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The following text is public information being presented here
at the Hospice Patients Alliance website to help the public
access this information. It is copied directly from the U.S.
Health Care Financing Administration (HCFA) website and is
entitled the "State Operations Manual" Section 2080 for
hospice regulations and is from: http://medicare.hcfa.gov/medicaid/hospice/hospice.htm.
HCFA administers the Medicare program for the federal government
and enforces regulations governing hospice via State operated
licensing and certification divisions, as well as through its own
division of investigations and enforcement. Guidelines contained
in HCFA manuals are used by State and HCFA
investigators/surveyors in inspecting hospices to determine if
the hospice complies with the Standards of Care and Conditions of
Participation ("CoPs")
Transmittal No. 265 December 1994, HCFA-Pub 7: Hospice Sections
2080 - 2087
CHAPTER 2
THE CERTIFICATION PROCESS
Hospices
Hospice - Citations and Description 2080
Hospice - Multiple Locations 2081
Election of Hospice Benefit by Resident of a SNF, NF, ICF/MR, or
Non-Certified Facility 2082
Hospice Regulations and Non-Medicare Patients 2083
Hospice Inpatient Services Furnished Directly or Furnished Under
Arrangements 2084
Operation of a Hospice Across State Lines 2085
Hospice Home Visits 2086
Compliance With Advance Directives 2087
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2080 THE CERTIFICATION PROCESS 03-98
Hospices
2080. HOSPICE - CITATIONS AND DESCRIPTION
A. Citations.--Section 1861(u) of the Act created hospices as a
provider category. Section 1861(dd) of the Act defines hospice
care and the hospice program. 42 CFR 418 sets forth the CoPs. 42
CFR Part 418.100 is an additional Condition applicable only to
hospices that provide short-term inpatient care and respite care
directly, rather than under arrangements with other participating
providers. Section 1866(a)(1)(Q) of the Act, as added by
§4206(a)(1)(C) of OBRA 1990, P.L. Number 101-508, requires
hospices, among other providers, to file an agreement with the
Secretary to comply with the requirements found in §1866 of
the Act regarding advance directives.
B. Description.--Hospice care is an approach to caring for
terminally ill individuals that stresses palliative care (relief
of pain and uncomfortable symptoms), as opposed to curative care.
In addition to meeting the patient's medical needs, hospice
care addresses the physical, psychosocial, and spiritual needs of
the patient, as well as the psychosocial needs of the
patient's family/caregiver. The emphasis of the hospice
program is on keeping the hospice patient at home with family and
friends as long as possible.
Although some hospices are located in hospitals, SNFs, and HHAs,
hospices must meet specific CoPs and be separately certified and
approved for Medicare participation. (See Exhibit 129 for Hospice
Survey and Deficiencies Report, Form HCFA-643 and Exhibit 72 for
Hospice Request for Certification in the Medicare Program, Form
HCFA-417.)
C. Services and Items Provided.--Substantially all core services
must be provided directly by hospice employees on a routine
basis. A hospice may use contracted staff for core services only
under extraordinary circumstances (i.e., to supplement hospice
employees in order to meet patients' needs during periods of
peak patient load.) If contracting is used, the hospice must
continue to maintain professional, financial, and administrative
responsibility for the services. The following are hospice core
services and must be provided directly by hospice employees:
o Nursing care provided by or under the supervision of an RN
functioning within a medically approved plan of care;
o Medical social services under the direction of a physician;
o Physician's services; and
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o Counseling (including dietary and bereavement counseling) with
respect to care of the terminally ill individual and adjustment
to death. When included in the patient's written plan of
care, the following services must be available as needed and
provided by the hospice, either directly or under arrangements
made by the hospice:
o Physical and occupational therapy and speech-language
pathology services;
o Home health aide services. A home health aide employed by a
hospice, either directly or under a contract, must meet the
personnel qualifications specified in 42 CFR Part 484.4 for
"home health aide" and must meet all the training,
attitude, and skill requirements for a home health aide working
in an HHA, as specified in 42 CFR Part 484.36;
2-32 Rev. 1
03-98 THE CERTIFICATION PROCESS 2081
o Homemaker services;
o Medical supplies (including drugs and biologicals) and the use
of medical appliances related to the terminal diagnosis;
o Short-term inpatient care (including both respite care and
procedures necessary for pain control and acute and chronic
symptom management) in a Medicare/Medicaid approved inpatient
facility; and
o Continuous home care provided for a period of 8 or more hours
in a day during a period of crisis, and only as necessary to
maintain the patient at home. It consists predominantly of
nursing care, but may also include homemaker services, home
health aide services, and other disciplines.
