Greetings and salutations . I'm Jennifer Kennedy , the lead for Compliance and Quality at CHAP , and welcome to CHAPcast .
I'm really excited for our new format this year that we're going to employ , particularly because I get to work with my colleague and friend , kim Skehan , to bring you topics that really impact your daily operations and clinical practice so that we can help you be the best hospice or home health or DME that you can possibly be .
So today we're going to talk about the new CMS Hospice Special Focus Program , or the SFP . So this is a really brand new hospice community experience , particularly for the 50 hospices that have been selected to participate in the first cohort that began January 1st 2025 . And , as I mentioned , in our new format , I'm going to be joined by Kim Skehan .
She is our vice president for accreditation . Kim and I know each other oh gosh forever .
So this is going to be talking about compliance and quality is absolutely going to be a blast for us , and I think opening out the first topic of the year with FSP is going to be a little bit challenging because of some of the things that swirl around it , but I think we're ready to have a robust conversation . What do you think , kim ?
I think so , Jennifer . We need to be ready , as do hospice providers , and I would agree .
First of all , Happy New Year everyone , and we are starting the new year off for hospices with a bang with the implementation of the SFP Both the challenges and opportunities for hospices to really be able to establish , you know , if you're not selected for the SFP , what you can do in terms of monitoring your status and mitigating your chances of being selected for
SFP in the future . I do agree . In the future . I do agree .
As you said , we have known each other for many years in hospice and regulatory and compliance and it's always always a lot of fun to be able to talk with you and share with you and share for the industry , even when it is these difficult subjects , and we want to be able to bring that information to everyone you know and be able to really provide strategies
for folks to be able to implement for effective compliance , if you will . So today is , as you said , SFP is , as we know , part of the Consolidated Appropriations Act . It's the last part of the Consolidations Appropriations Act to be implemented and this is part of CMS's and part of the responsibility of CMS to implement as a component of enforcement remedies .
Sfp is designed to monitor hospices identified as poor performers based on the selected quality indicators , regardless of the agency size , local location and profit or ownership status . What we have seen in the initial 50 agencies selected in the cohort is that there are some questions , even from the industry , regarding the selection process .
So there are from a federal I'm sorry , from a national standpoint . We know that there is advocacy in working with CMS to look at the algorithm and the accuracy .
But from the standpoint of certainly us as CHAP , but also other hospices , what we really want to look at is focus on the data , the data that is being used , the indicators , and it's in looking at those indicators , Jennifer , that I think we just want to really make sure that we focus on and help hospices , help to really understand what they can do in terms
of control .
So you know , when the rule came out about the SFP and you know what was going to be in that algorithm , there was a lot of feedback that came back with comments . You know not only individual hospices providing feedback but , like you said , those national organizations , and there was some pushback on the methodology and the balance of the items in that algorithm .
And you know , as late as this past fall , these national organizations have been still pushing back right , saying , you know , hey , we need you to relook at this . You know , we still don't feel like it is where it needs to be . And actually they lobbied Congress .
Congress came to CMS and said , hey , we think you should pull back a little bit , look at the algorithm . But here we are , though CMS pressed forth and we now have our first cohort of SFPs . So I mean , it's like a work in progress , isn't it , kim ? It's still . You know , we don't know what we don't know , because we're in a whole new territory .
Yep , absolutely , and again , it's kind of like fixing the plane when you're in the air . Yeah , and this is the approach that has been taken with programs , where programs have been launched and they need to be adjusted along the way .
So the hope here is that there is an ability to be able to work with CMS to make any adjustments that are needed as this unfolds . The unfortunate part at this point is that , with the release now , with the 2025 50 selectees , unless there's any congressional change , they are selected and moving forward currently with those 50 agencies .
And then we also know that ultimately , the plan is to publish the bottom 10% , what's called the bottom 10% or the 10% for performers , which can be over 600 hospices , I believe , and we understand that that's not going to current , that's on hold for public reporting or publishing right now , but you know we will again remains to be seen .
