January 22, 2025 • 28 mins
Join Jennifer Kennedy and Kim Skehan for an unfiltered conversation about the CMS Hospice Special Focus Program (SFP), launched on January 1, 2025. This transformative program is reshaping hospice care—and Jennifer and Kim are here to ensure you’re prepared to adapt and thrive.
In this episode, they simplify the complexities of SFP, exploring how it works, who it impacts, and most importantly, how your hospice can stay ahead. Learn how to interpret the program’s data-driven selection process, evaluate your organization’s readiness, and build the strategies you need to mitigate risks while maintaining top-quality care.
From the critical role of QAPI programs to the importance of strong policies during times of change, Jennifer and Kim provide actionable tools for leaders determined to deliver excellence in every aspect of hospice care. Whether you're navigating SFP or aiming to prevent future challenges, this episode is packed with insights that matter.
Don’t miss this essential guide to staying compliant, proactive, and focused on what truly counts—your patients.
Visit our website
Connect with us - LinkedIn, Twitter, YouTube, Facebook
Make Lives Better
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:07):
Greetings and salutations.
I'm Jennifer Kennedy, the leadfor Compliance and Quality at
CHAP, and welcome to CHAPcast.
I'm really excited for our newformat this year that we're
going to employ, particularlybecause I get to work with my
colleague and friend, kim Skehan, to bring you topics that
(00:27):
really impact your dailyoperations and clinical practice
so that we can help you be thebest hospice or home health or
DME that you can possibly be.
So today we're going to talkabout the new CMS Hospice
Special Focus Program, or theSFP.
So this is a really brand newhospice community experience,
(00:51):
particularly for the 50 hospicesthat have been selected to
participate in the first cohortthat began January 1st 2025.
And, as I mentioned, in our newformat, I'm going to be joined
by Kim Skehan.
She is our vice president foraccreditation.
(01:13):
Kim and I know each other ohgosh forever.
So this is going to be talkingabout compliance and quality is
absolutely going to be a blastfor us, and I think opening out
the first topic of the year withFSP is going to be a little bit
challenging because of some ofthe things that swirl around it,
(01:35):
but I think we're ready to havea robust conversation.
What do you think, kim?
Speaker 2 (01:41):
I think so, Jennifer.
We need to be ready, as dohospice providers, and I would
agree.
First of all, Happy New Yeareveryone, and we are starting
the new year off for hospiceswith a bang with the
implementation of the SFP Boththe challenges and opportunities
(02:02):
for hospices to really be ableto establish, you know, if
you're not selected for the SFP,what you can do in terms of
monitoring your status andmitigating your chances of being
selected for SFP in the future.
I do agree.
In the future.
(02:29):
I do agree.
As you said, we have known eachother for many years in hospice
and regulatory and complianceand it's always always a lot of
fun to be able to talk with youand share with you and share for
the industry, even when it isthese difficult subjects, and we
want to be able to bring thatinformation to everyone you know
(02:50):
and be able to really providestrategies for folks to be able
to implement for effectivecompliance, if you will.
So today is, as you said, SFPis, as we know, part of the
Consolidated Appropriations Act.
(03:11):
It's the last part of theConsolidations Appropriations
Act to be implemented and thisis part of CMS's and part of the
responsibility of CMS toimplement as a component of
enforcement remedies.
(03:32):
Sfp is designed to monitorhospices identified as poor
performers based on the selectedquality indicators, regardless
of the agency size, locallocation and profit or ownership
status.
What we have seen in theinitial 50 agencies selected in
(03:54):
the cohort is that there aresome questions, even from the
industry, regarding theselection process.
So there are from a federal I'msorry, from a national
standpoint.
We know that there is advocacyin working with CMS to look at
(04:15):
the algorithm and the accuracy.
But from the standpoint ofcertainly us as CHAP, but also
other hospices, what we reallywant to look at is focus on the
data, the data that is beingused, the indicators, and it's
in looking at those indicators,Jennifer, that I think we just
(04:37):
want to really make sure that wefocus on and help hospices,
help to really understand whatthey can do in terms of control.
Speaker 1 (04:49):
So you know, when the rule came out about the SFP and
you know what was going to bein that algorithm, there was a
lot of feedback that came backwith comments.
You know not only individualhospices providing feedback but,
like you said, those nationalorganizations, and there was
(05:10):
some pushback on the methodologyand the balance of the items in
that algorithm.
And you know, as late as thispast fall, these national
organizations have been stillpushing back right, saying, you
(05:31):
know, hey, we need you to relookat this.
You know, we still don't feellike it is where it needs to be.
And actually they lobbiedCongress.
Congress came to CMS and said,hey, we think you should pull
back a little bit, look at thealgorithm.
But here we are, though CMSpressed forth and we now have
(05:57):
our first cohort of SFPs.