In addition, the statute stipulates other specific requirements
including a limitation on the proportion of inpatient days for
hospice patients and a prohibition against discontinuing or
diminishing services for Medicare beneficiaries unable to pay for
hospice care.
Hospices must maintain professional management and financial
responsibility for services provided under arrangements,
regardless of the location or facility in which such services are
furnished. If a hospice is established by an entity which
participates in the Medicare program as another type of provider
(hospital, SNF, HHA), the SA should attempt to coordinate
simultaneous certification surveys of these entities, i.e., for
compliance with hospice CoPs and for compliance with the other
appropriate
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CoPs.
NOTE: Section 1861(dd)(4)(A) of the Act states that if a hospice
is approved as being part of another type of provider, with a
separate provider number, it shall be considered to meet those
CoPs that are common to both the hospice and the other type of
provider.
2081. HOSPICE - MULTIPLE LOCATIONS
Neither the statute nor the hospice regulations provides for
establishing hospice "satellite" offices. Nonetheless,
a hospice is not precluded from providing services at more than
one location if certain requirements assuring quality of care are
met and these locations are approved by the RO. The RO, in order
to support HCFA’s responsibility to protect the Medicare
trust fund against excessive and unnecessary costs, will also
ensure that the locations promote cost effective health care.
This includes reimbursing hospices at a rate that has been
established for the local area. The RO will make a final
determination on both quality and cost effectiveness issues with
the assistance of the State agency and the fiscal intermediary,
if necessary, and will notify all parties of its decision.
To support our concern for quality, HCFA requires a hospice who
provides services at more than one location, to comply with the
following:
o The hospice must be able to exert the supervision and control
necessary at each location to assure that all hospice care and
services continue to be responsive to the needs of the
patient/family at all times and in all settings. Hospice care
requires the closest of interventions and a distant
“parent” cannot provide the immediate access needed
to ensure health and safety.
o Each location must provide the same full range of services
that is required of the hospice issued the provider number;
o Each location must be responsible to the same governing body
and central administration that governs the hospice issued the
provider number, and the governing body and central
administration must be able to adequately manage the location and
assure quality of care at the location;
and
Rev. 1 2-33
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2081 (Cont.) THE CERTIFICATION PROCESS 03-98
o All hospice patients' clinical records requested by the
surveyor must be available at the hospice site issued the
provider number. If a proposed hospice location does not meet the
above criteria for quality and cost effectiveness, it must seek
Medicare approval as a separate hospice with its own provider
agreement and provider number.
If the hospice does operate at multiple locations, a deficiency
found at any location will result in a compliance issue for the
entire hospice.
2082. ELECTION OF HOSPICE BENEFIT BY RESIDENT OF SNF, NF,
ICF/MR, OR NON-CERTIFIED FACILITY
There is no indication in the statute that the term
"home" is to be limited for a hospice patient. A
patient's home is where he or she resides. A hospice may
furnish routine or continuous home care to a Medicare beneficiary
who resides in a SNF, NF, ICF/MR, or any residence or facility
not certified by Medicare or Medicaid. The facility is considered
to be the beneficiary's place of residence (the same as a
house or apartment), and the facility resident may elect the
hospice benefit if he/she also meets the hospice eligibility
criteria. The hospice then assumes full responsibility for
professional management of the individual's hospice care in
accordance with the hospice CoPs and makes any arrangements
necessary for inpatient care in a participating Medicare or
Medicaid facility.
