An Overview of Hospice Surveys
An Introduction to Hospice Surveys
A hospice survey is an evaluation of a hospice agency to determine the agency’s compliance with state rules and federal regulations. The survey evaluates the agency on such areas as nursing services, infection control, medical records, governing board, quality assessment and improvement, and home health aide service.
Pursuant to Indiana Code 16-25, hospice agencies must be licensed. The Indiana State Department of Health is the licensing authority and has adopted rules for the operation of hospice agencies. Hospice surveys evaluate the agency for compliance with these rules.
Medicare certification is under the authority of the U.S. Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS). The federal regulations (Conditions of Participation for hospice agencies) are found at 42 Code of Federal Regulations 418. Federal certification surveys and federal complaint surveys evaluate the agency for compliance with these regulations.
Surveys of Indiana hospice agencies are conducted by public health nurse surveyors from the Indiana State Department of Health (ISDH) Division of Acute Care. Surveyors from the U.S. Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) will occasionally participate in or conduct a survey. Surveyors are experienced registered nurses and receive extensive training in hospice rules and Hospice Conditions of Participation.
The Survey Process:
The survey process varies depending on the type of survey. Surveys may take only a few hours or last a week. All surveys are unannounced. Surveys generally include surveyor visits to the agency and any branch offices. During a survey, ISDH surveyors will interview staff, review patient records and conduct home visits to determine compliance with state rules and federal regulations.
At the conclusion of the survey, surveyors prepare a report of their findings. A separate survey report is prepared for state and federal surveys. The survey report lists and describes all violations of state rules or federal regulations.
If deficiencies are cited on a survey, the agency will be requested to complete a plan of correction on how and when they will achieve compliance with each deficiency and who will be responsible to ensure the corrections are made and will not reoccur in the future. The agency submits the plan of correction to the ISDH within fifteen (15) days of the issuance of the survey report. The ISDH reviews and approves the plan of correction.
Types of Surveys:
There are numerous types of hospice surveys. These include:
The following is a brief description of a few of the common hospice surveys.
State Licensure Surveys
Indiana Code 16-25 requires that every Indiana hospice be licensed. The Indiana State Department of Health (ISDH) is designated as the licensing authority. The ISDH may conduct a state licensure survey at each licensed hospice as often as needed to determine compliance.
The licensure survey is a comprehensive review of the agency and the agencies compliance with state rules. State licensure surveys are conducted by an ISDH Public Health Nurse Surveyor. The survey is unannounced. A state licensure survey is usually completed in one to four days. The survey includes surveyor visits to the licensed hospice and a sample of branch sites under the license. During a licensure survey, ISDH surveyors will interview staff, review patient records and conduct home visits of a sample of patients to determine compliance with state rules.
Many hospice agencies voluntarily submit themselves for accreditation by a hospice accreditation organization. If a hospice is accredited, the agency may substitute the accreditation survey for the state licensure on-site survey in calendar years when an accreditation survey is performed.
Federal and State Complaint Surveys
Any person may file a complaint with the ISDH about a hospice. The ISDH investigates all complaints. Complaints may be filed in person at the ISDH, in writing, by telephone, or by email. The toll-free complaint number is 1-800-246-8908. Instructions for submitting a complaint by email are found in the ISDH Regulatory Services Web site under “contact us”. Complaints are prioritized and scheduled for investigation based on their potential to place the health and safety of patients at risk. Complainants are informed (except anonymous complainants) upon receipt of the complaint by the surveyor and at closure of the complaint of the findings of the investigation.
A complaint survey is a focused survey reviewing the specific allegations of the complaint. The purpose of a complaint survey is to determine if the hospice is compliant with the state licensure rules and/or Conditions of Participation for hospice agencies (42 Code of Federal Regulation 416). A complaint survey is unannounced and the name of the complainant is not disclosed to the hospice. During the course of a complaint survey, surveyors may expand the scope of the survey if additional problems are observed. Complaint surveys are generally completed by only one or two surveyors and last a few hours to a day. Similar to the licensure survey, surveyors will visit the agency, interview staff, review records and conduct home visits to determine compliance with state rules and federal regulations.
If in the course of investigating the complaint allegations a violation of state rules or federal regulations or regulations is found by surveyors, the complaint is said to be “substantiated with findings”. These findings would be reported on the survey report issued at the conclusion of the survey.
While state rules do not require hospice agencies to be accredited, many agencies voluntarily apply for accreditation from the Joint Commission (JC), and Community Health Accreditation Program (CHAP), or other accreditation organizations. Accreditation surveys are performed by the accreditation organization once every three years. Accreditation is granted to the agency if the hospice meets the standards of a private accreditation organization.
Section 1861(e) and 186(1) of the U.S. Social Security Act allows institutions accredited as hospice agencies by the JC or CHAP to be deemed to meet the Conditions of Participation for hospice agencies. The ISDH also accepts the JC or CHAP inspection report in lieu of a state licensure on-site survey in calendar years when an accreditation survey is performed.
Federal Certification Surveys
Federal Medicare certification surveys are conducted to determine hospice compliance with the Federal Condition of Participation for hospice agencies. For non-accredited federally certified hospice agencies, a federal Medicare certification survey is completed once every three to six years. A federal certification survey may also be completed if the Center for Medicare and Medicaid Services (CMS) finds the hospice to be out of compliance with a federal condition of participation and CMS requests that a certification survey be completed.
In the case of a hospice that is accredited, an agency that meets accreditation standards is deemed to have met the Federal Conditions of Participation based on the accreditation survey. In that situation, the accreditation survey replaces the federal certification survey. Accredited hospice agencies will therefore likely not have a federal certification survey. If the Hospice Consumer Report indicates that the federal certification survey was “not applicable”, this indicates that the agency is accredited and an accreditation survey was performed in lieu of a federal certification survey.
If a federal certification survey is performed, it is very similar to the state licensure survey except that it evaluates the hospice on federal regulations rather than state rules. During a federal certification survey, the surveyors will tour the agency, interview staff, view patient records and conduct home visits to determine compliance with the Conditions of Participation for hospice agencies. Noncompliance with the Conditions of Participation for hospice agencies will result in issuance of a survey report specifying that the agency did not meet a specific regulation.