HCP 517 Week 2 Compliance Policies and Standard Operating Procedures Example

Three Hospice Policies and the Steps Behind Them: Eligibility and Recertification, General Inpatient Care and Referral Relationships, Written So a Night Nurse Can Follow Them

[Student Name]

University of Phoenix

HCP/517: Communication and Reporting Mechanisms in Compliance

Week 2 Assignment

[Instructor Name]

[Date]

The hospice, its policies and procedures are composites written for a model paper; federal requirements and findings come from the sources listed.

At 2 a.m., a hospice nurse at a patient's home faced a decision: the patient's pain had not responded to two dose increases, the family was exhausted and she wondered whether the patient qualified for general inpatient care in the hospice's unit. The hospice's old policy on the subject was four pages of regulatory language with no steps. This paper presents three rewritten policies and their procedures for the composite nonprofit hospice's highest risks, written so staff can use them at moments like that one.

Policies and Procedures

A policy states what the organization requires and why. A procedure explains, step by step, how staff meet that requirement. Policies change rarely and are approved by leadership; procedures change more often as work changes and are owned by the departments that use them. Each of the three policies below has a companion procedure.

Why These Three

The first paper identified eligibility, levels of care and referral relationships as the hospice's highest risks, consistent with inspector general findings of hospices enrolling patients who were not terminally ill, billing for care not provided and paying kickbacks (Office of Inspector General, 2018). Federal rules issued in 2023 also created a special focus program to identify and increase oversight of poorly performing hospices, raising the stakes for survey compliance (Centers for Medicare & Medicaid Services, 2023).

Policy One: Eligibility and Recertification

Purpose: to ensure every patient admitted and continued in hospice has a documented terminal prognosis. Rule: a patient may be admitted only after certification by the hospice medical director or physician member of the team, and by the attending physician if the patient has one, that, if the disease progresses as expected, the patient is likely to live no more than six months, supported by a brief physician-written narrative explaining the clinical findings; recertification is required at each benefit period, and from the third benefit period onward a hospice physician or nurse practitioner must see the patient in person beforehand, as federal hospice rules require (Centers for Medicare & Medicaid Services, 2026). Responsibility: the medical director, attending physicians and the admissions nurse.

Procedure One

1. The admissions nurse completes the initial assessment and records measurable findings, such as weight loss, functional scores, symptoms and disease-specific indicators.

2. The hospice physician reviews the findings and writes the narrative in their own words; templated narratives are not accepted.

3. Certification is signed before the claim is submitted.

4. Twenty days before each recertification, the team reviews the patient's course; for the third and later periods, the physician or nurse practitioner visit is scheduled and documented.

5. If findings no longer support a terminal prognosis, the team follows Procedure One-A for discharge planning.

6. The quality nurse audits ten recertifications a month for narrative quality and timeliness.

Policy Two: General Inpatient Care

Purpose: to provide the higher level of care only when it is needed and to document why. Rule: general inpatient care is provided for pain or symptoms that cannot be managed in any other setting, and the need is reassessed and documented at least daily. Responsibility: the on-call nurse, the hospice physician and the inpatient unit manager.

Procedure Two

1. The field or on-call nurse documents the symptom, interventions tried at home and their results.

2. The nurse calls the on-call hospice physician, who decides whether inpatient care is needed and documents the reason.

3. On admission to the unit, the physician documents the plan and goals.

4. Each day, the physician or nurse practitioner documents whether the symptoms still require inpatient care; when they are controlled, the patient returns to routine care, even if staying in the unit for respite or family reasons is arranged separately.

5. The unit manager reviews every stay longer than five days. The question each day is not whether the patient is sick, but whether the symptoms still need a bed only an inpatient unit can provide.

Policy Three: Referral Relationships

Purpose: to prevent kickbacks and protect patient choice. Rule: no employee may offer or give anything of value to a referral source, including nursing facilities, assisted living communities, physicians or discharge planners, to induce referrals; contracts with nursing facilities must be written, at fair market value and reviewed by compliance; marketing staff are paid without regard to admissions; and patients receive a list of hospices serving their area. Responsibility: the director of community relations and the compliance director.

Procedure Three

1. All proposed arrangements with facilities or physicians go to compliance before signing.

2. Marketing staff log visits and any items provided, which must be educational and of nominal value.

3. Quarterly, compliance compares admissions by source with contracts and logs.

Writing for Users

Draft procedures were tested with six field nurses, two physicians and the community relations staff. The nurses asked that Procedure Two fit on one screen of the mobile documentation device, which it now does, and a physician suggested adding examples of symptoms that usually can be managed at home.

Procedure One-A: When a Patient Stabilizes

Live discharge is a sensitive moment. When a patient no longer meets eligibility, the team explains the reason to the patient and family in person, arranges follow-up with the patient's physician and home health or palliative care services if needed, gives written notice and documents the conversation and plan. Discharging a stable patient is required when eligibility ends, but doing it abruptly can harm patients and families who have relied on the hospice team. The procedure also requires the medical director to review every live discharge, both to confirm it was appropriate and to look for patterns suggesting admissions that should not have occurred.

Connecting Procedures to Records

Each procedure is built into the electronic documentation system where possible. The eligibility narrative field cannot be completed with copied text, recertification dates generate reminders 20 days ahead and the general inpatient care order requires a reason code and daily reassessment note before the next day's billing is released. Building procedures into the system makes the right steps the easiest ones.

Approval and Publication

Policies are approved by the compliance committee and the board's quality and compliance committee; procedures by the owning department with compliance review. All are posted in the searchable online library and linked from the documentation system.

Review

Each policy and procedure is reviewed annually and whenever regulations change, such as the yearly hospice payment rule, or when audits reveal a gap.

Conclusion

Three policies for hospice's highest risks, eligibility, inpatient care and referral relationships, each with a procedure written in steps and tested with the staff who will use them, give the hospice rules that work at 2 a.m. as well as in a survey. Federal requirements, inspector general findings and the special focus program explain why they matter; approval, publication and review keep them current.

References

Centers for Medicare & Medicaid Services. (2023). Medicare program; Calendar year (CY) 2024 home health (HH) prospective payment system rate update; HH quality reporting program requirements; HH value-based purchasing expanded model requirements; home intravenous immune globulin items and services; hospice informal dispute resolution and special focus program requirements, certain requirements for durable medical equipment prosthetics and orthotics supplies; and provider and supplier enrollment requirements. Federal Register, 88, 77676. https://www.federalregister.gov/d/2023-24455

Centers for Medicare & Medicaid Services. (2026). Hospice care, 42 C.F.R. pt. 418. Electronic Code of Federal Regulations. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418

Office of Inspector General. (2018). Vulnerabilities in the Medicare hospice program affect quality care and program integrity: An OIG portfolio (OEI-02-16-00570). U.S. Department of Health and Human Services. https://oig.hhs.gov/oei/reports/oei-02-16-00570.pdf