Medicare and Medicaid Programs: Hospice Conditions of Participation, 30840-30893 [05-9935]

Agencies

• Centers for Medicare & Medicaid Services
• DEPARTMENT OF HEALTH AND HUMAN SERVICES

[Federal Register Volume 70, Number 102 (Friday, May 27, 2005)]
[Proposed Rules]
[Pages 30840-30893]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 05-9935]



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Part II





Department of Health and Human Services





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Centers for Medicare & Medicaid Services



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42 CFR Part 418



Medicare and Medicaid Programs: Hospice Conditions of Participation; 
Proposed Rule

Federal Register / Vol. 70, No. 102 / Friday, May 27, 2005 / Proposed 
Rules

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Part 418

[CMS-3844-P]
RIN 0938-AH27


Medicare and Medicaid Programs: Hospice Conditions of 
Participation

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Proposed rule.

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SUMMARY: This proposed rule would revise the existing conditions of 
participation that hospices must meet to participate in the Medicare 
and Medicaid programs. The proposed requirements focus on the care 
delivered to patients and their families by hospices and the outcomes 
of that care. The proposed requirements continue to reflect an 
interdisciplinary view of patient care and allow hospices flexibility 
in meeting quality standards. These changes are an integral part of the 
Administration's efforts to achieve broad-based improvements in the 
quality of health care furnished through the Medicare and Medicaid 
programs.

DATES: We will consider comments if we receive them at the appropriate 
address, as provided below, no later than 5 p.m. on July 26, 2005.

ADDRESSES: In commenting, please refer to file code CMS-3844-P. Because 
of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission.
    You may submit comments in one of three ways (no duplicates, 
please):
    1. Electronically. You may submit electronic comments to https://
www.cms.hhs.gov/regulations/ecomments (attachments should be in 
Microsoft Word, WordPerfect, or Excel; however, we prefer Microsoft 
Word).
    2. By mail. You may mail written comments (one original and two 
copies) to the following address ONLY: Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, Attention: CMS-3844-
P, P.O. Box 8010, Baltimore, MD 21244-8010.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By hand or courier. If you prefer, you may deliver (by hand or 
courier) your written comments (one original and two copies) before the 
close of the comment period to one of the following addresses. If you 
intend to deliver your comments to the Baltimore address, please call 
telephone number (410) 786-9994 in advance to schedule your arrival 
with one of our staff members. Room 445-G, Hubert H. Humphrey Building, 
200 Independence Avenue, SW., Washington, DC 20201; or 7500 Security 
Boulevard, Baltimore, MD 21244-1850.
    (Because access to the interior of the HHH Building is not readily 
available to persons without Federal Government identification, 
commenters are encouraged to leave their comments in the CMS drop slots 
located in the main lobby of the building. A stamp-in clock is 
available for persons wishing to retain a proof of filing by stamping 
in and retaining an extra copy of the comments being filed.)
    Comments mailed to the addresses indicated as appropriate for hand 
or courier delivery may be delayed and received after the comment 
period.
    Submission of comments on paperwork requirements. You may submit 
comments on this document's paperwork requirements by mailing your 
comments to the addresses provided at the end of the ``Collection of 
Information Requirements'' section in this document.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT:
Mary Rossi-Coajou, (410) 786-6051.
Danielle Shearer, (410) 786-6617.
Steve Miller, (410) 786-6656.

SUPPLEMENTARY INFORMATION:
    Submitting Comments: We welcome comments from the public on all 
issues set forth in this rule to assist us in fully considering issues 
and developing policies. You can assist us by referencing the file code 
CMS-3844-P and the specific ``issue identifier'' that precedes the 
section on which you choose to comment.
    Inspection of Public Comments: Comments received timely will be 
available for public inspection as they are received, generally 
beginning approximately 3 weeks after publication of a document, at the 
headquarters of the Centers for Medicare & Medicaid Services, 7500 
Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of 
each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view 
public comments, phone 1-800-743-3951.

I. Introduction

    As the single largest payer for health care services in the United 
States, the Federal Government assumes a critical responsibility for 
the delivery and quality of care furnished under its programs. 
Historically, we have adopted a quality assurance approach that has 
been directed toward identifying health care providers that furnish 
poor quality care or fail to meet minimum Federal standards. These 
problems would either be corrected or would lead to the exclusion of 
the provider from participation in the Medicare or Medicaid programs. 
However, we have found that this problem-focused approach has inherent 
limits. Ensuring quality through the enforcement of prescriptive health 
and safety standards, rather than improving the quality of care for all 
patients, has resulted in our expending much of our resources on 
dealing with marginal providers, rather than on stimulating broad-based 
improvements in quality of care.
    Eliciting quality health care for Federal beneficiaries from CMS-
certified providers and suppliers requires taking advantage of 
continuing advances in the health care delivery field. As a result, we 
are revising the Medicare hospice requirements, which are also used by 
Medicaid, to focus on a patient-centered, outcome-oriented process that 
promotes patient care foremost, rather than penalizing unproductive 
providers. We have developed a set of core requirements for hospice 
services that encompass the following: Patient rights, comprehensive 
assessment, and patient care planning and coordination by a hospice 
interdisciplinary group (IDG). Overarching these requirements is a 
quality assessment and performance improvement program that builds on 
the philosophy that a provider's own quality management system is key 
to improved patient care performance. The objective is to achieve a 
balanced regulatory approach by ensuring that a hospice furnishes 
health care that meets essential health and quality standards, while 
ensuring that it monitors and improves its own performance.
    To achieve this objective, we are working to revise not only the 
hospice requirements but the requirements for several other major 
health care provider types, such as hospitals, home health agencies, 
and end-stage renal disease facilities, through separate rules. All of 
the revised requirements are directed towards improving patient 
outcomes of care and satisfaction.

