see Federal Register, Vol. 73, No. 102, May 27, 2008) of its
May 23 statutory deadline, without which the process for changing the CoPs would have
had to begin anew.
The final CoPs were approved by the Office of Management & Budget (OMB) and sent
to the Federal Register for printing on May 27. The full document is available on-line:
http://www. federalregister.gov/page2.aspx, with an anticipated formal publication date
of June 5. There will be an extended implementation time frame of 180 days from the
date of publication. The anticipated effective date for the new CoPs is December 2, 2008.
NAHC noted that a number of the concerns expressed in its comments on the proposed
CoPs were addressed. However, there are many changes for hospices to embrace, and the
extended implementation time frame will be helpful to hospices nationwide. Following is
a summary of some of the changes in the CoPs of particular note:
Highlights of Changes in the New
Hospice CoPs
Subpart A – Definitions
Section 418.3 is amended by somerevisions and adding definitions:
 Bereavement Counseling. Must be before as well as after the patient’s death;
 Clinical Note. Notation of a patient or family contact;
 Comprehensive Assessment. Thorough evaluation of the patient’s physical,
psychosocial, emotional, and spiritual status;
 Dietary Counseling. May be provided by an RN, dietitian, or nutritionist;
 Initial Assessment. Evaluation of the patient’s status related to the terminal illness
and related conditions;
 Restraint. Any manual method, physical, or mechanical device, material, or
equipment that immobilizes or reduces the patient’s movements, a drug or
medication; and
 Seclusion. Involuntary confinement of a patient alone in an area; patient
physically prevented from leaving.
Subpart C – Patient Care
Section 418.52 Patient’s rights — During the initial assessment, in advance of providing
care, the hospice must provide verbal and written notice of the patient’s rights and
responsibilities in a language and manner that the patient understands. The hospice must
obtain written confirmation of receipt. The requirement in the proposed CoPs to notify
patients of a hospice’s drug policy at initial assessment was removed.
Section 418.54 — Initial and comprehensive assessment of the patient — RN must
complete initial assessment within 48 hours after election of hospice unless the physician,
patient, or representative requests that it be completed in less than 48 hours (expanded
from 24 hours in proposed CoPs). Time frame for completion of the comprehensive
assessment — the IDG (interdisciplinary group) must complete the comprehensive
assessment within five calendar days after election of the benefit (expanded from four
days in proposed CoPs).
Section 418.56 — Interdisciplinary group, care planning, and coordination of services —
The IDG must review and revise the plan of care at least every 15 calendar days (up from
14 in the proposed CoPs).
Section 418.58 — Quality assessment and performance improvement — The hospice
must develop, implement, and maintain an effective, ongoing, hospice-wide data-driven
QAPI program that reflects the complexity of its organization and services, and be able to
demonstrate its operation to CMS. Two hundred and forty days after publication of the
final rule (effective early February 2009), hospices must develop, implement, and
evaluate performance improvement projects.
Section 418.60 — Infection control — An infection control program is required.
Section 418.64 — Core services — Dietary counseling must be performed by a qualified
individual including dietitians as well as nurses and other individuals able to assure
dietary needs are met.
Section 418.76 — Hospice aide and homemaker services — Aides are now referred to as
hospice aides rather than home health aides. An RN must make a supervisory visit at least
every 14 days (aide need not be present), and an annual on-site visit to assess each aide
while performing care (the proposed CoPs required an on-site assessment every 28 days).
Subpart D – Organizational Environment
Section 418.102 – Medical director — The medical director has the responsibility for the
medical component of the hospice’s patient care program, but will not be required to
direct the hospice’s QAPI program (a change from the proposed CoPs).
Section 418.106 – Drugs and biologicals, medical supplies, and durable medical
equipment — The IDG must confer with an individual with education and training in
drug management, as defined in hospice policies and procedures and state law, who is an
employee or under contract with the hospice. Hospices must have written policies and
procedures for the management and disposal of controlled drugs in the patient’s home;
hospices must provide a written copy to the patient and family at the time controlled
drugs are first ordered and discuss the policies with the patient/family.
Section 418.108 – Short-term inpatient care – The requirement for 24-hour nursing care
is still required for the inpatient general level of care, but not for the inpatient respite
level of care. However, if a patient develops a need for an RN while in the inpatient
respite setting, a hospice must be able to meet that need, either with an RN employee on
call or through arrangements with the facility. There is a listing of specific requirements
for inpatient care provided under arrangements that must be included in a hospice’s
contract with an inpatient facility.
Section 418.110 – Hospices that provide inpatient care directly — A new standard has
been added with regard to restraint and seclusion giving very specific directions on its use
to bring the hospice CoPs more in line with those of other Medicare facility providers.
Section 418.112 – Hospices that provide care to residents of a SNF/NF or ICF/MR –
Additional standards have been added with very specific language on the responsibilities
of the hospice and facility. CMS has related to NAHC that the same language
requirements will be included in the SNF/NF CoPs.
Section 418.114 – Personnel qualifications — The greatest controversy here was the
educational requirements for a hospice social worker. The new CoPs state that a social
worker must have: a master of social work (MSW), degree from a school of social work
accredited by the Council on Social Work Education, or a baccalaureate degree in social
work (BSW) from an institution accredited by the Council, or a baccalaureate degree in
psychology, sociology, or other field related to social work; be supervised by an MSW;
and have one year of social work experience in a health care setting. A BSW employed
by a hospice before effective date of the final rule (early December 2008) will not require
supervision of an MSW.
Section 418.114 (d) Standard – Criminal background checks will be required for all
employees who have direct patient contact or access to patient records. Hospice contracts
must require contracting entity to obtain background checks for all personnel with similar
duties. Checks must be obtained in accordance with state requirements. Absent state
requirements, checks must be obtained within three months of the date of employment for
all states that the individual has lived or worked in the past three years.
NAHC is working on additional materials to aid hospices in planning to meet the
requirements of the new CoPs. Additionally, NAHC hosted a teleconference focusing on
the new CoPs on June 25 that was presented by the staffers at CMS responsible for
rewriting the CoPs and training surveyors on the new requirements.