February 25, 2025 • 15 mins
Understanding the top 10 hospice deficiencies for 2024 is crucial for providers committed to compliance and quality care. This episode explores key themes like survey readiness, comprehensive assessments, case management roles, and the importance of continuous improvement strategies.
• Importance of recognizing key hospice deficiencies
• Challenges in today's survey environment
• Trends focusing on care planning and assessments
• Case management as an essential component of patient care
• Emphasis on interdisciplinary teamwork and communication
• Necessity of mock surveys for ongoing readiness
• Strategies for maintaining compliance and enhancing care quality
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Greetings and salutations.
I'm Jennifer Kennedy, the leadfor compliance and quality at
CHAP, and welcome to thisepisode of CHAPcast.
Today we're going to be talkingabout the top 10 survey
deficiencies for hospiceproviders in 2024.
And these are CHAP top 10deficiencies.
So I'm so glad to be back withmy fantastic co-host, Kim Skehan
(00:25):
and thanks, Kim, it's alwaysgood to be together to talk
about hospice compliance andsurvey and all that good stuff.
Speaker 2 (00:36):
Absolutely, jennifer.
I'm so happy to be here.
We tag team very well togetherwhen it comes to regulatory
compliance and survey, so thisis a very important topic, and
today we're going to talk aboutwhy is it important to know the
top 10 hospice deficiencies, andduring this discussion we'll
(01:00):
talk about some of those keypoints that providers need to be
aware of, especially in thissurvey environment.
Speaker 1 (01:08):
So it is.
You know it is getting to be atougher survey environment.
Plus, we have the high stakesSFP special focus program that
you know plays a part of this.
So why do you think it'simportant for hospice providers
to be aware of what these top 10deficiencies are?
Speaker 2 (01:28):
I think it's part of an organization's overall survey
readiness making sure that theyare aware of the top
deficiencies, common areas thathospices are cited from CHAP and
also, specifically with hospice, the 11 quality of care
(01:49):
conditions of participation thatare also being included in the
SFP.
But hospices do need to makesure that they are in compliance
with all COPs and standards.
But knowing these top 10 reallyhelped to focus on these common
areas.
Speaker 1 (02:07):
Yeah, you know what.
I'm just going to pop thisright in here for our listeners.
You know we used to have accessto this website called QCOR,
which was a CMS-maintainedwebsite that had all survey
information in it, whether it beaccreditation organizations or
(02:27):
state or whatever and it wasgreat because you had all this
data and you could slice anddice it various ways to not only
see, maybe, your ownperformance over time hopefully
you'll be tracking that, thoughbut seeing what your area
hospice as a whole looks like.
(02:48):
Now we don't have that luxury.
Right now, cms has beenmigrating all of their data from
this QCOR website, which willeventually live in Keys, and we
don't have a hard date on whenthat is going to be complete in
terms of the migration, but Ithink when we do get that QIES
(03:13):
database up and running, it isimportant for providers to be
able to know where that is andplug into it so that they can
see data a variety of ways.
What are your thoughts on that,kim?
Speaker 2 (03:31):
Absolutely, and I think once that data also is
available, an organization stateassociation does also typically
have is able to obtain thatinformation, so maybe a resource
as well.
But either way, it's a great.
It is a great tool.
In the meantime, we have ourtop 10 deficiencies, which
closely align with what we haveknown as CMS findings, because
(03:52):
when you do look at our findings, which can be found on our CHAP
website, chapincorg, undersurvey readiness, resources and
for each service line, you canthen find the top 10
deficiencies and you'll see thatthey correlate with LTACs, so
they do correlate with CMS COPsand standards.
(04:19):
Jennifer, in looking at the top10 for hospice for 2024, which
is not uncommon to previousyears you can see that most of
the findings relate to careplanning, assessment and
coordination of care.
What are your thoughts on that?
Speaker 1 (04:40):
Well, that's sort of been the trend over years and
years on waffles as long as Ican remember.
Essentially we've had plan ofcare in that top 10.
You know, I'm sure I don't knowa chap's history, but I know
when I'm talking about top 10for CMS.
