Top 10 Hospice Survey Deficiencies According to CMS at the NHPCO MLC 2012

Representatives of CMS’ Survey and Certification Group provided valuable insight into the top 10 survey citations/deficiencies for hospice providers at the National Hospice and Palliative Care Organization’s, 27th Annual Management and Leadership Conference last week. The informative session discussed survey deficiencies,  the implementation of quality measures as well as CMS’ efforts to reform the hospice reimbursement system. Understanding the top 10 survey deficiencies is an important part of planning overall regulatory compliance initiatives and day to day operations. The top ten citations relate broadly to the areas of care planning, supervision and training of employees, and the provision of certain counseling services.

The CMS presentation outlined the deficiencies listed below as the most recent 10 ten cited –

  • L543 – §418.56(b) Standard: Plan of care
  • L629 – §418.76(h) Standard: Supervision of hospice aides
  • L545 – §418.56(c) Standard: Content of the plan of care
  • L530 – §418.54(c)(6) – Drug profile
  • L555 – §418.56(e)(2) – Ensure that the care and services are provided in accordance with the plan of care
  • L591 – §418.64(b) Standard: Nursing services
  • L552 – §418.56(d) Standard: Review of the plan of care
  • L596 – §418.64(d) – Counseling services
  • L615 – §418.76(c) Standard: Competency evaluation
  • L523 – §418.54(b) Standard: Timeframe for completion of the comprehensive assessment

Each of the L-Tag numbers corresponds to a particular regulatory section or subsection of the Hospice Conditions of Participation found in 42 C.F.R. Part §418. Additional information on the citations/deficiencies and the interpretive guidelines for surveyors can be found in the CMS State Operations Manual, Appendix M.

Hospice providers should focus regulatory compliance and operational resources in the areas covered by the citations listed as they represent the issues most often found by State Agencies in the Survey process.

Additional Information

For more information on any of the top ten deficiencies or developing a plan to focus on these issues within your compliance or operations staff, please feel free to contact a member of Benesch’s Health Care Department.

You can also get a copy of CMS’ State Operations Manual, Appendix M here —> Appendix M

You can get a copy of the most recently available Hospice Conditions of Participation here —> 42 C.F.R. §418 (2011 – USGPO Version)

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