The Plan of Care Part One: Compliance & Survey Success
The hospice Plan of Care (POC) serves as a blueprint for how each patient’s care needs are delivered. It outlines the medical, psychosocial, spiritual, and personal care needs of patients and the interventions that the interdisciplinary team will provide to meet them. So it makes sense that the plan of care is the "Go-To" to see what care and services a patient is being provided by a hospice. Where the problems come in is when the plan of care doesn't accurately reflect the patient's care needs.
Regulatory Requirements for the Hospice Plan of Care
§418.56: Condition of Participation: Interdisciplinary Group (IDG) , Care Planning, and Coordination
CoP §418.56 specifies that the IDG must establish and regularly update this plan to reflect the patient's current health status, preferences, and evolving care needs.
Impact on Reimbursement
Medicare reviews whether the services billed align with the patient’s documented needs. If the plan of care does not support the level of care and service provided, hospices risk recoupment of funds following an external audit.
Survey and Regulatory Compliance
Surveys conducted by CMS or accrediting bodies like ACHC or CHAP closely examine whether care plans are up-to-date and accurately reflect the patient’s condition. Four of the Top 10 Hospice Deficiencies for CHAP involve the Plan Of Care.
Top related deficiencies cited for the plan of care (Including the Aide Plan Of Care):
- L538 - The plan of care must specify hospice care and services necessary to meet the patient/family-specific needs identified in the assessment as the needs relate to the terminal illness and related conditions.
- L543 - Hospice-designated RN ensures services follow the orders in the individualized plan of care.
- L545 - individualized written plan of care for each patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions.
- L547 - Content of the Plan of Care: A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.
- L553 - Review of the Plan of Care: A revised plan of care must include information from the patient’s updated comprehensive assessment and must note the patient’s progress toward outcomes and goals specified in the plan of care.
- L555 - Coordination of Services: Ensure that the care and services are provided in accordance with the plan of care
- L625 - Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide.
- L626 - Hospice aide provides services ordered by the IDG and included in the plan of care.
- L628 - Hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities. Hospice aides must also complete appropriate records in compliance with the hospice’s policies and procedures.
Surveyors from CMS or accrediting organizations will assess whether:
- The plan of care is individualized and reflects the patient’s current condition and needs.
- Changes in care, are reflected in as they occur.
- All involved disciplines contribute to the plan of care.
- The physician has approved and contributed to the care plan.
ACHC TIPS FOR CARE PLAN COMPLIANCE:
- Ensure an individualized plan of care is established for each patient and family based on the identified needs in the assessments.
- Ensure the plan of care includes all services necessary for the palliation and management of the terminal illness to include medications, treatments, disciplines providing care, equipment, and supplies.
- Ensure all DME utilized by the patient is included on the plan of care.
- Ensure the medical record contains documentation to support progress or the lack of progress toward the patient’s goals as specified in the plan of care.
- Ensure the plan of care integrates changes based on re-assessment data of the patient and family as well as changes based on the progress made toward the patient’s goal.
- “Per patient request” and PRN orders should not be used on the hospice aide plan of care as the hospice aide lacks the decision-making ability to interpret information/data needed to revise the plan of care.
- Ensure documentation supports that the hospice aide provided care in accordance with the plan of care and that if the patient refuses care, the refusal is properly documented.
CHAP TIPS FOR CARE PLAN COMPLIANCE:
- Educate IDG / all disciplines on including problems, interventions and goals based on the completed initial comprehensive assessment and on-going clinical assessments
- Establish a PIP to achieve and sustain compliance with problems, interventions, goals
- Ensure that the plan of care addresses all needs identified in the comprehensive assessment.
- A focused audit of initial plans of care in comparison to the assessment would be beneficial to ensure all needs are addressed.
The nurses' visit narrative is low-hanging fruit. It will often contain key information that doesn't make it to the plan of care. Make sure that before survey window opens, all care plans have been reviewed. This also applies to facility patients. The facility plan of care and the hospice plan of care should be updated, readily accessible, and should match, reflecting the care being delivered and who is responsible for managing it (hospice or facility)!
If you need help with an audit, accreditation, or survey readiness, we can help.
