report by the U.S. Department of Health and Human Services, Office of Inspector General (OIG) finds that hospices did not always comply with the portion of the “hospice aide and homemaker services” condition of participation that requires a registered nurse to conduct a supervisory visit to a hospice patient’s home every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs.

OIG based its research for the report on data analytics and statistics to identify 189,00 high-risk registered nurse visit date-pairs—pairs of visits more than 14 days apart that presented a greater risk that the nurse did not assess the quality of care and services provided by a hospice aide.  OIG then selected a random sample of 78 date-pairs, requested supporting documentation from the hospice providers, and reviewed all registered nurses’ supervisory visits for those date-pairs.

Based on the findings from the 78 date-pairs for which underlying documentation was requested, OIG estimated that there were 99,000 instances in which registered nurses did not conduct supervisory visits and 5,000 instances in which supervisory nurses were not documented in accordance with Federal requirements.  Without explaining how it arrived at its conclusions, OIG attributed these deficiencies to a lack of oversight by the hospice agencies, scheduling errors, employee turnover, and a lack of knowledge by the registered nurses of the 14-day supervisory visit requirement.

With respect to its findings on documentation lapses, OIG explained that while supervisory visits must be documented in the hospice patient’s clinical record per the State Operations Manual, the guidance does not specifically explain how hospices should document such supervisory visits.  Accordingly, OIG notes that documentation “ranged from specific and detailed, such as including the name of hospice aides, to much less detailed.”

The Centers for Medicare and Medicaid Services (CMS) concurred with OIG’s recommendations to promote compliance by (a) working with State survey agencies and accreditation organizations to increase emphasis on oversight of the 14-day requirement, (b) educating hospices about the requirement, and (c) making the standard a quality measure for hospices.  Specifically, CMS stated that it would increase awareness through surveyor training and customary channels for outreach as well as its soon-to-be-launched Quality, Safety & Education training portal.  OIG also recommended that CMS “take action” to ensure that all supervisory visits are documented in accordance with applicable regulations and interpretive guidance.  CMS again concurred with the recommendation and stated it would educate providers through the aforementioned channels for outreach.

Because such reports always carry with them increased scrutiny and enforcement by survey agencies and accreditation organizations, providers should review their policies and procedures regarding the supervisory visit requirement, include training on the requirement for their registered nurses, and ensure that adequate technology is in place to flag patients with respect to whom a supervisory visit is due.