Greetings and salutations . I'm Jennifer Kennedy , the lead for compliance and quality at CHAP , and welcome to this episode of CHAPcast . Today we're going to be talking about the top 10 survey deficiencies for hospice providers in 2024 . And these are CHAP top 10 deficiencies .
So I'm so glad to be back with my fantastic co-host , Kim Skehan and thanks , Kim , it's always good to be together to talk about hospice compliance and survey and all that good stuff .
Absolutely , jennifer . I'm so happy to be here .
We tag team very well together when it comes to regulatory compliance and survey , so this is a very important topic , and today we're going to talk about why is it important to know the top 10 hospice deficiencies , and during this discussion we'll talk about some of those key points that providers need to be aware of , especially in this survey environment .
So it is . You know it is getting to be a tougher survey environment . Plus , we have the high stakes SFP special focus program that you know plays a part of this . So why do you think it's important for hospice providers to be aware of what these top 10 deficiencies are ?
I think it's part of an organization's overall survey readiness making sure that they are aware of the top deficiencies , common areas that hospices are cited from CHAP and also , specifically with hospice , the 11 quality of care conditions of participation that are also being included in the SFP .
But hospices do need to make sure that they are in compliance with all COPs and standards . But knowing these top 10 really helped to focus on these common areas .
Yeah , you know what . I'm just going to pop this right in here for our listeners .
You know we used to have access to this website called QCOR , which was a CMS-maintained website that had all survey information in it , whether it be accreditation organizations or state or whatever and it was great because you had all this data and you could slice and dice it various ways to not only see , maybe , your own performance over time hopefully you'll be
tracking that , though but seeing what your area hospice as a whole looks like . Now we don't have that luxury .
Right now , cms has been migrating all of their data from this QCOR website , which will eventually live in Keys , and we don't have a hard date on when that is going to be complete in terms of the migration , but I think when we do get that QIES database up and running , it is important for providers to be able to know where that is and plug into it so
that they can see data a variety of ways . What are your thoughts on that , kim ?
Absolutely , and I think once that data also is available , an organization state association does also typically have is able to obtain that information , so maybe a resource as well . But either way , it's a great . It is a great tool .
In the meantime , we have our top 10 deficiencies , which closely align with what we have known as CMS findings , because when you do look at our findings , which can be found on our CHAP website , chapincorg , under survey readiness , resources and for each service line , you can then find the top 10 deficiencies and you'll see that they correlate with LTACs , so they
do correlate with CMS COPs and standards . Jennifer , in looking at the top 10 for hospice for 2024 , which is not uncommon to previous years you can see that most of the findings relate to care planning , assessment and coordination of care . What are your thoughts on that ?
Well , that's sort of been the trend over years and years on waffles as long as I can remember . Essentially we've had plan of care in that top 10 . You know , I'm sure I don't know a chap's history , but I know when I'm talking about top 10 for CMS .
So you know , really , when we're talking about comprehensive assessment and plan of care , those are two like cornerstone COPs , I think in the COPs because we gather information about patients and families via the comprehensive assessment and then we use the plan of care to develop the roadmap for caring for these patients .
So it's like this never-ending cycle of assessment and plan of care . And I do think , kim , that if hospices aren't paying attention to their comprehensive assessment process or the assessment process overall , they might be at a deficit by the time we hit implementation for hope .
This is the time now for prepping for hope , for doing better on comprehensive assessments , which feeds into plan of care , of identifying gaps right now in your assessment process , because it's going to get a little more complicated when we're talking about adding in time visits and things like that from the hope process .
Absolutely . I completely agree and one of the when we look at strategies for organizations , hospices to implement , to improve particularly in this area . But overall care and treatment and services , organizations really have to make sure that the RN , hospice case managers understand the role of a case manager and case management .
This is a key component in connecting the dots and looking at the whole picture . Even though hospice is fortunate to have the IDG , very often we have nurses , rns , who are by regulation , by standard , required to lead the plan of care and drive the plan of care and the care for these patients and drive the plan of care and the care for these patients .
They often focus on , may focus only on , the nursing component and not understand the full complement and responsibilities associated with case management .