So I mean, it's like a work inprogress, isn't it, kim?
It's still.
You know, we don't know what wedon't know, because we're in a
whole new territory.
Speaker 2 (06:12):
Yep, absolutely, and again, it's kind of like fixing
the plane when you're in the air.
Yeah, and this is the approachthat has been taken with
programs, where programs havebeen launched and they need to
be adjusted along the way.
(06:32):
So the hope here is that thereis an ability to be able to work
with CMS to make anyadjustments that are needed as
this unfolds.
The unfortunate part at thispoint is that, with the release
now, with the 2025 50 selectees,unless there's any
(06:58):
congressional change, they areselected and moving forward
currently with those 50 agencies.
And then we also know thatultimately, the plan is to
publish the bottom 10%, what'scalled the bottom 10% or the 10%
for performers, which can beover 600 hospices, I believe,
(07:24):
and we understand that that'snot going to current, that's on
hold for public reporting orpublishing right now, but you
know we will again remains to beseen.
So for hospices that are not onthe 50, the hospices that are
selected, you know, as the 50agencies participating in the
(07:44):
SFP, there's still the potentialfor the publication for the
bottom 10%.
And again, a cautionary talefor all hospices, even if you're
not on the SFP, because this ispresumed to be an annual list,
an annual program.
Speaker 1 (08:06):
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 athree-year rolling look back
from year to year.
So I mean that's something thatI think organizations have to,
(08:26):
you know, put into theirconsideration when they're
looking at compliance andquality performance and
identifying gaps in places forimprovement.
So you know that Novemberrefresh on Medicare Compare of
(08:49):
the quality measures is reallythe trigger that gets the next
year cohort going right.
And it's interesting because ofNovember and it usually comes,
I don't know, mid-ish that thosemeasures are refreshed.
It puts people on a reallyshort timeline if they are
(09:12):
looped into that timelineprogram, don't you think?
Speaker 2 (09:16):
I do and, again, I also think that you know,
organizations really need tomonitor their quality reporting
as well as these substantiatedcomplaints and the condition
level deficiencies in those 11quality of care measures,
whether the surveys areconducted by the state agency or
(09:37):
the AO accrediting organization, because both are considered.
And one of the interestingthings that we saw, at least in
our preliminary review, is thatthe hospices that certainly that
we have looked at did not havea significant amount of
(09:57):
condition level deficiencies orcomplaint surveys or, and in
some cases, their quality scores, you know, do not appear to be,
they appear to be good orexcellent.
So what that tells me and us isthat hospices need to make sure
they're monitoring because andhospices need to make sure
they're monitoring because justbecause you've only had one
(10:20):
condition level deficiency orone substantiated complaint, you
know, or some low scores withyour HQRP or your low response
for CAPS, that doesn't mean thatyou will not be selected.
We don't know the answer tothat, because that falls under
the algorithm.
It's just to me that waseye-opening, to us and to others
(10:42):
in the industry that in factit's not what people think when
we look at fraud and abuse andCMS's focus on fraud and abuse
and increasing survey oversightin terms of poor performers.
So, without knowing, you knowthe algorithm and how they were
(11:07):
selected.
It's important that hospicesunderstand that it doesn't mean
that if you, you know, only haveone condition level or one
complaint, that you would notnecessarily be selected, at
least based on what we have seenselected, at least based on
what we have seen.
Speaker 1 (11:21):
Yeah, exactly.
So you know I watch all thoseHQRP scores that come out with
each refresh and you know I'mparticularly paying attention to
those national scores.
So organizations that you knowthey may be like, let's say, you
know one measure has a nationalscore of like 80, and they may
be at like 77.
They're not too far off thenational.
(11:57):
But you know am pulling out andciting those four CAPS measures
that pull into the SFPalgorithm in particular.
Yes, you need to beconcentrating on those, but you
should be concentrating on allof your measures, because it's
the whole hospice experiencethat influences how that
(12:18):
caregiver is going to completethat survey.
I also think, kim, since we aregoing to have a revised CAP
survey with April decedents in2025, that includes a web mode
that might help to increasesurvey return.
So you know, I'm anxious to seehow that sort of is going to
(12:42):
figure in moving forward.
Speaker 2 (12:45):
I think that's an excellent point because response
rate often is a key contributorto low scores.
So, again, as part of anorganization's quality reporting
and QAPI program, you know,making sure that they're looking
at the root cause if you willof you know any bottom, not less
(13:10):
I'm going to say it, less thantop box scores, as well as
certainly opportunities forimprovement with all outcomes.
And I agree that the focusneeds to be on all, all measures
really for quality.
I would say the same with theCOPs, because we want to make
sure that you have, you knowthat you're meeting the
(13:31):
conditions of participation inall areas and avoid condition
level deficiencies.