So you know, really, when we'retalking about comprehensive
(05:22):
assessment and plan of care,those are two like cornerstone
COPs, I think in the COPsbecause we gather information
about patients and families viathe comprehensive assessment and
then we use the plan of care todevelop the roadmap for caring
for these patients.
So it's like this never-endingcycle of assessment and plan of
care.
And I do think, kim, that ifhospices aren't paying attention
to their comprehensiveassessment process or the
(05:46):
assessment process overall, theymight be at a deficit by the
time we hit implementation forhope.
This is the time now forprepping for hope, for doing
better on comprehensiveassessments, which feeds into
plan of care, of identifyinggaps right now in your
(06:08):
assessment process, because it'sgoing to get a little more
complicated when we're talkingabout adding in time visits and
things like that from the hopeprocess.
Speaker 2 (06:19):
Absolutely.
I completely agree and one ofthe when we look at strategies
for organizations, hospices toimplement, to improve
particularly in this area.
But overall care and treatmentand services, organizations
really have to make sure thatthe RN, hospice case managers
(06:42):
understand the role of a casemanager and case management.
This is a key component inconnecting the dots and looking
at the whole picture.
Even though hospice isfortunate to have the IDG, very
often we have nurses, rns, whoare by regulation, by standard,
required to lead the plan ofcare and drive the plan of care
(07:04):
and the care for these patientsand drive the plan of care and
the care for these patients.
They often focus on, may focusonly on, the nursing component
and not understand the fullcomplement and responsibilities
associated with case management.
(07:25):
Having come from facilities,many RNs have not been trained
in that skill set, so hospicesreally need to make sure that
they can have a process to trainthe staff and ensure that those
strategies or requirementsreally characteristics are
implemented.
Speaker 1 (07:45):
Yeah, you know what.
I just want to poke in therefor a second.
Even though you make a goodpoint, you know it's an
interdisciplinary approach inhospice right, and we, you know,
we want to make sureorganizations understand that
nothing changes in assessmentwith this implementation of hope
, even though it is nursingheavy right.
(08:07):
Even though it is nursing heavyright that we can't forget we
are an interdisciplinary teamand that's the approach we take
for assessment and care planning.
Speaker 2 (08:19):
So I agree with you a thousand percent on the RN case
manager front.
Yeah, yes, again, justunderstanding that role.
I think that this would be agreat topic, because case
management, the principles ofcase management, the role of the
case manager is more in depththan we have time for, but I
think a future podcast or chatcast would be an excellent idea.
(08:40):
What do you think?
Speaker 1 (08:41):
I like that idea.
I think we should startthinking about how that's going
to map out.
Speaker 2 (08:47):
Absolutely.
And then, just, you know thecouple of other, just a few
other of the deficiencies thatyou want to talk about.
Waffles, Hospice aids areperennial pile on, you know
findings in the top 10.
Speaker 1 (09:06):
Do you see me hiding my eyes?
Do you see me?
Speaker 2 (09:08):
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 ourtop 10, we know that that's a
(09:30):
common area, particularlyrelated to home visits and you
know, and care of the patient inthe home.
So I think you know it's reallyworth it for organizations to
you know, to really look andmonitor as part of their own
process, survey readiness, theresources that we have right Top
(09:52):
10 deficiencies, any of theirown previous findings as well,
and those 11 quality of care,quality of care, cops, and
really make sure that they areimplementing what they need and
be survey ready.
Speaker 1 (10:09):
Yeah, I was.
I knew you were going to get tothat.
You know, kim, can we Thank you?
I think the strategies aregreat, but can we step back one
second?
Was there anything on that top10 list that surprised you at
all?
Speaker 2 (10:23):
For the.
Nothing really surprises mebecause, again, the majority are
related to initial andcomprehensive assessment and
care planning.
Hospice aides, perennial andphysician orders is also.
Making sure there are physicianorders is also something common
.
I do think that hospices needto be reminded that the copy of
(10:54):
the discharge summary does needto go to the attending physician
, if one is named, and also tothe facility.
If a patient is transferred toa facility, that's probably the
one that I see that is notconsistently on, or wasn't
consistently on, the federallist.