II. Background

A. The Medicare Hospice Benefit

    Hospice care is an approach to caring for the terminally ill 
individual that provides palliative care rather than traditional 
medical care and curative treatment. Palliative care is treatment for 
the relief of pain and other

[[Page 30841]]

uncomfortable symptoms through the appropriate coordination of all 
aspects of care needed to maximize personal comfort and relieve 
distress. Hospice care allows the patient to remain at home as long as 
possible by providing support to the patient and family, and keeping 
the patient as comfortable as possible while maintaining his or her 
dignity and quality of life. A hospice uses an interdisciplinary 
approach to deliver medical, social, physical, emotional, and spiritual 
services through the use of a broad spectrum of caregivers.
    Section 122 of the Tax Equity and Fiscal Responsibility Act of 1982 
(TEFRA), Public Law 97-248, added section 1861(dd) to the Social 
Security Act (the Act) to provide coverage for hospice care to 
terminally ill Medicare beneficiaries who elect to receive care from a 
Medicare-participating hospice.
    Under the authority of section 1861(dd) of the Act, the Secretary 
has established the Conditions of Participation (CoPs) that a hospice 
must meet to participate in Medicare and/or Medicaid, and these are 
currently set forth at 42 CFR part 418. The CoPs apply to a hospice as 
an entity as well as to the services furnished to each individual under 
hospice care. Under section 1861(dd) of the Act, the Secretary is 
responsible for ensuring that the CoPs, and their enforcement, are 
adequate to protect the health and safety of individuals under hospice 
care and to promote the effective and efficient use of Medicare funds. 
To implement this requirement, State survey agencies conduct surveys of 
hospices to assess their compliance with the CoPs.

B. Why Revise the Conditions of Participation?

    The hospice CoPs were originally promulgated on December 16, 1983 
(48 FR 56008) and were amended on December 11, 1990 (55 FR 50831) 
largely to implement provisions of section 6005(b) of the Omnibus 
Budget Reconciliation Act of 1989 (Pub. L. 101-239). However, many of 
the current CoPs have remained unchanged since their inception.
    We are proposing changes to the current CoPs based on four main 
considerations. First, we considered the suggestions that emerged from 
the Secretary's Advisory Committee on Regulatory Reform. In an effort 
to make regulations more predictable and responsive to relevant 
stakeholders, the Committee heard public testimony on a variety of 
hospice related topics and developed recommendations to address key 
issues that were highlighted. The two largest changes that resulted 
from the Committee's recommendations are the clarification of the 
relationship between nursing facilities and hospices at proposed Sec.  
418.112, and the changes to the nursing services standard at proposed 
Sec.  418.110(b).
    Our second consideration was the Balanced Budget Act of 1997 (Pub. 
L. 105-33) because it made changes to the hospice statute that need to 
be incorporated into the CoPs.
    Our third consideration was prompted by sections 408 and 946 of the 
Medicare Prescription Drug, Improvement, and Modernization Act of 2003 
(Pub. L. 108-173). Section 408 amended the Social Security Act to 
permit a nurse practitioner to be deemed a patient's attending 
physician when the patient elects hospice care. Section 946 amended 
section 1861(dd), Hospice Care: Hospice Program, of the Act to permit a 
hospice to enter into an arrangement with another hospice to provide 
core hospice services, or to provide highly specialized services of a 
registered professional nurse, in certain circumstances.
    Finally, this revision is part of a larger effort to bring about 
improvements in the quality of care furnished to Medicare and Medicaid 
beneficiaries through an outcome-oriented approach to quality of care 
responsibilities. The existing hospice CoPs do not contain patient-
centered, outcome-oriented standards, nor do they provide for the 
operation of a quality assessment and performance improvement program.
    Historically, we have established requirements for participation in 
the Medicare program that address the structure and process of health 
care. These early requirements are the result of professional 
consensus. Enforcing structure and process requirements by identifying 
deficient providers has not been adequate to meet the growing 
challenges associated with the changing hospice care environment. For 
example, rather than focusing on the relationship between the needs of 
patients and the staff available in an inpatient facility, the current 
regulations require that a registered nurse be present on every shift. 
Hospices often contract with local nursing facilities to provide 
inpatient respite care, and these facilities are only required to have 
a registered nurse on duty for a single eight hour shift each day. A 
hospice would have to supplement the nursing facility's staff with its 
own, at a significant cost to the hospice, even if the needs and acuity 
of the patient do not require a registered nurse. A hospice that did 
not supplement the facility's staff could be cited for not meeting the 
requirements, even though the requirements had no relevance to the 
needs of the patient. Thus, revisions to the hospice CoPs are 
essential.

C. Transforming the Hospice Conditions of Participation

    Before developing these proposed CoPs for hospices, we received 
advice and suggestions from the hospice industry, professional 
associations, practitioner communities, consumer advocates, and State 
and other governmental agencies with an interest in, or responsibility 
for, hospice regulation and oversight. Based on these suggestions, we 
have developed the following principles:
     Focus on the continuous, integrated health care process 
that a patient/family experiences across all aspects of hospice care, 
and on activities that center around patient assessment, care planning, 
service delivery, and quality assessment and performance improvement.
     Use a patient-centered, interdisciplinary approach that 
recognizes the contributions of various skilled professionals and other 
support personnel and their interaction with each other to meet the 
patient's needs.
     Incorporate an outcome-oriented quality assessment and 
performance improvement program.
     Facilitate flexibility in how a hospice meets performance 
expectations.
     Require that patient rights are ensured.
     Use performance measurement systems to evaluate and 
improve care.
    Based on these principles, we are proposing to set forth four core 
conditions of participation: Patient Rights, Patient/Family Assessment, 
Interdisciplinary Care Planning and Coordination of Services, and 
Quality Assessment and Performance Improvement.
     The Patient Rights CoP emphasizes a hospice's 
responsibility to respect and promote the rights of each hospice 
patient.
     The comprehensive Patient/Family Assessment CoP reflects 
the critical nature of a comprehensive assessment in determining 
appropriate treatments and accomplishing desired health outcomes.
     The Care Planning and Coordination of Services CoP 
incorporates the interdisciplinary team approach to providing hospice 
care.
     The Quality Assessment and Performance Improvement CoP 
charges each hospice with the responsibility for carrying out a 
performance effort to effect continuing improvement in the

