Eli's Hospice Insider

Published on Wed Sep 15, 2021 PDF

Your survey track record may be important.

Tougher and more frequent surveys are ahead for hospices, and that means more condition-level deficiencies likely are too.

The Centers for Medicare & Medicaid Services sets out these factors surveyors will use “to determine which remedy or remedies to apply” when they cite deficiencies, CMS says in the home health proposed rule for 2022:

• The extent to which the deficiencies pose Immediate Jeopardy to patient health and safety.
• The nature, incidence, manner, degree, and duration of the deficiencies or noncompliance.
• The presence of repeat condition-level deficiencies, the hospice’s compliance history in general, and specifically concerning the cited deficiencies, and any history of repeat deficiencies at any of the hospice’s additional locations.
• The extent to which the deficiencies are directly related to a failure to provide quality patient care.
• The extent to which the hospice is part of a larger organization with documented performance problems.
• Whether the deficiencies indicate a system-wide failure of providing quality care.

These factors “are consistent with the factors for HHA alternative sanctions,” CMS points out in the rule.