Knowing that the 11, the 11quality of avoid condition level
deficiencies.
Knowing that the 11, the 11quality of care, condition level
deficiencies impact, impact SFP.
Once you're on the SFP, youcannot have any condition level
deficiencies.
You know it doesn't specify justthose 11.
(13:52):
Also, of those 11, this iswhere the majority of findings
and condition level deficienciesare cited, because they really
focus on patient care, careplanning and assessment.
Speaker 1 (14:08):
Since you took the dive into COPs, I think we need
to talk about survey readiness,don't you?
Absolutely.
Speaker 2 (14:14):
Absolutely, and I never have a shortage of time to
talk about.
I do on the podcast, but ingeneral, we all know that I have
been preaching survey readinessand follow up for many, many
years I think you have a sash,don't you queen?
(14:42):
So I have preached surveyreadiness for many, many years
because it really is vitallyimportant to organizations for
survey success and I think it'sno more important than than now.
You know has not been ever moreimportant than now in terms of
organizations really making surethat they have a robust survey
(15:06):
readiness program thatencompasses education,
monitoring and oversight,conducting those mock surveys,
knowing appendix M and staffunderstanding their role in
survey and clinicaldocumentation, home visits,
really focusing on all COPs,really patient care, safe health
(15:29):
, safe patient care and qualityof care.
And what we found is, no matterwhat size your hospice is and
what we found is, no matter whatsize your hospice is, if you're
small, if you're one providerwith a couple of ADSs or even an
inpatient unit, or you're alarge corporate organization
(15:49):
with many providers, you want tomake sure you have a process
for oversight, trust, but verifyin our world, and this means,
don't you know, make sure thatthe policies, programs,
processes you're putting in,you're implementing in an
organization that it is beingfollowed through, especially in
(16:12):
you know, with new changes instaff and management.
Speaker 1 (16:27):
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 bedsideclinicians, it includes
leadership.
But if you have policies, ifyou have SOPs in place and
you're educating people andholding them to that, I feel
(16:52):
that you know that's a big piecethat sometimes organizations
don't do well with right.
Speaker 2 (16:59):
I agree, I agree.
It's so important, it'saccountability.
You're right, both with surveyreadiness, compliance with
standards, implementation ofQAPI, performance improvement
projects, follow-up if there's aplan of correction.
But it's also important tounderstand that survey readiness
is not an event.
(17:20):
It's not when we're ready forthe next, we know that we're in
the window for the next surveyRight, right, right.
It needs to occur all the timebecause it you know you can have
a complaint survey at any timeand it is in those complaint
surveys that often there are,you know, there are findings
that may rise to condition level.
(17:40):
But having everyone understand,you know and be ready always is
, you know, a regular processfor oversight and follow-up is
really a best practice.
Speaker 1 (17:52):
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 QAPIprogram is continuous 360
assessment.
Right, you can have all the datasources that CMS can give you
and they're great, they're veryhelpful.
But taking the temperatureinside your organization in all
(18:13):
facets is really going to tellyou how you're doing, because
we're putting it up against COPs, we're putting it up against if
you're looking at conditionsfor payment, we're putting it up
against subpart B, right, we'redoing all of those things and
that I think that is the mostimportant data source is keeping
(18:34):
up on that continuousassessment within all corners of
your organization.
And, if you need to, you knowif you identify a problem and
you're running it through yourprogram as a PIP.
You know, don't relax on someother things, like you know your
regular thresholds fordocumentation review, for
(18:56):
example.
So, yeah, I agree with you andI think a compliant organization
is survey ready.
They should be survey ready andwe owe it to every patient that
we admit into every hospice inthe United States for them to
have a quality experience and wecan only guarantee that with
(19:20):
compliance right as a foundation.
What are your thoughts on that?
Speaker 2 (19:24):
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 inaddition to and providing safe,
quality care for patients.
You know taking care of theirpatients, taking care of their
staff, making sure that they youknow all of the operational
(19:47):
needs that they have to addressevery single day.
On top of you know absolutelycompliance, which I call
compliance, billing compliance,payment compliance, audits,
making sure that they're billingproperly, and then quality I
mean, I'm sorry, regulatory, sosurvey readiness, cops, which
(20:09):
are not the same as payment,another lens as well as and then
wrapping all of those effortsand monitoring to your point
into their QAPI program andkeeping it afloat.
It's challenging.
Speaker 1 (20:24):
It is.
Speaker 2 (20:25):
I do think that you know I'll give you a shout-out
for the PI compendium, thecompliance compendium.
The compliance compendiumbecause I think that it's
incredibly important forhospices to have resources to be
able to help keep them on trackwith their everything that
(20:47):
needs to be monitored andaddressed and, operationally,
look at the most efficient andeffective way to be able to
optimize that monitoring whilestill again collecting
meaningful data.