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quality of care it furnishes to its patients and their families.
    The last three requirements establish a cycle of individual care 
and hospice-wide performance improvement. First, the patient's needs 
are comprehensively assessed and outcome measure data are collected. 
Second, the interdisciplinary group, in consultation with the patient's 
attending physician, establishes a plan of care to address those needs. 
Third, the plan of care is implemented and the results of the care are 
evaluated through updates of the comprehensive assessment and plan of 
care. Fourth, the outcome measure data collected during the initial and 
updated comprehensive assessments are analyzed to identify practices 
that lead to positive outcomes as well as opportunities for 
improvement. Finally, the hospice uses the results of such analyses to 
implement performance improvement activities. These activities will 
influence the establishment of plans of care and their implementation, 
thus creating a continuous cycle of individual care and an ongoing 
effort to improve the hospice's performance related to identified 
outcomes of care for all patients.
    This cycle of care adapts to changing standards of practice while 
addressing issues that surveyors have identified. Below is a list of 
the most cited deficiencies found by surveyors (year ending September 
3, 2002):
    1. Plan of care was not complete.
    2. No written plan was established.
    3. Plan was not reviewed at specific intervals.
    4. Plan did not include an assessment of needs.
    5. Plan was not established before providing care.
    6. RN supervisory visits were not made for home health aide 
services.
    7. No plan of care was included for bereavement services.
    8. Hospice did not conduct a self-assessment of quality and care 
provided.
    9. Clinical record was not maintained for every patient.
    10. Interdisciplinary group did not review and update the plan of 
care for each patient.
    We note that 8 of the 10 top deficiencies are related to plan of 
care, assessment, and quality assurance. Based on industry comments and 
our own surveys, we believe that the current plan of care condition 
contained in Sec.  418.58 must be strengthened. We did this by creating 
a separate condition for the assessment of individual needs and for the 
time frames related to that assessment. We also revised the quality 
assurance requirement and strengthened the plan of care requirement.
    These requirements would focus provider and surveyor efforts on the 
actual care delivered to the patient, the performance of the hospice as 
an organization, and the impact of the medical, physical, social, 
emotional, and spiritual care delivered to the patient.
    We are proposing to retain some of the current process-oriented 
requirements when they are likely to produce desirable outcomes and/or 
prevent harmful outcomes. These proposed CoPs invest in hospices the 
responsibility for improving patient care performance, rather than 
relying on an externally based approach where prescriptive requirements 
are enforced through the punitive aspects of the survey process.
    This change signals an opportunity for CMS, hospices, and States to 
join in a partnership for improvement. When implemented, hospice 
programming will reflect a patient-centered, outcome-oriented approach 
that will likely alter the manner in which CMS and States manage the 
survey process. We believe that this approach will provide 
opportunities for improvement in patient care that have been lacking in 
the past. The addition of a strong quality assessment and performance 
improvement requirement will stimulate the hospice to continuously 
monitor its performance and find opportunities for improvement.

D. Development of Outcome-Based Performance Measures for Hospices

[If you choose to comment on issues in this section, please include the 
caption ``OUTCOME-BASED PERFORMANCE MEASURES'' at the beginning of your 
comments.]
    We are proposing to require that hospices implement an outcome-
based internal performance improvement program that can be used to 
measure individual patient outcomes. The information a hospice gleans 
from its own data analysis will serve as a baseline for hospice quality 
improvement. Measures quantify quality and are tools for the hospice to 
use in assessing and improving patient care, outcomes, and 
satisfaction. An outcome based performance program can help hospices 
improve the effectiveness and efficiency of their services, improve the 
outcomes of care they provide, and increase patient satisfaction with 
their services.
    Hospice outcome measures, data elements, tools, and instructions 
for using them have already been developed by the industry. A Task 
Force initiative was sponsored and convened by the National Hospice 
Work Group (NHWG) and the National Hospice and Palliative Care 
Organization (NHPCO) in 1999. We participated in the development of the 
measures and provided technical assistance for pilot testing of the 
measures. The Task Force was invited to present the results of the 
measurement development work and results of the pilot studies to us in 
November 2000.
    The work of the Task Force resulted in four measures for the 
outcome domains of self-determination, comfort, safety, and effective 
grieving. The hospice industry rapidly moved to include these four 
measures in the data set that they encourage member hospices to use and 
report. The data elements and instructions for using the measures are 
publicly available on the NHPCO Web site at https://www.nhpco.org.
    These outcome-based measures are part of a national reporting 
process created by the hospice industry. If a hospice chooses to 
participate in the NHCPO process, it submits its data to the NHPCO (or 
its contractor). Reports are then generated for a hospice to compare 
its performance with other hospices. The hospice may also choose to 
send additional information for the NHPCO reporting process in the 
areas of pertinent utilization data, appropriateness and effectiveness 
of services, and patient/family satisfaction. All hospices that 
participate in the NHPCO reporting process must comply with regulations 
mandated by the Health Insurance Portability and Accountability Act of 
1996 (Pub.L. 104-191, ``HIPAA''). Regulations implementing HIPAA were 
published on December 28, 2000 (65 FR 82462) and were amended on August 
14, 2002 (67 FR 53182).
    We are not proposing to require that hospices participate in the 
NHPCO process described above, but hospices may choose to use some of 
the measures the NHPCO is already using as part of its comprehensive 
assessment of the patient, and as part of the organization's quality 
assessment and performance improvement program. Hospices may also 
develop their own data elements and measurement processes. 
Participating in the NHPCO outcome measurement and reporting process 
would assist hospices in meeting the requirements of proposed Sec.  
418.54(e). At this time, we are neither proposing that hospices use any 
particular measures of outcomes, nor that they report data to us. 
However, we may consider doing so in the future.
    We invite comments from the public on this aspect of the proposed 
rule.

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III. Provisions of the Proposed Regulations

A. Overview

    Under our proposal, the hospice conditions of participation would 
continue to be set forth in regulations under 42 CFR part 418. However, 
since many of the existing requirements in part 418 would be revised, 
consolidated with other requirements, or eliminated, we are proposing 
changes to the existing organizational scheme. A significant change 
would be to group all CoPs directly related to patient care and place 
them together in a separate subpart. CoPs concerning hospice 
organization and administration would be contained in another subpart. 
We believe that this proposed organization better reflects a patient/
family-centered orientation and helps illustrate that patient 
assessment, care planning, and quality assessment and improvement 
efforts are central to the delivery of high quality care.