A. Compliance With SNF/NF CoPs.--The SNF/NF CoPs are applicable
to all of the residents in a SNF/NF facility. Neither the statute
nor the regulations setting out SNF/NF requirements exempt
hospice patients in a SNF/NF from those regulations. Sections
1819(c)(4) and 1919(c)(4) provide that a SNF or NF must
"establish and maintain identical policies and
practices" regarding transfer, discharge, and the provision
of covered services under Medicare or Medicaid "for all
individuals regardless of source of payment."
Sections 1819 and 1919 of the Act set forth requirements for
SNFs and NFs to ensure that these facilities provide quality care
and services to their residents. Even though the SNF/NF is the
hospice patient's residence for purposes of the hospice
benefit, the SNF/NF must still comply with all SNF/NF
Requirements for participation in Medicare or Medicaid. This
means that the resident must be assessed using the information
contained in the Resident Assessment Instrument (RAI) (which
includes both the Minimum Data Set (MDS) and the Resident
Assessment Protocols (RAPs)), have a plan of care, which, in this
case, will be jointly developed with and agreed upon by the
hospice, and be provided with all services contained in the plan
of care. The plan of care must be consistent with the hospice
philosophy of care. When a resident of a Medicare/Medicaid
participating SNF/NF elects the Medicare hospice benefit, the
hospice and the SNF/NF must communicate, establish, and agree
upon a coordinated plan of care
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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 SNF/NF. The plan of care must be written
in accordance with 42 CFR Part 418.58 and include the
individual's current medical, physical, psychosocial, and
spiritual needs. The hospice must designate an RN from the
hospice to coordinate the implementation of the plan of care.
(See 42 CFR 418.68(d).)
This coordinated plan of care must identify the care and
services which the SNF/NF and hospice will provide in order to be
responsive to the unique needs of the patient/resident and
his/her expressed desire for hospice care. The plan of care must
include directives for managing pain and other uncomfortable
symptoms and be revised and updated as necessary to reflect the
individual's current status.
2-34 Rev. 1
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03-98 THE CERTIFICATION PROCESS 2082 (Cont.)
The SNF/NF and the hospice are responsible for performing each
of their respective functions which have been agreed upon and
included in the plan of care. The hospice retains overall
professional management responsibility for directing the
implementation of the plan of care. In addition:
o All covered hospice services must be available as necessary to
meet the needs of the patient;
o Substantially all core services must be routinely provided
directly by hospice employees and cannot be delegated to the
SNF/NF. (See 42 CFR Part 418.80);
o Drugs and medical supplies must be provided as needed for the
palliation and management of the terminal illness and related
conditions. Drugs must be furnished in accordance with accepted
professional standards of practice. (See 42 CFR Part
§418.96); and
o The plan of care should reflect the participation of the
hospice, SNF/NF, and the patient to the extent possible. The
hospice and the SNF/NF must communicate with each other when any
changes are indicated to the plan of care, and each provider must
be aware of the other's responsibilities in implementing the
plan of care.
Evidence of this coordinated plan of care must be present in the
clinical records of both providers. All aspects of the plan of
care should reflect the hospice philosophy.
The SNF/NF services must be consistent with the plan of care
developed in coordination with the hospice. The hospice patient
residing in a SNF/NF should not experience any lack of SNF/NF
services or personal care because of his/her status as a hospice
patient. The plan of care must include directives for managing
pain and other uncomfortable symptoms and be revised and updated
as necessary to reflect the individual's current status. The
SNF/NF must offer the same services to its residents who have
elected the hospice benefit as it furnishes to its residents who
have not elected the hospice benefit. The patient/resident has
the right to refuse any services.