But what do we do with it?
Because it's going to beextremely important to stay on
top of these indicators, on ontop of these, these indicators,
(21:10):
on top of everything else, and Ifeel that with with hospices
and the challenges that theyhave, they do.
Speaker 1 (21:17):
And I didn't, you know, I didn't intend to
undercut or or say you know thatI don't recognize there are
challenges.
You know you and I've been twofeet in a hospice working in our
career and it is.
You know, you have all thosethings that you know that pop up
and go wrong and all of that.
But you know, I still feel wehave to get it right with every
(21:42):
patient because for the majorityof patients coming through a
hospice program, you get onechance, you get one.
Well, that's what.
Yeah.
Speaker 2 (21:50):
And that's the number one priority, honestly, is the
health and safety of patientsand the quality of care.
So organizations need to beable to balance that ultimate
priority with making sure thatthey know what is needed to be
able to continue to againprovide that education,
(22:13):
monitoring and oversight in allof these areas, and you know so
how that is implemented withintheir organization.
Sometimes it can becomeoverwhelming, but it can be done
.
Speaker 1 (22:27):
Yeah, absolutely it can be done and you know there
are so many information sourcesout there to help keep people
updated.
Yeah, I know some organizationsmaybe they're on here right now
going what is SFP?
I had no idea.
You know this was out there andyou got to have to get a buy by
(22:51):
not getting selected in thiscohort.
But you know, staying informedI think is one of those key
compliance pieces Because whenwe're talking about quality CMS,
that's still attached tocompliance right, attached to
compliance right.
You know caps measures, his andsoon to be hope down the line.
(23:15):
But you know being informed Ithink is key and you know, if
you're not prioritizing either,where to get information that
pops into your email box, whichyou can do easily with CMS.
You sign up for stuff and itcomes right to your mailbox and
(23:38):
you know the same with CHAPinformation.
You have to go out, you have tomake it a priority and an
action to look for information.
Speaker 2 (23:51):
Absolutely and certainly.
In addition to CHAP and CMS,the state associations and the
national associations are reallya key resource for timely
information regarding importantareas such as SFP.
So, as we think about takeawaysfrom our conversation today,
(24:39):
kim, what are your thoughtsabout?
What would you like people orlisteners here to take away away
is SFP organizations have beenselected the 50, for 2025, and
they will enter into the SFPprogram and we are all learning
the program as it's beingimplemented.
But every hospice needs tolearn from the SFP and the
indicators and ensure that theyhave a process to monitor those
areas and also implement againan ongoing survey, readiness
(25:03):
program and QAPI program.
Speaker 1 (25:06):
Yeah, I couldn't agree with you more.
I mean, you know we don't havethat list that CMS is keeping
back right now.
So there's hospices on therethat don't know they're on there
right.
So again, you can't sit backand say, yay, I got a buy, I'm
good.
You know, right now Maybeyou're not, maybe you are on a
(25:26):
list somewhere that CMS hasn'tposted yet.
But I agree, you know, surveyreadiness, performance,
improvement all the way around,with particular focus on those
items indicator items in the SFPcrucial for every hospice.
Speaker 2 (25:42):
Absolutely.
Speaker 1 (25:45):
All right.
Well, this has been a greatconversation with my friend Kim.
Well, this has been a greatconversation with my friend Kim.
You know we live and breathethis stuff every day and you
know it might be something thatyou don't, but hopefully, what
(26:09):
we've brought you here today,there's more interesting topics
to come in 2025 and share theepisode with your organization.
We would appreciate that.
Also, you know, exploring allof our information on CHAP is
going to be helpful for you, kim.
Thank you for mentioning theHospice Program Integrity
Compendium resource.
(26:29):
We put that together last yearfor you, kim.
Thank you for mentioning theHospice Program Integrity
Compendium resource.
We put that together last yearfor you so that you would have
all the information in aone-stop shop for all your
program integrity needs, if youhave those needs.
I think everybody has thoseneeds at this point in hospice
history.
Any final thoughts, kim, as wewrap up.
Speaker 2 (26:52):
No, again, this is likely the first of more than a
few either podcasts orpublications or resources that
certainly we will be discussing.
But, as well as the industryand you know, I would just
encourage hospices to take itone step at a time.
If you have, you know, multipleareas to implement and also
(27:16):
please, you know, continue toshare your thoughts and comments
regarding the process and anyquestions that you have with CMS
.
They have an SFP website emailaddress with CMS.
They have an SFP website emailaddress also, certainly with us
(27:37):
and with the state and nationalassociations, so that we can
really get a handle on how thisprocess is going to be playing
out for hospices this year andgoing forward.
Speaker 1 (27:51):
Absolutely so.
Thanks, kim, for spending sometime with me.
Today.
