Slide 1 - Oregon Hospice Association

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					                        2011 PPE
                  Disclosure Statement
It is the policy of the Oregon Hospice Association's (OHA) Continuing Medical Education Program to
insure balance, independence, objectivity, and scientific rigor in all its educational programs. All
faculty participating in any OHA-sponsored programs are expected to disclose to the program
audience any real or apparent affiliation(s) that may have a direct bearing on the subject matter of
the continuing education program. This pertains to relationships with pharmaceutical companies,
biomedical device manufacturers, or other corporations whose products or services are related to
the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker
from making a presentation. It is merely intended that any relationships should be identified openly
so that the listeners may form their own judgments about the presentation with the full disclosure
of the facts.

This presenter has no significant relationships with companies relevant to
this presentation to disclose.

Dana Selover MD, MPH
Section Manager, Health Care Regulation and Quality Improvement
Public Health Division
Oregon Health Authority

                                            September 27, 2011
   Participants will be able to describe the difference
    between Federal Certification and State Licensure

   Participants will be able to proactively assess the
    compliance with tools provided in presentation

   Participants will be able to build a strategy for
    ongoing compliance with Federal and State hospice

   Participants will be able to choose from available
    resources to improve compliance status
   Oregon Health Authority/Public Health
   Licensure and Certification update
   Surveys
   Improving compliance and survey success

   Final Organizational Structure still pending
   OHA working on health reform for Oregon:
    Oregon Health Policy Board, Health
    Insurance Exchange, Coordinated Care Orgs
    and HB 3650
   Public Health: PH Accreditation,
    Organizational Performance Improvement
   Office of Community Health and Health
    Planning: new administrator, Jody Noon
   Hospice Licensure since Jan 1, 2011
     Oregon Administrative Rules Chapter 333 Division
      ▪ Align with Federal CMS Conditions of Participation
      ▪ State-only provisions like criminal background checks
   Hospice FAQs online at:
   Hospice Licensure since Jan 1, 2011
   Licensing process went smoothly
   50 licensed hospice in Oregon
   47 certified and 3 license-only (other states)
   Dual Home Health/Hospice Licensure
     Originally 10
     8 applied and were licensed, 1 dropped hospice
     and 1 is still in process

   Certification – meeting the Federal
    Conditions of Participation (CoPs)
     State Operations Manual
     HCRQI is the State Agency for CMS
      ▪ Performs the surveys
      ▪ Ensures compliance with CoPs

   Hospice Team update – Darla Madigan and
    Phyllis Lebo
     Licensure program in development
     Licensed hospices should be surveyed at least
     once every three years
      ▪ Combination of State surveys and Accreditation surveys
     Federal surveys were less frequent
     Transition period

Survey Type                   Number of Surveys
Federal complaint             6
State-level complaint         1
Recertification/Relicensure   8
Follow-up visit               1
Total                         16

   Total Citations: 98
   Most frequent Citations by tag number with 3 each:
       0502 – Notice of Rights and Responsibilities
       0509 – Exercise of Rights/Respect for Property/Person
       0714 – Inpatient Care provided under arrangements
       0715 - Inpatient Care provided under arrangements
       0716 - Inpatient Care provided under arrangements
       0774 – Hospice Plan of Care
       0782 – Orientation and Training of staff
   14 other citation types with 2 each
   49 other citation types with 1 each
Data does not include most recent surveys with substantial citations
Condition (CoP)                           Number of citations
Patient’s Rights (418.52)                 17
Hospice care to residents of SNF/NF or    15
ICF/MR (418.112)
Short-term inpatient care (418.108)       14
Organization/Administration of Services   9
Hospice Aide and home maker services      9

   Condition-level citations: 3
     Interdisciplinary group, care planning and
      coordination of services
     Infection control
     Volunteers
   Other frequent citations by condition:
     Interdisciplinary group, care planning and
      coordination of services
     Initial and comprehensive assessment
     Core services
     Drugs and biologicals, medical supplies and DME

   Time between surveys presents challenges
     HCRQI is working towards increasing frequency
     Experience in other programs like Ambulatory
      Surgery Centers
     Consider validation of Hospice Association surveys
   Drifting from original policies and procedures
     Failure to update P&P
   Very small programs – difficulty meeting CoPs
   QAPI and Infection Control – must be an
    « active » program

   Multiple location survey – plan to do this more
    after directive from CMS
   P&P should align with the regulations and
    crosswalk with practice
     Especially an issue when computer software was
     Benefits of regular P&P review
   Written contracts with SNF/NF and inpatient
    care continue to be an issue
     Issue with patient rights

 State Operations Manual (see link above)
  includes Interpretive Guidelines, which are
  updated more frequently than actual regulations
 HCRQI Licensure tool – available soon
 Specific consideration to high frequency
     Patient’s rights, working with patients in SNFs and
      hospitals and others on slides # 11 and 12
   Accreditation Organizations – offer support and
    additional tools

   See surveyors comments above
   Regular review of P&Ps
   Extra caution with electronic medical records
    and other software upgrades
   Track updates from CMS and HCRQI
   Build a strong QAPI program as a proactive
    assessment of how your hospice measures
    up, meets your goals

   CMS Hospice Center:
   HCRQI:
   Hospice Assessment Intervention and
    Measurement (AIM) Toolkit:
   Accreditation Organizations:
     Oregon Hospice Assocation (for State licensure
     Joint Commission:
     Community Health Accreditation Program

   Health Care Regulation and Quality
    Improvement HCRQI
     Phyllis Lebo, Surveyor
     Darla Madigan, Surveyor
     Chris Campbell, Survey Manager,
     Dana Selover, Section Manager,

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