Speaker 1 (11:13):
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'reabsolutely spot on with we have
(11:35):
to make sure that everythingthat we do is geared towards,
you know, having somebodywhether it you know it's a
surveyor, or even like anauditor walk into your
organization and start to lookat all of your documents or all
(11:57):
of the things that you're doing.
And I think I would just say Ithink hospices need to do a
better job in that for sure.
Speaker 2 (12:07):
Absolutely, and it's an ongoing process.
This is not a one and donegetting ready when you know
you're in the window.
You really want to be ready atall times.
Speaker 1 (12:18):
Absolutely so if we were going to suggest, you know,
a few takeaways today for ourorganizations that are plugged
in and listening.
Speaker 2 (12:36):
What will come to your top of your mind, Kim?
Number one again, making surethat hospices are aware of what
those top 10 deficiencies areand those 11 quality of care
COPs, but also as anorganization, making sure that
there is a process for ongoingsurvey readiness and monitoring
of all standards, and you'llhear me say it every single time
we strongly recommend mocksurveys as a way to make sure
(13:02):
that you are on top of anypotential issues, and that's
really my key takeaway.
And then, as I said, realizingso many years with the
assessment and plan of careissues that we've seen that
really looking at casemanagement so that the RNs do
(13:25):
understand the coordination ofcare component when it comes to
implementing the plan of care inconjunction with the IDG.
Speaker 1 (13:36):
Yeah, I agree with you.
You know talking about surveys.
You know all the year throughand what we have to do to be
compliant.
It's a continuous process, it'snot just when you're, you know,
six months out from your nextsurvey.
So, yeah, totally agree withthat.
Speaker 2 (13:55):
Especially when a complaint survey can come at any
time.
Speaker 1 (14:00):
That is true.
All right, so I'm going to echoyou, kim, and invite our
listeners to check out the top10 survey deficiencies for 2024.
And those are up on our webpageunder the hospice tab.
With that, I think we're goingto wrap up today.
(14:21):
We gave you our thoughts andour suggestions for success, so
we'll hope that you can takesome of those pearls of wisdom
away with you.
And again, thank you for takingtime out of your day to spend
some time with us listening tothe podcast from Kim, me and the
(14:42):
entire CHAP staff.
Keep your quality needlessurging forward and stay safe
and well, and thanks for all youdo.
Greetings and salutations.
I'm Jennifer Kennedy, the leadfor compliance and quality at
CHAP, and welcome to thisepisode of CHAPcast.
Today we're going to be talkingabout the top 10 survey
deficiencies for hospiceproviders in 2024.
And these are CHAP top 10deficiencies.
So I'm so glad to be back withmy fantastic co-host, Kim Skehan
(00:25):
and thanks, Kim, it's alwaysgood to be together to talk
about hospice compliance andsurvey and all that good stuff.
Speaker 2 (00:36):
Absolutely, jennifer.
I'm so happy to be here.
We tag team very well togetherwhen it comes to regulatory
compliance and survey, so thisis a very important topic, and
today we're going to talk aboutwhy is it important to know the
top 10 hospice deficiencies, andduring this discussion we'll
(01:00):
talk about some of those keypoints that providers need to be
aware of, especially in thissurvey environment.
Speaker 1 (01:08):
So it is.
You know it is getting to be atougher survey environment.
Plus, we have the high stakesSFP special focus program that
you know plays a part of this.
So why do you think it'simportant for hospice providers
to be aware of what these top 10deficiencies are?
Speaker 2 (01:28):
I think it's part of an organization's overall survey
readiness making sure that theyare aware of the top
deficiencies, common areas thathospices are cited from CHAP and
also, specifically with hospice, the 11 quality of care
(01:49):
conditions of participation thatare also being included in the
SFP.
But hospices do need to makesure that they are in compliance
with all COPs and standards.
But knowing these top 10 reallyhelped to focus on these common
areas.
Speaker 1 (02:07):
Yeah, you know what.
I'm just going to pop thisright in here for our listeners.