B. Subpart A, General Provisions

    The revised conditions would begin with existing Sec.  418.2 that 
specifies the statutory authority and scope of the part for the ensuing 
regulations. Section 418.1 would remain unchanged.
1. Scope of the Part (Proposed Sec.  418.2)
    Section 418.2 would be revised to reflect the reorganization of the 
part and to include an introductory statement describing the purpose of 
the part.
2. Definitions (Proposed Sec.  418.3)
    Existing Sec.  418.3 sets forth definitions for terms used in the 
hospice CoPs. This section is being revised in order to provide further 
clarification. We are proposing to move existing definitions of 
``physician'' and ``social worker'' to proposed Sec.  418.114, 
personnel requirements. We believe these definitions better fit in this 
new condition. We propose to include the following definitions:
     Attending physician (revised)
     Bereavement counseling (revised)
     Cap Period (same)
     Clinical note (new)
     Drug restraint (new)
     Employee (revised)
     Hospice (revised)
     Hospice care (new)
     Licensed professional (new)
     Palliative care (new)
     Physical restraint (new)
     Progress note (new)
     Representative (revised)
     Restraint (new)
     Satellite location (new)
     Seclusion (new)
     Terminally ill (revised)

    These definitions would be revised to read as follows:
    Attending physician means a--
    (a)(1) Doctor of medicine or osteopathy legally authorized to 
practice medicine and surgery by the State in which he or she performs 
that function or action; or (2) Nurse practitioner who meets the 
training, education and experience requirements as the Secretary may 
prescribe; and
    (b) Is identified by the individual, at the time he or she elects 
to receive hospice care, as having the most significant role in the 
determination and delivery of the individual's medical care.
    Here after, except as indicated, the term ``attending physician'' 
includes nurse practitioners.
    We modified this definition to address changes made to the Act by 
Congress in section 408 of the Medicare Prescription Drug, Improvement, 
and Modernization Act of 2003 (Pub. L. 108-173) (``MMA''). Nurse 
practitioners are often the primary medical health care professionals 
for some patients, particularly those residing in rural areas. For 
example, a nurse practitioner that works in conjunction with a doctor 
may be the health care professional a patient sees most often. The 
patient would develop a relationship with the nurse practitioner, and 
would like the nurse practitioner to continue to be involved in his or 
her care once he or she elects the hospice benefit. Under the current 
regulations, this is not allowed. Under the proposed regulations, we 
would permit a nurse practitioner to continue serving his or her 
patient as that patient's attending physician once that patient elects 
to receive hospice care. We believe that this would ensure the 
continuity of care and improve the quality of care because the health 
care professional most familiar with the patient, his or her 
conditions, and his or her personal situation would be involved in 
developing the plan of care and in making other important decisions.
    Within the provisions of section 408 of the MMA nurse practitioners 
are prohibited from certifying or recertifying a patient's terminal 
illness. CMS will publish additional information regarding section 408 
in a forthcoming Federal Register document.
    Bereavement counseling means emotional, psychosocial, and spiritual 
support and services provided after the death of the patient to assist 
with issues related to grief, loss, and adjusting.
    Cap period means the 12-month period ending October 31 used in the 
application of the cap on overall hospice reimbursement as specified in 
Sec.  418.309.
    Clinical note means a notation of a contact with the patient that 
is written and dated by any person providing services, and that 
describes signs and symptoms, treatments and medications administered, 
including the patient's reaction and/or response, and any changes in 
physical or emotional condition.
    Drug restraint means a medication used to control behavior or to 
restrict the patient's freedom of movement which is not a standard 
treatment for a patient's medical or psychiatric condition.
    Employee means a person who works for the hospice and for whom the 
hospice is required to issue a W-2 form on his or her behalf, or if the 
hospice is a subdivision of an agency or organization, an employee of 
the agency or organization who is appropriately trained and assigned to 
the hospice or is a volunteer under the jurisdiction of the hospice.
    Hospice means a public agency or private organization or 
subdivision of either of these that is primarily engaged in providing 
hospice care as defined in this section.
    Hospice care means a comprehensive set of services described in 
1861(dd)(1) of the Act, identified and coordinated by an 
interdisciplinary team to provide for the physical, psychosocial, 
spiritual, and emotional needs of a terminally ill patient and/or 
family members, as delineated in a specific patient plan of care.
    Licensed professional means a licensed person sanctioned by the 
State in which services are delivered, furnishing services such as 
skilled nursing care, physical therapy, speech-language pathology, 
occupational therapy, and medical social services.
    Palliative care means patient and family-centered care that 
optimizes quality of life by anticipating, preventing, and treating 
suffering. Palliative care throughout the continuum of illness involves 
addressing physical, intellectual, emotional, social, and spiritual 
needs and to facilitate patient autonomy, access to information, and 
choice.
    Physical restraint means any manual method or physical or 
mechanical device, material, or equipment attached to the patient's 
body that he or she cannot easily remove that restricts freedom of 
movement or normal access to one's body.
    Progress note means a written notation, dated and signed by any 
person providing services, that summarizes facts about the care 
furnished and the patient's response during a given period of time.

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    Representative means an individual who has the authority under 
State law (whether by statute or pursuant to an appointment by the 
courts of the State) to authorize or terminate medical care or to elect 
or revoke the election of hospice care on behalf of a terminally ill 
patient who is mentally or physically incapacitated. This may include a 
legal guardian.
    Restraint means either a physical restraint or a drug used as a 
restraint.
    Satellite location means a Medicare-approved location from which 
the hospice provides hospice care and services within a portion of the 
total geographic area served by the hospice provider issued the 
provider agreement number. The satellite location is part of the 
hospice and shares administration, supervision, and services in a 
manner that renders it unnecessary for the satellite location to 
independently meet the conditions of participation as a hospice.
    We are proposing to add this definition to recognize long-standing 
Medicare survey and certification policies, which allow for the 
operation of multiple locations by a single hospice provider. We are 
proposing that a hospice satellite location be approved by CMS before 
it begins to furnish service to patients. In the past, some hospices 
were found to be furnishing services from locations that had not been 
shown to be in compliance with applicable regulations. We envision the 
approval process to be consistent with determining that patients 
receive safe services from the satellite location in question. As is 
done for other appropriate providers and suppliers, we are accepting 
comment on applying the Medicare Appeals Procedures that affect 
participation in the Medicare program (42 CFR 498.3). If a hospice, 
including any or all satellite locations, is accredited by an 
accrediting organization such as JCAHO or CHAP, the hospice and each 
satellite location must still receive Medicare approval.
    Seclusion means the confinement of a person in a room or an area 
where a person is isolated and physically prevented from leaving.
    Terminally ill means that a patient has a medical prognosis that 
his or her life expectancy is six months or less if the illness runs 
its normal course.

C. Subpart B, Eligibility, Election and Duration of Benefits

    Subpart B concerns eligibility, election, and duration of hospice 
benefits. We are not proposing changes to this subpart at this time.