So for hospices that are not on the 50 , the hospices that are selected , you know , as the 50 agencies participating in the SFP , there's still the potential for the publication for the bottom 10% . And again , a cautionary tale for all hospices , even if you're not on the SFP , because this is presumed to be an annual list , an annual program .
Yeah , I mean just because you get a pass shoo for the first cohort , you know , doesn't mean that you're exempted for life and it's a three-year rolling look back from year to year .
So I mean that's something that I think organizations have to , you know , put into their consideration when they're looking at compliance and quality performance and identifying gaps in places for improvement . So you know that November refresh on Medicare Compare of the quality measures is really the trigger that gets the next year cohort going right .
And it's interesting because of November and it usually comes , I don't know , mid-ish that those measures are refreshed . It puts people on a really short timeline if they are looped into that timeline program , don't you think ?
I do and , again , I also think that you know , organizations really need to monitor their quality reporting as well as these substantiated complaints and the condition level deficiencies in those 11 quality of care measures , whether the surveys are conducted by the state agency or the AO accrediting organization , because both are considered .
And one of the interesting things that we saw , at least in our preliminary review , is that the hospices that certainly that we have looked at did not have a significant amount of condition level deficiencies or complaint surveys or , and in some cases , their quality scores , you know , do not appear to be , they appear to be good or excellent .
So what that tells me and us is that hospices need to make sure they're monitoring because and hospices need to make sure they're monitoring because just because you've only had one condition level deficiency or one substantiated complaint , you know , or some low scores with your HQRP or your low response for CAPS , that doesn't mean that you will not be selected .
We don't know the answer to that , because that falls under the algorithm . It's just to me that was eye-opening , to us and to others in the industry that in fact it's not what people think when we look at fraud and abuse and CMS's focus on fraud and abuse and increasing survey oversight in terms of poor performers .
So , without knowing , you know the algorithm and how they were selected . It's important that hospices understand that it doesn't mean that if you , you know , only have one condition level or one complaint , that you would not necessarily be selected , at least based on what we have seen selected , at least based on what we have seen .
Yeah , exactly . So you know I watch all those HQRP scores that come out with each refresh and you know I'm particularly paying attention to those national scores . So organizations that you know they may be like , let's say , you know one measure has a national score of like 80 , and they may be at like 77 . They're not too far off the national .
But you know am pulling out and citing those four CAPS measures that pull into the SFP algorithm in particular . Yes , you need to be concentrating on those , but you should be concentrating on all of your measures , because it's the whole hospice experience that influences how that caregiver is going to complete that survey .
I also think , kim , since we are going to have a revised CAP survey with April decedents in 2025 , that includes a web mode that might help to increase survey return . So you know , I'm anxious to see how that sort of is going to figure in moving forward .
I think that's an excellent point because response rate often is a key contributor to low scores .
So , again , as part of an organization's quality reporting and QAPI program , you know , making sure that they're looking at the root cause if you will of you know any bottom , not less I'm going to say it , less than top box scores , as well as certainly opportunities for improvement with all outcomes .
And I agree that the focus needs to be on all , all measures really for quality . I would say the same with the COPs , because we want to make sure that you have , you know that you're meeting the conditions of participation in all areas and avoid condition level deficiencies . Knowing that the 11 , the 11 quality of avoid condition level deficiencies .
Knowing that the 11 , the 11 quality of care , condition level deficiencies impact , impact SFP . Once you're on the SFP , you cannot have any condition level deficiencies . You know it doesn't specify just those 11 .
Also , of those 11 , this is where the majority of findings and condition level deficiencies are cited , because they really focus on patient care , care planning and assessment .
Since you took the dive into COPs , I think we need to talk about survey readiness , don't you ? Absolutely .