You know we used to have accessto this website called QCOR,
which was a CMS-maintainedwebsite that had all survey
information in it, whether it beaccreditation organizations or
(02:27):
state or whatever and it wasgreat because you had all this
data and you could slice anddice it various ways to not only
see, maybe, your ownperformance over time hopefully
you'll be tracking that, thoughbut seeing what your area
hospice as a whole looks like.
(02:48):
Now we don't have that luxury.
Right now, cms has beenmigrating all of their data from
this QCOR website, which willeventually live in Keys, and we
don't have a hard date on whenthat is going to be complete in
terms of the migration, but Ithink when we do get that QIES
(03:13):
database up and running, it isimportant for providers to be
able to know where that is andplug into it so that they can
see data a variety of ways.
What are your thoughts on that,kim?
Speaker 2 (03:31):
Absolutely, and I think once that data also is
available, an organization stateassociation does also typically
have is able to obtain thatinformation, so maybe a resource
as well.
But either way, it's a great.
It is a great tool.
In the meantime, we have ourtop 10 deficiencies, which
closely align with what we haveknown as CMS findings, because
(03:52):
when you do look at our findings, which can be found on our CHAP
website, chapincorg, undersurvey readiness, resources and
for each service line, you canthen find the top 10
deficiencies and you'll see thatthey correlate with LTACs, so
they do correlate with CMS COPsand standards.
(04:19):
Jennifer, in looking at the top10 for hospice for 2024, which
is not uncommon to previousyears you can see that most of
the findings relate to careplanning, assessment and
coordination of care.
What are your thoughts on that?
Speaker 1 (04:40):
Well, that's sort of been the trend over years and
years on waffles as long as Ican remember.
Essentially we've had plan ofcare in that top 10.
You know, I'm sure I don't knowa chap's history, but I know
when I'm talking about top 10for CMS.
So you know, really, when we'retalking about comprehensive
(05:22):
assessment and plan of care,those are two like cornerstone
COPs, I think in the COPsbecause we gather information
about patients and families viathe comprehensive assessment and
then we use the plan of care todevelop the roadmap for caring
for these patients.
So it's like this never-endingcycle of assessment and plan of
care.
And I do think, kim, that ifhospices aren't paying attention
to their comprehensiveassessment process or the
(05:46):
assessment process overall, theymight be at a deficit by the
time we hit implementation forhope.
This is the time now forprepping for hope, for doing
better on comprehensiveassessments, which feeds into
plan of care, of identifyinggaps right now in your
(06:08):
assessment process, because it'sgoing to get a little more
complicated when we're talkingabout adding in time visits and
things like that from the hopeprocess.
Speaker 2 (06:19):
Absolutely.
I completely agree and one ofthe when we look at strategies
for organizations, hospices toimplement, to improve
particularly in this area.
But overall care and treatmentand services, organizations
really have to make sure thatthe RN, hospice case managers
(06:42):
understand the role of a casemanager and case management.
This is a key component inconnecting the dots and looking
at the whole picture.
Even though hospice isfortunate to have the IDG, very
often we have nurses, rns, whoare by regulation, by standard,
required to lead the plan ofcare and drive the plan of care
(07:04):
and the care for these patientsand drive the plan of care and
the care for these patients.
They often focus on, may focusonly on, the nursing component
and not understand the fullcomplement and responsibilities
associated with case management.
(07:25):
Having come from facilities,many RNs have not been trained
in that skill set, so hospicesreally need to make sure that
they can have a process to trainthe staff and ensure that those
strategies or requirementsreally characteristics are
implemented.
Speaker 1 (07:45):
Yeah, you know what.
I just want to poke in therefor a second.
Even though you make a goodpoint, you know it's an
interdisciplinary approach inhospice right, and we, you know,
we want to make sureorganizations understand that
nothing changes in assessmentwith this implementation of hope
, even though it is nursingheavy right.
(08:07):
Even though it is nursing heavyright that we can't forget we
are an interdisciplinary teamand that's the approach we take
for assessment and care planning.
Speaker 2 (08:19):
So I agree with you a thousand percent on the RN case
manager front.
Yeah, yes, again, justunderstanding that role.