We're spending time together totalk about SFP, and thanks to
all of you for taking time outof your day to listen to our
podcast From Kim, me and theentire CHAP staff.
Keep your quality needlesurging forward.
Stay safe and well, and theentire CHAP staff.
(28:12):
Keep your quality needlesurging forward, stay safe and
well, and thanks for all you do.
Greetings and salutations.
I'm Jennifer Kennedy, the leadfor Compliance and Quality at
CHAP, and welcome to CHAPcast.
I'm really excited for our newformat this year that we're
going to employ, particularlybecause I get to work with my
colleague and friend, kim Skehan, to bring you topics that
(00:27):
really impact your dailyoperations and clinical practice
so that we can help you be thebest hospice or home health or
DME that you can possibly be.
So today we're going to talkabout the new CMS Hospice
Special Focus Program, or theSFP.
So this is a really brand newhospice community experience,
(00:51):
particularly for the 50 hospicesthat have been selected to
participate in the first cohortthat began January 1st 2025.
And, as I mentioned, in our newformat, I'm going to be joined
by Kim Skehan.
She is our vice president foraccreditation.
(01:13):
Kim and I know each other ohgosh forever.
So this is going to be talkingabout compliance and quality is
absolutely going to be a blastfor us, and I think opening out
the first topic of the year withFSP is going to be a little bit
challenging because of some ofthe things that swirl around it,
(01:35):
but I think we're ready to havea robust conversation.
What do you think, kim?
Speaker 2 (01:41):
I think so, Jennifer.
We need to be ready, as dohospice providers, and I would
agree.
First of all, Happy New Yeareveryone, and we are starting
the new year off for hospiceswith a bang with the
implementation of the SFP Boththe challenges and opportunities
(02:02):
for hospices to really be ableto establish, you know, if
you're not selected for the SFP,what you can do in terms of
monitoring your status andmitigating your chances of being
selected for SFP in the future.
I do agree.
In the future.
(02:29):
I do agree.
As you said, we have known eachother for many years in hospice
and regulatory and complianceand it's always always a lot of
fun to be able to talk with youand share with you and share for
the industry, even when it isthese difficult subjects, and we
want to be able to bring thatinformation to everyone you know
(02:50):
and be able to really providestrategies for folks to be able
to implement for effectivecompliance, if you will.
So today is, as you said, SFPis, as we know, part of the
Consolidated Appropriations Act.
(03:11):
It's the last part of theConsolidations Appropriations
Act to be implemented and thisis part of CMS's and part of the
responsibility of CMS toimplement as a component of
enforcement remedies.
(03:32):
Sfp is designed to monitorhospices identified as poor
performers based on the selectedquality indicators, regardless
of the agency size, locallocation and profit or ownership
status.
What we have seen in theinitial 50 agencies selected in
(03:54):
the cohort is that there aresome questions, even from the
industry, regarding theselection process.
So there are from a federal I'msorry, from a national
standpoint.
We know that there is advocacyin working with CMS to look at
(04:15):
the algorithm and the accuracy.
But from the standpoint ofcertainly us as CHAP, but also
other hospices, what we reallywant to look at is focus on the
data, the data that is beingused, the indicators, and it's
in looking at those indicators,Jennifer, that I think we just
(04:37):
want to really make sure that wefocus on and help hospices,
help to really understand whatthey can do in terms of control.
Speaker 1 (04:49):
So you know, when the rule came out about the SFP and
you know what was going to bein that algorithm, there was a
lot of feedback that came backwith comments.
You know not only individualhospices providing feedback but,
like you said, those nationalorganizations, and there was
(05:10):
some pushback on the methodologyand the balance of the items in
that algorithm.
And you know, as late as thispast fall, these national
organizations have been stillpushing back right, saying, you
(05:31):
know, hey, we need you to relookat this.
You know, we still don't feellike it is where it needs to be.
And actually they lobbiedCongress.
Congress came to CMS and said,hey, we think you should pull
back a little bit, look at thealgorithm.
But here we are, though CMSpressed forth and we now have
(05:57):
our first cohort of SFPs.
So I mean, it's like a work inprogress, isn't it, kim?
It's still.
You know, we don't know what wedon't know, because we're in a
whole new territory.
Speaker 2 (06:12):
Yep, absolutely, and again, it's kind of like fixing
the plane when you're in the air.
Yeah, and this is the approachthat has been taken with
programs, where programs havebeen launched and they need to
be adjusted along the way.
(06:32):
So the hope here is that thereis an ability to be able to work
with CMS to make anyadjustments that are needed as
this unfolds.
The unfortunate part at thispoint is that, with the release
now, with the 2025 50 selectees,unless there's any
(06:58):
congressional change, they areselected and moving forward
currently with those 50 agencies.