Absolutely , and I never have a shortage of time to talk about . I do on the podcast , but in general , we all know that I have been preaching survey readiness and follow up for many , many years I think you have a sash , don't you queen ?
So I have preached survey readiness for many , many years because it really is vitally important to organizations for survey success and I think it's no more important than than now .
You know has not been ever more important than now in terms of organizations really making sure that they have a robust survey readiness program that encompasses education , monitoring and oversight , conducting those mock surveys , knowing appendix M and staff understanding their role in survey and clinical documentation , home visits , really focusing on all COPs , really patient
care , safe health , safe patient care and quality of care .
And what we found is , no matter what size your hospice is and what we found is , no matter what size your hospice is , if you're small , if you're one provider with a couple of ADSs or even an inpatient unit , or you're a large corporate organization with many providers , you want to make sure you have a process for oversight , trust , but verify in our world ,
and this means , don't you know , make sure that the policies , programs , processes you're putting in , you're implementing in an organization that it is being followed through , especially in you know , with new changes in staff and management .
It's vitally important for that ongoing oversight in addition to QAPI , and with that I will turn over to you . You know that includes bedside clinicians , it includes leadership .
But if you have policies , if you have SOPs in place and you're educating people and holding them to that , I feel that you know that's a big piece that sometimes organizations don't do well with right .
I agree , I agree . It's so important , it's accountability . You're right , both with survey readiness , compliance with standards , implementation of QAPI , performance improvement projects , follow-up if there's a plan of correction . But it's also important to understand that survey readiness is not an event .
It's not when we're ready for the next , we know that we're in the window for the next survey Right , right , right . It needs to occur all the time because it you know you can have a complaint survey at any time and it is in those complaint surveys that often there are , you know , there are findings that may rise to condition level .
But having everyone understand , you know and be ready always is , you know , a regular process for oversight and follow-up is really a best practice .
Well , and that does tie back to quality into your QAPI program because you know , one of the biggest things that you're doing in your QAPI program is continuous 360 assessment . Right , you can have all the data sources that CMS can give you and they're great , they're very helpful .
But taking the temperature inside your organization in all facets is really going to tell you how you're doing , because we're putting it up against COPs , we're putting it up against if you're looking at conditions for payment , we're putting it up against subpart B , right , we're doing all of those things and that I think that is the most important data source is
keeping up on that continuous assessment within all corners of your organization . And , if you need to , you know if you identify a problem and you're running it through your program as a PIP . You know , don't relax on some other things , like you know your regular thresholds for documentation review , for example .
So , yeah , I agree with you and I think a compliant organization is survey ready . They should be survey ready and we owe it to every patient that we admit into every hospice in the United States for them to have a quality experience and we can only guarantee that with compliance right as a foundation . What are your thoughts on that ?
Absolutely , and I also understand how challenging it is for hospices of any size , especially with so many areas that they need to look at in addition to and providing safe , quality care for patients .
You know taking care of their patients , taking care of their staff , making sure that they you know all of the operational needs that they have to address every single day .
On top of you know absolutely compliance , which I call compliance , billing compliance , payment compliance , audits , making sure that they're billing properly , and then quality I mean , I'm sorry , regulatory , so survey readiness , cops , which are not the same as payment , another lens as well as and then wrapping all of those efforts and monitoring to your point into their
QAPI program and keeping it afloat . It's challenging .
It is .
I do think that you know I'll give you a shout-out for the PI compendium , the compliance compendium .
The compliance compendium because I think that it's incredibly important for hospices to have resources to be able to help keep them on track with their everything that needs to be monitored and addressed and , operationally , look at the most efficient and effective way to be able to optimize that monitoring while still again collecting meaningful data .
But what do we do with it ? Because it's going to be extremely important to stay on top of these indicators , on on top of these , these indicators , on top of everything else , and I feel that with with hospices and the challenges that they have , they do .