B. Professional Management.--The use of the term
"professional management" for a hospice patient who
resides in a SNF/NF should have the same meaning to a hospice
that it would have if the hospice patient were living in his/her
own home. The professional services usually provided by the
hospice to the patient in his/her home should continue to be
provided by the hospice to the resident in a SNF, NF, or other
place of residence. This includes furnishing any necessary
medical services to those patients that the hospice would
normally furnish to patients in their homes. In addition,
substantially all hospice core services (physician services,
nursing services, medical social services, and counseling) must
be routinely provided directly by hospice employees and cannot be
delegated. The hospice may involve the SNF/NF nursing personnel
in assisting with the administration of prescribed therapies
included in the plan of care only to the extent that the hospice
would routinely utilize the services of a hospice patient's
family/caregiver in implementing the plan of care. (For example,
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SNF/NF staff who are permitted by the facility and by law may
assist in the administration of medication as established by the
plan of care developed by the hospice interdisciplinary group
(IDG), in coordination with the SNF/NF.)
C. Provision of Non-Core Services To SNF/NF Residents.--The
hospice may arrange to have non-core hospice services provided by
the SNF/NF if the hospice assumes professional management
responsibility for these services and assures that these services
are performed in accordance with the policies of the hospice and
the patient's plan of care. (See 42 CFR Part §418.56.)
Rev. 1 2-35
2082 (Cont.) THE CERTIFICATION PROCESS 03-98
D. SNF/NF Residents and Dually-Eligible Beneficiaries.--A
Medicare beneficiary who resides in a SNF/NF may elect the
hospice benefit when the residential care is paid for by the
beneficiary.
A Medicare beneficiary who is also eligible for Medicaid and
whose NF care is being paid for by Medicaid may also elect the
Medicare hospice benefit if the hospice and the facility have a
written agreement under which the hospice takes full
responsibility for the professional management of the
individual's hospice care and the facility agrees to provide
room and board to the individual. The hospice patient must remain
in a Medicaid certified bed while residing in the NF. The SMA
pays the hospice the amount determined as payment for room and
board while the patient is receiving hospice care, and the
hospice pays the facility. Room and board services include:
o Performing personal care services;
o Assisting with activities of daily living;
o Administering medication;
o Socializing activities;
o Maintaining the cleanliness of a resident's room; and
o Supervising and assisting in the use of DME and prescribed
therapies.
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In States that offer the Medicaid hospice benefit, and an
individual is eligible for Medicare as well as Medicaid, the
hospice benefit must be elected or revoked under both programs,
and each program notified as to the patient's decision.
2083. HOSPICE REGULATIONS AND NON-MEDICARE PATIENTS
The hospice CoPs apply to all patients of the hospice (Medicare
and non-Medicare), with the exception of the following
regulations, which apply only to Medicare beneficiaries:
42 CFR Part 418.60 - the continuation of care requirement; and
42 CFR Part 418.98(c) - the 80-20 inpatient care limitation.
2084. HOSPICE INPATIENT SERVICES FURNISHED DIRECTLY OR FURNISHED
UNDER ARRANGEMENTS
Hospices must make inpatient care available for pain control,
symptom management, and respite purposes. This inpatient care may
be provided directly by the hospice, or indirectly under
arrangements made by the hospice. If services are provided under
arrangements, the hospice must ensure that the services are in
full compliance with all applicable standards relating to
inpatient care.
A. Hospice Provides Inpatient Care Directly.--If a hospice
provides inpatient care directly, either in owned or leased space
in another facility, the inpatient location must be surveyed for
compliance with 42 CFR Part 418.100. The leased inpatient unit
may consist of several beds, a group of beds, or a wing.
2-36 Rev. 1
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03-98 THE CERTIFICATION PROCESS 2084 (Cont.)
B. Hospice Provides Inpatient Services Under Arrangements.--When
inpatient services are being provided under arrangements with a
Medicare participating hospital or SNF, a Medicaid participating
NF (for respite care only), or an inpatient unit of another
hospice, a separate survey of each site is not required. In these
cases, the SA reviews the agreement and patient files to assure
that standards in 42 CFR Part 418.100(a) (24-hour nursing
service) and (e) (comfort and privacy of patient and family
members) are satisfied. However, if in reviewing contracts and
other documentation (e.g., clinical records, plans of care),
questions arise concerning the contract arrangements, the SA
conducts an onsite visit to the institution providing the
inpatient services. This includes hospitals that are accredited
by the The Joint Commission or AOA that are providing inpatient services under
arrangements.