D. Subpart C, Conditions of Participation--Patient Care

1. Patient's Rights, Condition of Participation (Proposed Sec.  418.52)
[If you choose to comment on issues in this section, please include the 
caption ``PATIENTS RIGHTS'' at the beginning of your comments.]
    This section would replace the current condition of participation, 
Informed consent, laid out at Sec.  418.62. This condition would set 
forth certain rights to which hospice patients would be entitled, and 
would require that hospices inform each patient of these rights and 
that hospice personnel ensure and support these rights. Among these 
rights would be the following, laid out at proposed Sec.  418.52: Being 
informed in advance regarding the care to be provided; having an 
opportunity to participate in care planning; voicing grievances; being 
assured of confidentiality of records; having personal property 
respected; being informed whether services are covered or not covered, 
and having information provided in writing. We are proposing to specify 
that the patient must also be informed about factors that affect 
palliation and comfort. We believe that these revisions would act as an 
additional safeguard of patient health and safety. Open communication 
between hospice staff and the patient, and patient access to palliative 
information is vital to enhancing the patient's participation in his or 
her coordinated care planning. All hospices must also comply with the 
Privacy Rule published in the Federal Register on December 28, 2000 (65 
FR 82461) as amended on August 14, 2002 (67 FR 53182) and contained in 
45 CFR parts 160 and 164.
    We are specifically soliciting public comment on this proposed 
condition of participation.
2. The Cycle of Care: Assessment, Planning, and Delivery (Proposed 
Sec.  418.54 Through Sec.  418.62)
    The patient care assessment, planning, and palliative care process 
represented by the next four CoPs (Sec.  418.54 through Sec.  418.62) 
can be seen as a cycle. Through the use of a comprehensive assessment, 
accurate and timely patient information is made available for use in 
the patient care process. The palliative care process consists of all 
hospice care and services furnished to the patient and family. The 
patient palliative care process results in an effect on the patient's 
condition, whether it is positive or negative. The assessment of the 
effectiveness of palliative care then results in subsequent care 
decisions, and the cycle begins anew. Through this cycle, accurate 
patient and family information obtained from each comprehensive 
assessment should yield effective and appropriate palliative care 
decisions, thus generating a positive effect on patient care and 
desired outcomes.
Condition of Participation: Comprehensive Assessment of the Patient 
(Proposed Sec.  418.54)
    The proposed comprehensive assessment requirement reflects our view 
that a patient-centered, interdisciplinary, and systematic patient 
assessment is essential to improving patient quality of care and 
patient outcomes.
    In hospice care, the comprehensive assessment of the patient 
contributes to quality of care improvements in closely linked stages. 
First, the information generated from an interdisciplinary 
comprehensive assessment is a vital tool for developing a hospice 
patient's plan of care that will guide decisions on how best to 
determine the individual care and support needs of the patient. Second, 
based on updates of the comprehensive assessment, a hospice is able to 
track the patient's progress towards achieving the desired care 
outcomes, and where this does not occur, make appropriate changes to 
the patient's plan of care. Finally, the hospice is able to evaluate 
the results of its care decisions, thus yielding information to help 
form the hospice's future care planning process. We believe this 
approach reflects contemporary standard practice for many hospices, and 
we are proposing to revise the CoPs to support this outcome-oriented 
approach.
    The centerpiece of this outcome-oriented approach is that each 
patient receives a patient-specific comprehensive assessment that 
identifies the patient's need for medical, nursing, psychosocial, 
emotional and spiritual care. The care needs identified in the 
assessment would include, but not be limited to, those necessary for 
palliation and management of the terminal illness and related medical 
conditions. The comprehensive assessment would be completed by the 
interdisciplinary group in consultation with the individual's attending 
physician to ensure that each member of the interdisciplinary group 
provided input within the scope of that individual's practice. We 
believe that the patient-specific comprehensive assessment requirement 
we are proposing is already recognized and practiced by the hospice 
industry in general.

[[Page 30845]]