And I didn't , you know , I didn't intend to undercut or or say you know that I don't recognize there are challenges . You know you and I've been two feet in a hospice working in our career and it is . You know , you have all those things that you know that pop up and go wrong and all of that .
But you know , I still feel we have to get it right with every patient because for the majority of patients coming through a hospice program , you get one chance , you get one . Well , that's what . Yeah .
And that's the number one priority , honestly , is the health and safety of patients and the quality of care .
So organizations need to be able to balance that ultimate priority with making sure that they know what is needed to be able to continue to again provide that education , monitoring and oversight in all of these areas , and you know so how that is implemented within their organization . Sometimes it can become overwhelming , but it can be done .
Yeah , absolutely it can be done and you know there are so many information sources out there to help keep people updated . Yeah , I know some organizations maybe they're on here right now going what is SFP ? I had no idea . You know this was out there and you got to have to get a buy by not getting selected in this cohort .
But you know , staying informed I think is one of those key compliance pieces Because when we're talking about quality CMS , that's still attached to compliance right , attached to compliance right . You know caps measures , his and soon to be hope down the line .
But you know being informed I think is key and you know , if you're not prioritizing either , where to get information that pops into your email box , which you can do easily with CMS . You sign up for stuff and it comes right to your mailbox and you know the same with CHAP information .
You have to go out , you have to make it a priority and an action to look for information .
Absolutely and certainly . In addition to CHAP and CMS , the state associations and the national associations are really a key resource for timely information regarding important areas such as SFP . So , as we think about takeaways from our conversation today , kim , what are your thoughts about ?
What would you like people or listeners here to take away away is SFP organizations have been selected the 50 , for 2025 , and they will enter into the SFP program and we are all learning the program as it's being implemented .
But every hospice needs to learn from the SFP and the indicators and ensure that they have a process to monitor those areas and also implement again an ongoing survey , readiness program and QAPI program .
Yeah , I couldn't agree with you more . I mean , you know we don't have that list that CMS is keeping back right now . So there's hospices on there that don't know they're on there right . So again , you can't sit back and say , yay , I got a buy , I'm good . You know , right now Maybe you're not , maybe you are on a list somewhere that CMS hasn't posted yet .
But I agree , you know , survey readiness , performance , improvement all the way around , with particular focus on those items indicator items in the SFP crucial for every hospice .
Absolutely .
All right . Well , this has been a great conversation with my friend Kim . Well , this has been a great conversation with my friend Kim .
You know we live and breathe this stuff every day and you know it might be something that you don't , but hopefully , what we've brought you here today , there's more interesting topics to come in 2025 and share the episode with your organization . We would appreciate that .
Also , you know , exploring all of our information on CHAP is going to be helpful for you , kim . Thank you for mentioning the Hospice Program Integrity Compendium resource . We put that together last year for you , kim . Thank you for mentioning the Hospice Program Integrity Compendium resource .
We put that together last year for you so that you would have all the information in a one-stop shop for all your program integrity needs , if you have those needs . I think everybody has those needs at this point in hospice history . Any final thoughts , kim , as we wrap up .
No , again , this is likely the first of more than a few either podcasts or publications or resources that certainly we will be discussing . But , as well as the industry and you know , I would just encourage hospices to take it one step at a time .
If you have , you know , multiple areas to implement and also please , you know , continue to share your thoughts and comments regarding the process and any questions that you have with CMS . They have an SFP website email address with CMS .
They have an SFP website email address also , certainly with us and with the state and national associations , so that we can really get a handle on how this process is going to be playing out for hospices this year and going forward .
Absolutely so . Thanks , kim , for spending some time with me . Today . We're spending time together to talk about SFP , and thanks to all of you for taking time out of your day to listen to our podcast From Kim , me and the entire CHAP staff . Keep your quality needle surging forward . Stay safe and well , and the entire CHAP staff .
Keep your quality needle surging forward , stay safe and well , and thanks for all you do .