C. Hospice Provides Inpatient Services in Space Shared With
Medicare-Approved Hospital or SNF at Same Location.--When
inpatient services are provided at a location also approved as a
SNF or hospital (dual or multiple certification), the SA inspects
for compliance with 42 CFR Part 418.100(a) and (e).
APPLICABILITY OF INPATIENT CARE CoP 42 CFR Part 418.100
LOCATION WHERE INPATIENT CARE IS APPLICABILITY OF CONDITION
PROVIDED
Hospice inpatient unit Survey for compliance with 42 CFR Part
418.100. Medicare-approved hospital or Survey for compliance with
42 CFR Part SNF under arrangements with hospice 418.100(a) and
418.100(e).
Review both the agreement between the contracting parties and
patient records to assure that the hospice arrangements are in
compliance with the regulations. The institution already meets
the remaining requirements of 42 CFR Part 418.100 as a
Medicare-approved hospital or SNF. Do not inspect the hospital or
SNF. Hospice dually certified as hospital or SNF and Survey for
compliance with 42 CFR Part as a hospice 418.100(a) and
418.100(e).
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The institution already meets the remaining requirements of 42
CFR Part 418.100 as a Medicare-approved hospital or SNF.
Medicaid-approved NF (respite care only) Survey for compliance
with 42 CFR Part 418.100(a) and 418.100(e).
Rev. 1 2-37
2085 THE CERTIFICATION PROCESS 03-98
2085. OPERATION OF HOSPICE ACROSS STATE LINES
The provision of services across State lines is appropriate in
most circumstances. Areas in which community services, such as
hospitals, public transportation, and personnel services are
shared on both sides of State boundaries are most likely to
generate an extension of services. When a hospice provides
services across State lines, it must be certified by the State in
which its provider number is based, and its personnel must be
qualified in all States in which such personnel provide services.
Each respective SA must be aware of and approve the action. The
involved States should have a reciprocal agreement, either verbal
or written, permitting the hospice to provide services in this
manner. The SA must verify that each State's applicable
personnel licensure and other requirements are met.
2086. HOSPICE HOME VISITS
The SA makes home visits to a sample of Medicare/Medicaid
hospice patients during a hospice survey, if any of six
conditions exist. Refer to Appendix M, Part III, Task 3.B. for
complete instructions. (See model consent for hospice home visit
form (Exhibit 128).)
2087. COMPLIANCE WITH ADVANCE DIRECTIVES
Under §§1866(a)(1)(Q) and 1902(a)(57) of the Act, a
hospice is required to be in compliance with all Federal
requirements in §§1866(f)(1) and 1902(w) of the Act,
respectively, concerning advance
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directives. Specifically, a hospice must agree to maintain
written policies and procedures with respect to all adult
individuals receiving medical care by or through the hospice and
must, at the time of initial receipt of hospice care by the
individual from the program: o Provide the individual with
written information concerning his or her rights under State law
(whether statutory or as recognized by the courts of the State)
to make decisions concerning medical care, including the right to
accept or refuse medical or surgical treatment and the right to
formulate advance directives;
o Provide the individual with the hospice's written policies
and procedures concerning the implementation of such rights;
o Document in the individual's medical record whether he/she
has executed an advance directive;
o Not condition the provision of care or otherwise discriminate
against an individual based on whether or not the individual has
executed an advance directive;
o Ensure compliance with requirements of State law (whether
statutory or as recognized by the courts of the State) concerning
advance directives; and
o Provide (individually or with others) for education of staff
and the community on issues concerning advance directives.
The facility is not required to provide care that conflicts with
an advance directive. In addition, the facility is also not
required to implement an advance directive if, as a matter of
conscience, the facility cannot implement an advance directive
and State law allows the provider to conscientiously object.
Compliance with the advance directives requirements is necessary
for continued participation in the Medicare and Medicaid
programs.
2-38 Rev. 1
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This is the end of the text from HCFA document State Operations
Manual Section 2080
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