    The existing CoPs contain few requirements that address the need 
for patient assessment; therefore, we are emphasizing the importance of 
the comprehensive assessment by establishing it as a separate CoP. In 
hospice surveys nationwide, we have identified a pattern of healthcare 
related deficiencies that indicate that the current assessment 
requirements are not sufficient. The fourth most frequently cited 
deficiency is that the plan of care did not include an assessment of 
the patient's needs. The frequency with which this area is cited 
indicates that there are a significant number of hospices that are not 
doing enough to properly assess their patients.
    The expanded assessment condition would guide these deficient 
hospices in thoroughly assessing their patients by identifying the 
general areas that should be included in each assessment and by 
identifying time frames for the completion of assessments. We believe 
that this proposed CoP would enable hospices to specifically identify 
patient care needs. Once a hospice has completed a timely and thorough 
assessment of the patient, it can develop an accurate plan of care that 
reflects the needs identified during the assessment. The accuracy and 
timeliness of the plan of care may lead to an improvement in the 
quality of the hospice experience for the patient and his or her 
family.
    In addition, we believe that the broad assessment outline we are 
proposing will encourage hospices to exercise flexibility in 
determining how best to achieve positive outcomes. We believe that this 
approach is consistent with currently accepted practices in hospices.
    In Sec.  418.54(a), Initial assessment, we are proposing that a 
registered nurse make the initial assessment visit to determine the 
patient's immediate care and support needs within 24 hours after the 
hospice receives a physician's admission order for care (unless another 
date is specified by the physician). We realize that some hospices meet 
with patients and their families, at their request, before the actual 
admission for care orders are received, and this regulation would not 
prevent this practice. However, meeting with a patient and his or her 
family before the patient's physician orders hospice care would not 
satisfy the initial assessment requirement.
    In Sec.  418.54(b), Time frame for completion of the comprehensive 
assessment, we are proposing that the hospice interdisciplinary group, 
in consultation with the hospice medical director or physician designee 
and/or the individual's attending physician, complete the comprehensive 
assessment in a timely manner consistent with the patient's immediate 
needs, but no later than 4 calendar days after the patient elects the 
hospice benefit. We believe that most hospices already complete the 
assessment within this time frame and, due to the decreased length of 
stay, as explained in the discussion of Sec.  418.54(d), Update of the 
comprehensive assessment, and the potential severity of the patient's 
condition, we believe it is essential to ensure that patients are 
assessed in a timely manner.
    Section Sec.  418.54(c), Content of the comprehensive assessment, 
would describe the requirements for the content of the comprehensive 
assessment that we believe are critical to quality hospice care. These 
content requirements are at the core of hospice care and are needed to 
evaluate the patient's need for physical, social, emotional, medical, 
and spiritual care.
    Under proposed Sec.  418.54(c)(3)(ii), Drug therapy, the patient's 
comprehensive assessment would have to` include a review of the 
patient's current medication. The review and accompanying documentation 
would include identification of the following items:
     Ineffective drug therapy;
     Unwanted side and toxic effects; and
     Drug interactions.
    This review must be repeated as necessary to ensure that the 
patient continues to receive drug therapy that is effective and 
appropriate for his or her needs. A review of a patient's drugs would 
be included in the initial assessment and in the development of the 
plan of care. This review could occur at any time, but specifically 
when a patient is prescribed or begins to take any new drug and/or when 
use of a drug is discontinued.
    In Sec.  418.54(d), Update of the comprehensive assessment, we are 
proposing that the comprehensive assessment be updated by the 
interdisciplinary group as frequently as the patient's condition 
requires, but no less frequently than every 14 days. We believe that 
these frequent reviews are necessary and predictive of quality outcomes 
for two reasons:
    (1) In the terminal stages of care, patient status needs, 
circumstances, and family expectations can change greatly, affecting 
the type and frequency of services that should be furnished. 
Reassessments assist the hospice in developing a more responsive care 
plan. The interdisciplinary group would use assessment information to 
guide necessary reviews and/or changes to the patient's plan of care.
    (2) We are proposing that a hospice medical director or physician 
designee be required to recertify a patient for hospice care at 
specific intervals as stated in Sec.  418.21. We believe 
recertification, which occurs at the end of the initial and subsequent 
90-day benefit periods (and at the end of the remaining benefit periods 
as described in Sec.  418.21), serves as a logical point for updating 
an assessment in addition to the minimum 14 days and when the patient's 
condition changes.
    We believe that to ensure quality and timely care for our hospice 
beneficiaries, timely completion of the initial assessment requirement 
and the comprehensive assessment update requirement is necessary. In 
2001 the average length of enrollment in hospice care was 51 days (2002 
Nov. Medicare National Summary for HHA, Hospice, SNF, and outpatient CY 
1999-2001, https://www.cms.hhs.gov/statistics/feeforservice/National 
Summary.pdf). According to research by the NHPCO, in 2000 the average 
length of enrollment in hospice care was 48 days (2000 NHPCO National 
Data Set Summary Report, 2001 Nov.). There has been some concern 
regarding short lengths of stay. Hospices have been admitting patients 
late in their terminal illness and those patients need extensive 
hospice services and resources initially, and right before death. In 
order to ensure that patients receive the necessary services and thus 
begin to benefit from hospice care at the earliest time possible, we 
believe that it is important that the comprehensive patient assessment 
be completed within the time frame that we have proposed. A delay in 
completing the initial comprehensive assessment and the updated 
assessments is ultimately not as beneficial to the patient and family 
as if the patient had entered hospice care and received timely 
assessments to determine the proper care to be provided.
    These requirements, though process-oriented in part, are predictive 
of good patient care and safety. Our rationale for requiring the 
completion of the initial comprehensive assessment is that a new 
patient being referred to a hospice for initiation of services is at a 
point of immediate need and often in crisis. Likewise, maintaining an 
ineffective plan of care could jeopardize patient health and safety. 
Regular assessment updates would minimize this possibility.
    We believe that the comprehensive assessment requirements pose 
little or no burden for hospices because it is a current standard of 
practice to

[[Page 30846]]

comprehensively assess hospice patients. However, we recognize that the 
proposed 4-day timeframe for completing the initial comprehensive 
assessment as proposed in Sec.  418.54(b) and 14-day timeframe for 
updating the comprehensive assessment as proposed in Sec.  418.54(d) 
may set higher performance expectations for some hospices then the 
self-imposed standards they currently utilize. We believe that if a 
hospice recognizes that it is not capable of furnishing services within 
these timeframes, new patients should not be accepted for care.
    We welcome public comments on the review of our proposed timeframes 
for the initial comprehensive assessment and updated comprehensive 
assessment. We believe the timeframes are reasonable and consistent 
with current hospice practice.

[If you choose to comment on issues in this section, please include the 
caption ``ASSESSMENT TIME FRAMES'' at the beginning of your comments.]
    Under the proposed Sec.  418.54(e), Patient outcome measures, we 
are proposing that a patient's comprehensive assessment include 
measurement and documentation of aspects of care that are essential 
outcomes of optimal hospice care. Documentation is carried out in the 
same way for all patients through what we refer to as data elements. 
The hospice may develop its own data elements or use existing, 
externally developed data elements. However, some of the data elements 
should be related to the domains of self-determination, comfort, 
safety, and effective grieving related to bereavement services. If a 
hospice chooses to collect information for the data elements developed 
by the NHPCO, it may also choose to submit this information to the 
NHCPO. However, submission must be in accordance with the HIPAA privacy 
rule (45 CFR Parts 160 and 164). The hospice may also choose to send 
additional information for the NHPCO reporting process in the areas of 
pertinent utilization data, appropriateness and effectiveness of 
services, and patient/family satisfaction.
    The data elements used by the hospice must be an integral part of 
both the initial comprehensive and updated assessments. The application 
of these data elements to the identified domains must be documented in 
a systematic and retrievable way for each patient, as the outcome 
measurements will be used in patient care planning and coordinating 
services. Measurements will also be used (in the aggregate) for the 
hospice quality assessment and performance improvement program.
    We want to emphasize that we are not proposing that hospices use 
any specific data elements to measure domain outcomes. We are simply 
proposing that hospices collect the data necessary to evaluate the 
quality of care they are providing and use this information in a 
systematic and retrievable way. Hospices may develop their own data 
elements related to the aspects of care related to hospice and 
palliation, such as self-determination, comfort, safety, and effective 
grieving, or may use the data elements related to the seven outcome 
measures in the NHPCO data set (https://www.nhpco.org).
    Currently, there is insufficient evidence for a valid and reliable 
common set of measures (that is, data elements) for use in hospice 
care. We are aware that the industry is studying this area. We also 
know that there are many measures that are currently used to help gauge 
the processes of care for hospice patients and to make adjustments to 
care on their basis. For example, there are multiple scales for use in 
pain management, anxiety, and depression, and there are several 
quality-of-life scales appearing in the relevant literature (https://
www.nhpco.org and https://www.chcr.brown.edu/pcoc/toolkit.htm). Some 
measurable outcomes can be captured in single items while others 
require multiple items to capture the full range of measurement issues.
    We welcome comments on our ``outcome measures'' approach to this 
proposed regulation. We are particularly interested in comments as to 
whether this approach is necessary in assessment, care planning, 
service delivery, and most importantly, to the hospice's quality 
assessment and performance improvement program.

