The Buck Stops Here - RN Practice Within the New CoPs

In 1945, President Harry S. Truman received a present for the Oval Office from an Oklahoma prison warden – a small wooden desk plaque inscribed with the words "The Buck Stops Here." According to the Truman Library, the expression originated from poker playing during the frontier times and meant taking a pass as dealer by handing over a small buckhorn knife or marker to the next player. (http://www.trumanlibrary.org/buckstop.htm). To Truman, who served our nation during a challenging postwar economy, the expression meant that the responsibility lay squarely on his shoulders as president.

The new Medicare and Medicaid Hospice Conditions of Participation ("CoPs") focus on a patient-centered, outcome-oriented and transparent process that promotes quality patient care for every patient, every time (73 Federal Register 32088 [June 5, 2008]). Under the CoPs, registered nurses ("RNs") have expanded roles and responsibilities that will help the hospice agency reach its desired quality outcomes.

On a daily basis, hospice nurses practice within the parameters of the CoPs and accreditation standards and probably refer more often to coverage and regulatory manuals than to the Nurse Practice Act ("Act"). Fortunately, when we take a look at the components of RN practice as defined in the Act, we see that they closely align with the CoPs.

For example, consider RNs’ role in both sets of regulations, as related to patient assessment.

NC Nurse Practice Act
The practice of nursing consists of ten components, including: Assessing the patient’s physical and mental health, including the following.

1. The patient’s reaction to illnesses and treatment regimens Recording and reporting the results of the nursing assessment
2. Planning, initiating, delivering and evaluating appropriate
3. Nursing acts Reporting and recording the plan for care, nursing care given and
4. The patient’s response to that care - N.C.G.S. §90-171.20(7)  

Hospice Conditions of Participation
418.54(a) Standard. Initial Assessment: The initial assessment must be completed by an RN within 48 hours after the election of the hospice care by the patient.

418.64(b)(1) Standard: Nursing Services. The hospice must provide nursing care and services by or under the supervision of an RN. Nursing services must ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment and updated assessments.

Under the CoPs, the initial assessment is done to determine the patient’s immediate care and support needs. The Interpretive Guidelines point out that this is not a "meet-and-greet" visit, but an assessment of the patient’s immediate physical, psychosocial, emotional and spiritual status related to his or her terminal illness and related conditions. The purpose of the RN assessment per the Act is similar. Notably, both sets of regulations seem to give a substantial nod to the Nursing Process and place value on continued assessment and re-evaluation by the RN as care is planned and implemented.

Last year, the National Association for Home Care and Hospice ("NAHC"), during its Washington, D.C., Law Symposium, convened a panel of Centers for Medicare and Medicaid Services ("CMS") experts who conveyed that plan of care ("POC") deficiencies were among the top three hospice survey citations across the nation. Surveyors found, for example, that disciplines did not visit patients as ordered in the POC; the POC was not reviewed and updated at specified intervals; some treatments being provided were not included in the POC; some treatments in the POC were not required or needed by the patient; and some hospices used canned POC statements rather than individualized plans (NAHC Report, Tuesday, May 6, 2008).

Why was compliance with POC requirements such a problem, given that the "old" CoPs, at §418.68(d), required that the hospice designate an RN to coordinate the implementation of the POC for each patient? Recognizing that the POC serves as an ever-evolving, patient-specific, problem-centered document, does the new expanded role of the RN as care coordinator ensure greater compliance with the CoP standards and better patient/family outcomes?

North Carolina’s Nurse Practice Act certainly supports RNs’ role as collaborator, but the new CoPs spell out more clearly RNs’ responsibilities in ensuring continuous patient/family assessment and implementing the interdisciplinary plan of care. This greater accountability may require hospices to strengthen their current policies and processes in several ways in order to be successful with this standard. 

For example:
NC Nurse Practice Act
Components of the practice of nursing also include: Teaching, assigning, delegating to or supervising other personnel

1. In implementing the treatment regimen Collaborating with other health care providers in determining
2. The appropriate health care for a patient - N.C.G.S. §90-171.20(7)

New Hospice Conditions of Participation
CoP 418.56(a)(1) Interdisciplinary group, care planning and coordination of services. The hospice must designate a registered nurse who is a member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs and implement the interdisciplinary plan of care.

Hospice agencies will need to review their orientation policies and processes to ensure that every member of the IDG understands the role of RNs as care coordinators. Hospices should also review their competency sets for nurses as related to care coordination. It’s one thing to be able to deliver safe, effective nursing care and another to oversee an IDG POC. Likewise, hospices will want to review their RN job descriptions and consider linking performance evaluations to desired outcomes in patient care and compliance. Hospices should also ensure that RNs have available the tools needed to help monitor the IDG POC and consider what impact, if any, this expanded RN role has on the current IDG dynamics.

Like President Truman’s plaque, the new hospice CoPs indicate where the "buck stops" as related to care coordination. Hospice agencies will need to consider how they might provide greater support for this greater accountability to help ensure that this expanded role is carried out successfully – for both the hospice and registered nurses.

For more information about this article, please contact Cindy Morgan of AHHC of NC at 919.971.8731 or cindymorgan@homeandhospicecare.org.

p.s.  It is interesting to note that when individuals commented on the proposed hospice CoPs, they called for the care coordinator to have expertise in physical, psychological and spiritual issues of terminally ill patients and to also act as a negotiator, advocate and leader when working with the IDG. CMS decided that the clinician who could uniquely fill this role was a registered nurse, stating that "a registered nurse has the necessary medical and interpersonal background to meet the demands of the coordinator position in a way that no other discipline does. The unique skills of registered nurses, who are educated to assess and manage the overall aspects of a patient’s physical and psychosocial care, can be used to oversee the coordination and implementation of the care identified by the IDG." 73 Federal Register 32112 (June 5, 2008)