Having come from facilities , many RNs have not been trained in that skill set , so hospices really need to make sure that they can have a process to train the staff and ensure that those strategies or requirements really characteristics are implemented .
Yeah , you know what . I just want to poke in there for a second . Even though you make a good point , you know it's an interdisciplinary approach in hospice right , and we , you know , we want to make sure organizations understand that nothing changes in assessment with this implementation of hope , even though it is nursing heavy right .
Even though it is nursing heavy right that we can't forget we are an interdisciplinary team and that's the approach we take for assessment and care planning .
So I agree with you a thousand percent on the RN case manager front . Yeah , yes , again , just understanding that role .
I think that this would be a great topic , because case management , the principles of case management , the role of the case manager is more in depth than we have time for , but I think a future podcast or chat cast would be an excellent idea . What do you think ?
I like that idea . I think we should start thinking about how that's going to map out .
Absolutely . And then , just , you know the couple of other , just a few other of the deficiencies that you want to talk about . Waffles , Hospice aids are perennial pile on , you know findings in the top 10 .
Do you see me hiding my eyes ? Do you see me ?
Yes , yes , yes . So again , just you know , reminding you know , hospice aides and implementation , completion of the tasks in accordance with the plan of care , making sure that they are reporting any changes in status , as well as areas such as infection prevention and control .
Even though that's not on our top 10 , we know that that's a common area , particularly related to home visits and you know , and care of the patient in the home .
So I think you know it's really worth it for organizations to you know , to really look and monitor as part of their own process , survey readiness , the resources that we have right Top 10 deficiencies , any of their own previous findings as well , and those 11 quality of care , quality of care , cops , and really make sure that they are implementing what they need
and be survey ready .
Yeah , I was . I knew you were going to get to that . You know , kim , can we Thank you ? I think the strategies are great , but can we step back one second ? Was there anything on that top 10 list that surprised you at all ?
For the . Nothing really surprises me because , again , the majority are related to initial and comprehensive assessment and care planning . Hospice aides , perennial and physician orders is also . Making sure there are physician orders is also something common .
I do think that hospices need to be reminded that the copy of the discharge summary does need to go to the attending physician , if one is named , and also to the facility . If a patient is transferred to a facility , that's probably the one that I see that is not consistently on , or wasn't consistently on , the federal list .
Yeah , you know , nothing really stood out to me in terms of , you know , oh boy , I'm flabbergasted in terms of what our top 10 are looking like .
But again , I think you're absolutely spot on with we have to make sure that everything that we do is geared towards , you know , having somebody whether it you know it's a surveyor , or even like an auditor walk into your organization and start to look at all of your documents or all of the things that you're doing .
And I think I would just say I think hospices need to do a better job in that for sure .
Absolutely , and it's an ongoing process . This is not a one and done getting ready when you know you're in the window . You really want to be ready at all times .
Absolutely so if we were going to suggest , you know , a few takeaways today for our organizations that are plugged in and listening .
What will come to your top of your mind , Kim ?
Number one again , making sure that hospices are aware of what those top 10 deficiencies are and those 11 quality of care COPs , but also as an organization , making sure that there is a process for ongoing survey readiness and monitoring of all standards , and you'll hear me say it every single time we strongly recommend mock surveys as a way to make sure that you
are on top of any potential issues , and that's really my key takeaway . And then , as I said , realizing so many years with the assessment and plan of care issues that we've seen that really looking at case management so that the RNs do understand the coordination of care component when it comes to implementing the plan of care in conjunction with the IDG .
Yeah , I agree with you . You know talking about surveys . You know all the year through and what we have to do to be compliant . It's a continuous process , it's not just when you're , you know , six months out from your next survey . So , yeah , totally agree with that .
Especially when a complaint survey can come at any time .
That is true . All right , so I'm going to echo you , kim , and invite our listeners to check out the top 10 survey deficiencies for 2024 . And those are up on our webpage under the hospice tab . With that , I think we're going to wrap up today .
We gave you our thoughts and our suggestions for success , so we'll hope that you can take some of those pearls of wisdom away with you . And again , thank you for taking time out of your day to spend some time with us listening to the podcast from Kim , me and the entire CHAP staff .
Keep your quality needles surging forward and stay safe and well , and thanks for all you do .