I think that this would be agreat topic, because case
management, the principles ofcase management, the role of the
case manager is more in depththan we have time for, but I
think a future podcast or chatcast would be an excellent idea.
(08:40):
What do you think?
Speaker 1 (08:41):
I like that idea.
I think we should startthinking about how that's going
to map out.
Speaker 2 (08:47):
Absolutely.
And then, just, you know thecouple of other, just a few
other of the deficiencies thatyou want to talk about.
Waffles, Hospice aids areperennial pile on, you know
findings in the top 10.
Speaker 1 (09:06):
Do you see me hiding my eyes?
Do you see me?
Speaker 2 (09:08):
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 ourtop 10, we know that that's a
(09:30):
common area, particularlyrelated to home visits and you
know, and care of the patient inthe home.
So I think you know it's reallyworth it for organizations to
you know, to really look andmonitor as part of their own
process, survey readiness, theresources that we have right Top
(09:52):
10 deficiencies, any of theirown previous findings as well,
and those 11 quality of care,quality of care, cops, and
really make sure that they areimplementing what they need and
be survey ready.
Speaker 1 (10:09):
Yeah, I was.
I knew you were going to get tothat.
You know, kim, can we Thank you?
I think the strategies aregreat, but can we step back one
second?
Was there anything on that top10 list that surprised you at
all?
Speaker 2 (10:23):
For the.
Nothing really surprises mebecause, again, the majority are
related to initial andcomprehensive assessment and
care planning.
Hospice aides, perennial andphysician orders is also.
Making sure there are physicianorders is also something common
.
I do think that hospices needto be reminded that the copy of
(10:54):
the discharge summary does needto go to the attending physician
, if one is named, and also tothe facility.
If a patient is transferred toa facility, that's probably the
one that I see that is notconsistently on, or wasn't
consistently on, the federallist.
Speaker 1 (11:13):
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'reabsolutely spot on with we have
(11:35):
to make sure that everythingthat we do is geared towards,
you know, having somebodywhether it you know it's a
surveyor, or even like anauditor walk into your
organization and start to lookat all of your documents or all
(11:57):
of the things that you're doing.
And I think I would just say Ithink hospices need to do a
better job in that for sure.
Speaker 2 (12:07):
Absolutely, and it's an ongoing process.
This is not a one and donegetting ready when you know
you're in the window.
You really want to be ready atall times.
Speaker 1 (12:18):
Absolutely so if we were going to suggest, you know,
a few takeaways today for ourorganizations that are plugged
in and listening.
Speaker 2 (12:36):
What will come to your top of your mind, Kim?
Number one again, making surethat hospices are aware of what
those top 10 deficiencies areand those 11 quality of care
COPs, but also as anorganization, making sure that
there is a process for ongoingsurvey readiness and monitoring
of all standards, and you'llhear me say it every single time
we strongly recommend mocksurveys as a way to make sure
(13:02):
that you are on top of anypotential issues, and that's
really my key takeaway.
And then, as I said, realizingso many years with the
assessment and plan of careissues that we've seen that
really looking at casemanagement so that the RNs do
(13:25):
understand the coordination ofcare component when it comes to
implementing the plan of care inconjunction with the IDG.
Speaker 1 (13:36):
Yeah, I agree with you.
You know talking about surveys.
You know all the year throughand what we have to do to be
compliant.
It's a continuous process, it'snot just when you're, you know,
six months out from your nextsurvey.
So, yeah, totally agree withthat.
Speaker 2 (13:55):
Especially when a complaint survey can come at any
time.
Speaker 1 (14:00):
That is true.
All right, so I'm going to echoyou, kim, and invite our
listeners to check out the top10 survey deficiencies for 2024.
And those are up on our webpageunder the hospice tab.
With that, I think we're goingto wrap up today.
(14:21):
We gave you our thoughts andour suggestions for success, so
we'll hope that you can takesome of those pearls of wisdom
away with you.
And again, thank you for takingtime out of your day to spend
some time with us listening tothe podcast from Kim, me and the
(14:42):
entire CHAP staff.
Keep your quality needlessurging forward and stay safe
and well, and thanks for all youdo.
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