[If you choose to comment on issues in this section, please include the 
caption ``OUTCOME MEASURES'' at the beginning of your comments.]
Condition of Participation: Interdisciplinary Group Care Planning and 
Coordination of Services (Proposed Sec.  418.56)
[If you choose to comment on issues in this section, please include the 
caption ``PLAN OF CARE'' or ``COORDINATION OF SERVICES'' where 
appropriate, at the beginning of your comments.]
    The existing condition of participation concerning the plan of care 
is set forth at Sec.  418.58. We are proposing to revise the contents 
of this section and place them in a new condition, ``Interdisciplinary 
group care planning and coordination of services'' (proposed Sec.  
418.56). The proposed condition would contain five standards that 
reflect the interdisciplinary approach to hospice care delivery.
    As proposed, each patient and family would have a written plan of 
care developed by the hospice interdisciplinary group in consultation 
with the patient's attending physician that specifies the hospice care 
and services necessary to meet the patient/family-specific needs 
identified in the comprehensive and updated assessments. All hospice 
services furnished to patients and their families must follow this 
written plan of care.
    Under proposed Sec.  418.56(a), Approach to service delivery, we 
are proposing that the hospice designate an interdisciplinary group or 
groups composed of individuals who work together to meet the physical, 
medical, social, emotional, and spiritual needs of the hospice patients 
and families facing terminal illness and bereavement. We believe that 
the role of the interdisciplinary group is paramount in directing and 
monitoring the patient care and is one of the factors that makes the 
hospice benefit unique. The hospice would designate a qualified health 
care professional who is a member of the interdisciplinary group to 
provide program coordination, ensure the continuous assessment of each 
patient's and family's needs, and ensure the implementation and 
revision of the plan of care.
    The proposed standard at Sec.  418.56(b), Plan of care, is the same 
as the existing standard at Sec.  418.58(a), with one addition. We are 
including a reference to the patient's family when establishing the 
plan of care. We would require that all hospice services furnished to 
patients and their families follow a written plan of care established 
by the hospice interdisciplinary group in collaboration with the 
attending physician. Family plays an important role in the care of a 
hospice patient, and this change reflects that role.
    Under the proposed standard at Sec.  418.56(c), Content of the plan 
of care, we would require that each patient's plan of care reflect 
interventions for problems identified in the comprehensive and updated 
assessments. This requirement ensures that care and services are 
appropriate to the level of each patient's and family's specific needs. 
The plan of care must include the following:
     Interventions to facilitate the management of pain and 
symptoms;
     A detailed statement of the scope and frequency of 
services required to meet the patient's and family's specific needs;

[[Page 30847]]

     Measurable outcomes anticipated from implementing and 
coordinating the plan of care;
     Drugs and treatment necessary to meet the needs of the 
patient;
     Medical supplies and appliances required to meet the needs 
of the patient; and
     The interdisciplinary group's documentation in the 
clinical record indicating the patient's and family's understanding, 
involvement, and agreement with the plan.
    As we noted in the description of the previous standard, we are 
proposing to add a requirement that the plan address the patient's and 
family's expectations, understanding, agreement, and ability to 
participate in the care as the patient and family desire. Since family 
members need to understand the importance of their role in care of the 
hospice patient, their input and agreement regarding care is essential 
in developing a productive relationship with the hospice. We would 
expect a hospice to document the patient's and family's understanding 
of and agreement to the plan of care in accordance with its own 
policies. This could include an attestation signed by the patient and 
family, a note in the clinical record, and/or another form of 
documentation decided upon by the hospice governing body.
    Proposed standard Sec.  418.56(d), Review of the plan of care, 
would require that a revised plan of care include current information 
from the patient's updated comprehensive assessment and information 
concerning the patient's progress toward achieving outcomes specified 
in the plan of care. The plan of care must be reviewed at intervals 
specified in the plan but no less frequently than every 14 calendar 
days. We believe that it is essential to include the requirement that 
actual care provided also be changed as needed, thus establishing the 
essential linkage between assessment information, evaluation of 
treatment results, and plan of care modification.
    We also propose to require that the hospice take steps to involve 
the patient's attending physician in the review of the patient's plan 
of care. The attending physician often has had a lengthy relationship 
with the patient; and his or her input into the review of the plan of 
care can be invaluable. We do not have the authority in the Conditions 
of Participation governing hospices to require that an attending 
physician, an individual who is not an employee of the hospice and thus 
not governed by these hospice regulations, participate in this process. 
However, we can and are proposing that the hospice collaborate with the 
patient's attending physician to the extent possible when reviewing the 
plan of care. We believe that requiring hospices to involve interested 
attending physicians will benefit patients by helping to ensure that 
the care described in the plan of care reflects the needs and desires 
of patients and their families.
    We are proposing to add a new standard, Coordination of services, 
at Sec.  418.56(e). This standard would require that the hospice 
maintain a system of communication and integration to enable the 
interdisciplinary group to ensure the overall provision of care and the 
efficient implementation of the day-to-day policies. These new 
standards would also make it easier for the hospice to ensure that the 
care and services are provided in accordance with the plan of care, and 
that all care and services provided are based on the comprehensive and 
updated assessments of the patient's and family's needs. An effective 
communication system would also enable the hospice to ensure ongoing 
liaison of all disciplines providing care and services in the home, 
outpatient, and inpatient settings, notwithstanding the manner in which 
the care and services are furnished.
    We believe that this standard is appropriate for two reasons. 
First, a hospice patient typically encounters many services delivered 
at different times by a variety of individuals with different skills. 
An efficient method of communication and integration of observations 
among members of the interdisciplinary group and others providing care 
is essential to meet and respond to the patient's and family's needs in 
a timely manner. Second, effective communication and coordination of 
services will assist a hospice in avoiding a duplication of effort or a 
furnishing of conflicting services.
    We recognize the value of an interdisciplinary approach to the 
delivery of hospice services. This approach to care reflects actual 
industry practice, and as a result, we believe the proposed requirement 
is in step with the hospice industry.
    We are specifically soliciting public comment on the proposed 
requirements for the content of the plan of care, the time frames for 
review of the plan of care, and the new coordination of services 
standard.
Condition of Participation: Quality Assessment and Performance 
Improvement (Proposed Sec.  418.58)
[If you choose to comments on issues in this section, please include 
the caption ``QAPI'' at the beginning of your comments.]
    The existing Sec.  418.66, Condition of participation--Quality 
assurance, relies on a problem-oriented approach to identify and 
resolve patient care issues. Failure to meet the quality assurance 
condition is consistently one of the top 10 deficiencies cited by 
surveyors nationwide. According to the hospice industry associations, 
hospices are no longer using the quality assurance model. During the 
last decade the health care industry, including the hospice industry, 
has moved beyond the problem-oriented, after-the-fact corrective 
approach of quality assurance to an approach that focuses on a pre-
emptive plan that continuously addresses quality assessment and 
performance improvement (QAPI). Hospice industry associations have 
indicated that their upgraded QAPI systems are incompatible with the 
existing quality assurance condition. Therefore, the providers who have 
moved beyond quality assurance in order to make meaningful and 
sustained quality improvements in their own programs are actually in 
violation of the outdated quality assurance condition.
    On the other end of the spectrum are providers who are truly 
deficient because they do not have any quality program. These providers 
would find more guidance in the proposed regulation. In the following 
section of this preamble we will discuss two publicly available 
resources for data measures, an integral part of the proposed QAPI 
requirement. In the proposed regulation we have outlined when those 
should be collected and what role they play in the proposed QAPI 
condition. In addition, we have described the scope of the proposed 
QAPI program requirement, the guidelines for identifying performance 
improvement activities, and the individuals responsible for ensuring 
that a hospice has a QAPI program. The proposed regulations provide 
hospices that are unsure of what is expected of them with the 
guidelines to begin tailoring a QAPI program that meets their needs and 
circumstances.
    Therefore, we believe that this proposed condition will reduce the 
number of deficient providers by recognizing those who are practicing 
QAPI and guiding reluctant providers to meet current standards of 
practice. The proposed QAPI requirement would raise the performance 
expectations for hospices seeking entrance into the Medicare program, 
as well the expectations of those currently participating in Medicare. 
We are proposing that each hospice develop,

