Tip of the Month
New Tip Sheet Addresses Federal Survey Deficiencies
Top 10 Areas Cited
Staff from the Centers for Medicare and Medicaid Services (CMS) announced results of its annual compliance audit at NHPCO’s 27th Management and Leadership Conference in late March. These results were based on 1,169 hospice surveys conducted during FY 2011-2012, and include a compilation of the top 10 most frequently cited survey deficiencies. The areas cited (shown below) include aspects of care planning, staff supervision and oversight, and the provision of certain services. Understanding them—and identifying those areas where your organization may be falling short—is the key to becoming survey-ready!
Tip Sheet and Audit Tool
The NHPCO Regulatory team has developed its annual Top Ten Hospice Survey Deficiencies Tip Sheet and Compliance Audit tool that can help you educate staff and conduct a compliance self assessment.
1. L543: §418.56(b) Standard: Plan of care 2. L629: §418.76(h) Standard: Supervision of Hospice Aides 3. L545: §418.56(c) Standard: Content of the Plan of Care 4. L530: §418.54(c)(6) Drug Profile 5. L555 – §418.56(e)(2) Ensure that Care and Services are Provided in Accordance with Plan of Care 6. L591 – §418.64(b) Standard: Nursing Services 7. L552 – §418.56(d) Standard: Review of Plan of Care 8. L596 – §418.64(d) – Counseling Services
The Tip Sheet lists the survey deficiency by 10. L523 – §418.54(b) Standard: Timeframe for Completion of the L-Tag Identifier and the Comprehensive Assessment Medicare hospice CoP; provides an example of For details, see the NHPCO Tip Sheet. the deficiency based on CMS survey deficiency data; offers suggestions for compliance from clinical and administrative perspectives; and lists the standard and practice example from the NHPCO Standards of Practice for Hospice Programs (2010).
9. L615 – §418.76(c) Standard: Competency Evaluation
The Compliance Audit tool will help you perform a self assessment to identify areas of risk that require action. Both resources can be found in the Regulatory and Compliance Center—on the Tools for Care and Compliance page.
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Table of Contents for the Digital Edition of NewsLine - June 2012