And then we also know thatultimately, the plan is to
publish the bottom 10%, what'scalled the bottom 10% or the 10%
for performers, which can beover 600 hospices, I believe,
(07:24):
and we understand that that'snot going to current, that's on
hold for public reporting orpublishing right now, but you
know we will again remains to beseen.
So for hospices that are not onthe 50, the hospices that are
selected, you know, as the 50agencies participating in the
(07:44):
SFP, there's still the potentialfor the publication for the
bottom 10%.
And again, a cautionary talefor all hospices, even if you're
not on the SFP, because this ispresumed to be an annual list,
an annual program.
Speaker 1 (08:06):
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 athree-year rolling look back
from year to year.
So I mean that's something thatI think organizations have to,
(08:26):
you know, put into theirconsideration when they're
looking at compliance andquality performance and
identifying gaps in places forimprovement.
So you know that Novemberrefresh on Medicare Compare of
(08:49):
the quality measures is reallythe trigger that gets the next
year cohort going right.
And it's interesting because ofNovember and it usually comes,
I don't know, mid-ish that thosemeasures are refreshed.
It puts people on a reallyshort timeline if they are
(09:12):
looped into that timelineprogram, don't you think?
Speaker 2 (09:16):
I do and, again, I also think that you know,
organizations really need tomonitor their quality reporting
as well as these substantiatedcomplaints and the condition
level deficiencies in those 11quality of care measures,
whether the surveys areconducted by the state agency or
(09:37):
the AO accrediting organization, because both are considered.
And one of the interestingthings that we saw, at least in
our preliminary review, is thatthe hospices that certainly that
we have looked at did not havea significant amount of
(09:57):
condition level deficiencies orcomplaint surveys or, and in
some cases, their quality scores, you know, do not appear to be,
they appear to be good orexcellent.
So what that tells me and us isthat hospices need to make sure
they're monitoring because andhospices need to make sure
they're monitoring because justbecause you've only had one
(10:20):
condition level deficiency orone substantiated complaint, you
know, or some low scores withyour HQRP or your low response
for CAPS, that doesn't mean thatyou will not be selected.
We don't know the answer tothat, because that falls under
the algorithm.
It's just to me that waseye-opening, to us and to others
(10:42):
in the industry that in factit's not what people think when
we look at fraud and abuse andCMS's focus on fraud and abuse
and increasing survey oversightin terms of poor performers.
So, without knowing, you knowthe algorithm and how they were
(11:07):
selected.
It's important that hospicesunderstand that it doesn't mean
that if you, you know, only haveone condition level or one
complaint, that you would notnecessarily be selected, at
least based on what we have seenselected, at least based on
what we have seen.
Speaker 1 (11:21):
Yeah, exactly.
So you know I watch all thoseHQRP scores that come out with
each refresh and you know I'mparticularly paying attention to
those national scores.
So organizations that you knowthey may be like, let's say, you
know one measure has a nationalscore of like 80, and they may
be at like 77.
They're not too far off thenational.
(11:57):
But you know am pulling out andciting those four CAPS measures
that pull into the SFPalgorithm in particular.
Yes, you need to beconcentrating on those, but you
should be concentrating on allof your measures, because it's
the whole hospice experiencethat influences how that
(12:18):
caregiver is going to completethat survey.
I also think, kim, since we aregoing to have a revised CAP
survey with April decedents in2025, that includes a web mode
that might help to increasesurvey return.
So you know, I'm anxious to seehow that sort of is going to
(12:42):
figure in moving forward.
Speaker 2 (12:45):
I think that's an excellent point because response
rate often is a key contributorto low scores.
So, again, as part of anorganization's quality reporting
and QAPI program, you know,making sure that they're looking
at the root cause if you willof you know any bottom, not less
(13:10):
I'm going to say it, less thantop box scores, as well as
certainly opportunities forimprovement with all outcomes.
And I agree that the focusneeds to be on all, all measures
really for quality.
I would say the same with theCOPs, because we want to make
sure that you have, you knowthat you're meeting the
(13:31):
conditions of participation inall areas and avoid condition
level deficiencies.
Knowing that the 11, the 11quality of avoid condition level
deficiencies.
Knowing that the 11, the 11quality of care, condition level
deficiencies impact, impact SFP.
Once you're on the SFP, youcannot have any condition level
deficiencies.
You know it doesn't specify justthose 11.
(13:52):
Also, of those 11, this iswhere the majority of findings
and condition level deficienciesare cited, because they really
focus on patient care, careplanning and assessment.
Speaker 1 (14:08):
Since you took the dive into COPs, I think we need
to talk about survey readiness,don't you?
Absolutely.
Speaker 2 (14:14):
Absolutely, and I never have a shortage of time to
talk about.
I do on the podcast, but ingeneral, we all know that I have
been preaching survey readinessand follow up for many, many
years I think you have a sash,don't you queen?