[[Page 30848]]

implement, and maintain an effective, continuous quality assessment and 
performance improvement program that stimulates the hospice to 
constantly monitor and improve its own performance, and to be 
responsive to the needs, desires, and satisfaction levels of the 
patients and families it serves.
    The desired overall outcome of this proposed CoP is that the 
hospice will drive its own quality improvement activities and improve 
its provision of services. With an effective quality assessment and 
performance improvement program in place and operating properly, the 
hospice can better identify and reinforce the activities it is doing 
well, identify its activities that are leading to poor patient 
outcomes, and take actions to improve performance.
    This proposed condition requires the hospice to develop, implement, 
and maintain an effective data driven quality assessment and 
performance improvement program (QAPI). The program establishes a 
planned approach to quality improvement and takes into account the 
complexity of the hospice's organization and services, including those 
provided directly or under arrangement. The hospice must take whatever 
actions are necessary to implement improvements in its performance as 
identified by its quality assessment and performance improvement 
program. The hospice is also responsible for ensuring that the 
professional services it offers are carried out within current clinical 
practice guidelines as well as professional practice standards 
applicable to hospice care.
    In the first proposed standard under this condition at Sec.  
418.58(a), Standard: Program scope, we are proposing that the hospice's 
quality assessment and performance improvement program must include, 
but not be limited to, an ongoing program that is able to show 
measurable improvement in indicators that are linked to improving 
palliative outcomes and end-of-life support services. We expect that a 
hospice will use standards of care and the findings made available in 
current literature to select indicators to monitor its program. The 
hospice must measure, analyze, and track these quality indicators, 
including areas such as adverse patient events and other aspects of 
performance that assess processes of care, hospice services, and 
operations. Adverse patient events, as used in the field, are 
occurrences that are harmful or contrary to the targeted patient 
outcomes.
    The second proposed standard under Sec.  418.58(b) Program data, 
would require the hospice program to incorporate quality indicator 
data, including patient care data and other relevant data, into its 
QAPI program. This would include data that are received from or 
submitted to hospice professional organizations. A fundamental barrier 
in identifying quality care at the end of life is the lack of 
measurement tools. Measurement tools can identify opportunities for 
improving medical care and examining the impact of interventions.
    CMS does not currently require the submission of data from hospices 
to calculate quality measures but is interested in the development of a 
set of measures. Hospice measures were submitted and discussed as part 
of the recent National Quality Forum process identifying home health 
measures but were withdrawn and added to the more focused end of life 
discussions. CMS would be interested in comments regarding clinical 
measures, patient experience of care measures, and systems measures 
(use of information technology, staffing, follow up mechanisms) 
specific to hospice care. These comments should include existing 
measures in use, measures to be developed, data collection methods and 
issues, and how measures are currently being used. We are especially 
interested in the feasibility, usability, if the measures presented are 
proprietary or publicly available, and burden of collecting and 
reporting the measures.
    An example of available measurement tools would be the hospice 
outcome measures, data elements, tools, and instructions developed by a 
hospice industry task force in which the CMS participated as a 
stakeholder. A Task Force initiative was sponsored and convened by the 
National Hospice Work Group (NHWG) and the National Hospice and 
Palliative Care Organization (NHPCO) in 1999. We participated in 
developing the measures and provided technical assistance for pilot 
testing the measures. In addition to the work that has already been 
done in this area, we are committed to working with all relevant 
interest groups and associations as they develop and provide hospices 
with model quality assessment and performance improvement programs and 
other services.
    The work of the Task Force resulted in measures addressing the 
outcome domains of self-determined life closure, comfortable dying, 
safe dying, and effective grieving. The hospice industry moved to 
include these measures in the data set that they encourage member 
hospices to use and report. The data elements, tools, and instructions 
for using the measures are publicly available on the NHPCO website 

                    

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