Transferring a patient

[holistic1028]

Question, are there CMS guidelines on transferring a hospice patient? If so can someone pls send me a link? This agency I currently work for have no clue what CMS guidelines are for anything and it scares me. I have to learn all on my own, I am okay with that but what bothers me is when someone goes over me and does something for a patient I am case managing that doesnt follow guidelines, and without my knowledge.

If you had a patient that was transferring to another state and needed assistance with transferring hospice agencies, isnt that something the SW would help with? Nope, this agency didnt even have a SW so I had to find one for patient.

If your patient's set move date was 2 weeks AFTER recert date wouldnt it make sense to go ahead and recertify the patient and then do transfer when patient is transferred?? Nope, this agency discharged my patient, without my knowledge after I had already completed re-cert documentation which was jst sitting in the computer, in void. They discharged instead 2 weeks PRIOR to transfer/move date, didnt tell me as Case Manager or the Hospice Aide, so I've been visiting and following up with patient and also the aide has been going 3x week.

And isnt there guidelines for even "discharging" a patient ie. ABN, 5 day noticed, DME pickup etc? This agency just discharged, thats it, no documentation, didnt inform me or patient. Doesnt make sense to me.

[lifelearningrn, BSN, RN]

Run away, run fast and far. The company you work for sounds like bad news. I'm pretty sure CMS REQUIRES a social worker. This company is non-complaint in obvious ways, and in the end, it's your license on the line when they get audited.

[GrumpyRN63, ADN, RN]

Wow, no words really. Many thing troubling about this post, but you are continuing to see this Pt ,along with the HHA after discharged? I would be very concerned about liability and risk to your license. If that Pt has been discharged, you are visiting, providing care, who is covering your back?? NOT the agency. Do yourself a favor and get out.

[toomuchbaloney]

You need to protect yourself now and get out of this situation.

The agency you are working for is NOT compliant with federal regulations and should be reported.

Your brief post reveals a number of alarming failures and outright ignorance of pertinent law and regulations and the agency has put your professional license at risk with their ignorance.

Run, do not walk away from this employer.

Report them please.

[NRSKarenRN, BSN, RN]

Hospice. - Centers for Medicare & Medicaid Services

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R65SOMA.pdf

Section 2/2080C Hospice Required Services -- MSW is part of core service along with physician, nursing and pastoral/counseling.

2/2082 Discharge from Hospice Care

§418.104 Condition of participation: Clinical records.

e) Standard: Discharge or transfer of care. (1) If the care of a patient is transferred to another Medicare/Medicaid-certified facility, the hospice must forward to the receiving facility, a copy of—(i) The hospice discharge summary; and

(ii) The patient's clinical record, if requested.

(2) If a patient revokes the election of hospice care, or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician, a copy of—

(i) The hospice discharge summary; and

(ii) The patient's clinical record, if requested.

(3) The hospice discharge summary as required in paragraph (e)(1) and (e)(2) of this section must include—

(i) A summary of the patient's stay including treatments, symptoms and pain management.

(ii) The patient's current plan of care.

(iii) The patient's latest physician orders. and

(iv) Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility.

Hospice Surveyor Guidelines lists surveyor questions and expected care guidelines.

Agree with your assessment situation and other members: poorly run program, is lack MSW temporary??--carefully consider continued employment versus moving to other Hospice program.