(14:42):
So I have preached surveyreadiness for many, many years
because it really is vitallyimportant to organizations for
survey success and I think it'sno more important than than now.
You know has not been ever moreimportant than now in terms of
organizations really making surethat they have a robust survey
(15:06):
readiness program thatencompasses education,
monitoring and oversight,conducting those mock surveys,
knowing appendix M and staffunderstanding their role in
survey and clinicaldocumentation, home visits,
really focusing on all COPs,really patient care, safe health
(15:29):
, safe patient care and qualityof care.
And what we found is, no matterwhat size your hospice is and
what we found is, no matter whatsize your hospice is, if you're
small, if you're one providerwith a couple of ADSs or even an
inpatient unit, or you're alarge corporate organization
(15:49):
with many providers, you want tomake sure you have a process
for oversight, trust, but verifyin our world, and this means,
don't you know, make sure thatthe policies, programs,
processes you're putting in,you're implementing in an
organization that it is beingfollowed through, especially in
(16:12):
you know, with new changes instaff and management.
Speaker 1 (16:27):
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 bedsideclinicians, it includes
leadership.
But if you have policies, ifyou have SOPs in place and
you're educating people andholding them to that, I feel
(16:52):
that you know that's a big piecethat sometimes organizations
don't do well with right.
Speaker 2 (16:59):
I agree, I agree.
It's so important, it'saccountability.
You're right, both with surveyreadiness, compliance with
standards, implementation ofQAPI, performance improvement
projects, follow-up if there's aplan of correction.
But it's also important tounderstand that survey readiness
is not an event.
(17:20):
It's not when we're ready forthe next, we know that we're in
the window for the next surveyRight, right, right.
It needs to occur all the timebecause it you know you can have
a complaint survey at any timeand it is in those complaint
surveys that often there are,you know, there are findings
that may rise to condition level.
(17:40):
But having everyone understand,you know and be ready always is
, you know, a regular processfor oversight and follow-up is
really a best practice.
Speaker 1 (17:52):
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 QAPIprogram is continuous 360
assessment.
Right, you can have all the datasources that CMS can give you
and they're great, they're veryhelpful.
But taking the temperatureinside your organization in all
(18:13):
facets is really going to tellyou how you're doing, because
we're putting it up against COPs, we're putting it up against if
you're looking at conditionsfor payment, we're putting it up
against subpart B, right, we'redoing all of those things and
that I think that is the mostimportant data source is keeping
(18:34):
up on that continuousassessment within all corners of
your organization.
And, if you need to, you knowif you identify a problem and
you're running it through yourprogram as a PIP.
You know, don't relax on someother things, like you know your
regular thresholds fordocumentation review, for
(18:56):
example.
So, yeah, I agree with you andI think a compliant organization
is survey ready.
They should be survey ready andwe owe it to every patient that
we admit into every hospice inthe United States for them to
have a quality experience and wecan only guarantee that with
(19:20):
compliance right as a foundation.
What are your thoughts on that?
Speaker 2 (19:24):
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 inaddition to and providing safe,
quality care for patients.
You know taking care of theirpatients, taking care of their
staff, making sure that they youknow all of the operational
(19:47):
needs that they have to addressevery single day.
On top of you know absolutelycompliance, which I call
compliance, billing compliance,payment compliance, audits,
making sure that they're billingproperly, and then quality I
mean, I'm sorry, regulatory, sosurvey readiness, cops, which
(20:09):
are not the same as payment,another lens as well as and then
wrapping all of those effortsand monitoring to your point
into their QAPI program andkeeping it afloat.
It's challenging.
Speaker 1 (20:24):
It is.
Speaker 2 (20:25):
I do think that you know I'll give you a shout-out
for the PI compendium, thecompliance compendium.
The compliance compendiumbecause I think that it's
incredibly important forhospices to have resources to be
able to help keep them on trackwith their everything that
(20:47):
needs to be monitored andaddressed and, operationally,
look at the most efficient andeffective way to be able to
optimize that monitoring whilestill again collecting
meaningful data.
But what do we do with it?
Because it's going to beextremely important to stay on
top of these indicators, on ontop of these, these indicators,
(21:10):
on top of everything else, and Ifeel that with with hospices
and the challenges that theyhave, they do.
Speaker 1 (21:17):
And I didn't, you know, I didn't intend to
undercut or or say you know thatI don't recognize there are
challenges.
You know you and I've been twofeet in a hospice working in our
career and it is.
You know, you have all thosethings that you know that pop up
and go wrong and all of that.
But you know, I still feel wehave to get it right with every
(21:42):
patient because for the majorityof patients coming through a
hospice program, you get onechance, you get one.
Well, that's what.
Yeah.
Speaker 2 (21:50):
And that's the number one priority, honestly, is the
health and safety of patientsand the quality of care.
So organizations need to beable to balance that ultimate
priority with making sure thatthey know what is needed to be
able to continue to againprovide that education,
(22:13):
monitoring and oversight in allof these areas, and you know so
how that is implemented withintheir organization.
Sometimes it can becomeoverwhelming, but it can be done
.
Speaker 1 (22:27):
Yeah, absolutely it can be done and you know there
are so many information sourcesout there to help keep people
updated.
Yeah, I know some organizationsmaybe they're on here right now
going what is SFP?
I had no idea.
You know this was out there andyou got to have to get a buy by
(22:51):
not getting selected in thiscohort.
But you know, staying informedI think is one of those key
compliance pieces Because whenwe're talking about quality CMS,
that's still attached tocompliance right, attached to
compliance right.
You know caps measures, his andsoon to be hope down the line.
(23:15):
But you know being informed Ithink is key and you know, if
you're not prioritizing either,where to get information that
pops into your email box, whichyou can do easily with CMS.
You sign up for stuff and itcomes right to your mailbox and
(23:38):
you know the same with CHAPinformation.
You have to go out, you have tomake it a priority and an
action to look for information.
Speaker 2 (23:51):
Absolutely and certainly.
In addition to CHAP and CMS,the state associations and the
national associations are reallya key resource for timely
information regarding importantareas such as SFP.
So, as we think about takeawaysfrom our conversation today,
(24:39):
kim, what are your thoughtsabout?
What would you like people orlisteners here to take away away
is SFP organizations have beenselected the 50, for 2025, and
they will enter into the SFPprogram and we are all learning
the program as it's beingimplemented.
But every hospice needs tolearn from the SFP and the
indicators and ensure that theyhave a process to monitor those
areas and also implement againan ongoing survey, readiness
(25:03):
program and QAPI program.
Speaker 1 (25:06):
Yeah, I couldn't agree with you more.
I mean, you know we don't havethat list that CMS is keeping
back right now.
So there's hospices on therethat don't know they're on there
right.
So again, you can't sit backand say, yay, I got a buy, I'm
good.
You know, right now Maybeyou're not, maybe you are on a
(25:26):
list somewhere that CMS hasn'tposted yet.
But I agree, you know, surveyreadiness, performance,
improvement all the way around,with particular focus on those
items indicator items in the SFPcrucial for every hospice.
Speaker 2 (25:42):
Absolutely.
Speaker 1 (25:45):
All right.
Well, this has been a greatconversation with my friend Kim.
Well, this has been a greatconversation with my friend Kim.
You know we live and breathethis stuff every day and you
know it might be something thatyou don't, but hopefully, what
(26:09):
we've brought you here today,there's more interesting topics
to come in 2025 and share theepisode with your organization.
We would appreciate that.
Also, you know, exploring allof our information on CHAP is
going to be helpful for you, kim.
Thank you for mentioning theHospice Program Integrity
Compendium resource.
(26:29):
We put that together last yearfor you, kim.
Thank you for mentioning theHospice Program Integrity
Compendium resource.
We put that together last yearfor you so that you would have
all the information in aone-stop shop for all your
program integrity needs, if youhave those needs.
I think everybody has thoseneeds at this point in hospice
history.
Any final thoughts, kim, as wewrap up.
Speaker 2 (26:52):
No, again, this is likely the first of more than a
few either podcasts orpublications or resources that
certainly we will be discussing.
But, as well as the industryand you know, I would just
encourage hospices to take itone step at a time.
If you have, you know, multipleareas to implement and also
(27:16):
please, you know, continue toshare your thoughts and comments
regarding the process and anyquestions that you have with CMS
.
They have an SFP website emailaddress with CMS.
They have an SFP website emailaddress also, certainly with us
(27:37):
and with the state and nationalassociations, so that we can
really get a handle on how thisprocess is going to be playing
out for hospices this year andgoing forward.
Speaker 1 (27:51):
Absolutely so.
Thanks, kim, for spending sometime with me.
Today.
We're spending time together totalk about SFP, and thanks to
all of you for taking time outof your day to listen to our
podcast From Kim, me and theentire CHAP staff.
Keep your quality needlesurging forward.
Stay safe and well, and theentire CHAP staff.
(28:12):
Keep your quality needlesurging forward, stay safe and
well, and thanks for all you do.
Popular Podcasts
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
24/7 News: The Latest
The latest news in 4 minutes updated every hour, every day.
Therapy Gecko
An unlicensed lizard psychologist travels the universe talking to strangers about absolutely nothing. TO CALL THE GECKO: follow me on https://www.twitch.tv/lyleforever to get a notification for when I am taking calls. I am usually live Mondays, Wednesdays, and Fridays but lately a lot of other times too. I am a gecko.