Healthcare Provider Solutions

There are more than 4,000 hospices in the United States. They serve approximately 1.5 million people, and their families. We estimate that there are at least 225,000 hospice staff members providing these services. All of these staff members – whether it is the CEO new to the hospice arena, the contracted therapist, or the administrative office volunteer – need to be trained and oriented to hospice and their role in delivering care and carrying out the mission of their particular organization.

What must be included in the orientation? The Medicare Conditions of Participation require that hospices:

  • Provide orientation about the hospice philosophy to all employees and contracted staff who have direct patient contact.
  • Provide an initial orientation for each employee that addresses the employee’s specific job duties
  • Maintain, document and provide volunteer orientation and training that is consistent with hospice industry standards
  • For homemakers: orientation addressing the needs and concerns of patients and families coping with a terminal illness
  • Infection Control:
    • Orientation of all new hospice personnel to infections, communicable diseases, and to the infection control program;
    • The hospice must provide infection control education to employees, contracted providers, patients, and family members and other caregivers.

For hospices providing inpatient care directly:

  • A disaster plan must be periodically reviewed and rehearsed with staff (including non-employee staff) with special emphasis placed on carrying out the procedures necessary to protect patients and others. Surveyors are looking for orientation/periodic education of the components of the disaster plan.
  • All patient care staff working in the hospice inpatient facility must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion*
    • Before performing any of the actions specified in this paragraph;
    • As part of orientation; and Subsequently on a periodic basis consistent with hospice policy.

For all staff that apply restraint or seclusion, monitor, assess, or otherwise provide care for patients in restraint or seclusion:

  • Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion.
  • The use of nonphysical intervention skills.
  • Choosing the least restrictive intervention based on an individualized assessment of the patient’s medical, or behavioral status or condition.
  • The safe application and use of all types of restraint or seclusion used in the hospice, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia).
  • Clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary.
  • Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special  equirements specified by hospice policy associated with the 1-hour face-to-face evaluation.
  • The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification.

* Interpretive Guidance for this standard further indicates: All staff working in a hospice that precludes the use of restraints or seclusion would not have to be trained or demonstrate competencies specified in this standard since no staff in a restraint free facility would be applying restraints or placing patients in seclusion. In this situation, the hospice should ensure that all staff are aware of its restraint and seclusion free philosophy and provide ongoing training in this philosophy. The hospice should also closely monitor patients to be sure that the use of any restraint or seclusion technique is not used.

In addition to orienting hospice staff, the Medicare CoPs further state at 418.100(g)(3): “A hospice must assess the skills and competence of all individuals furnishing care, including volunteers furnishing services, and, as necessary, provide in-service training and education programs where required. The hospice must have written policies and procedures describing its method(s) of assessment of competency and maintain a written description of the in-service training provided during the previous 12 months.”

Surveyors are instructed to review a sample of personnel records to verify that initial orientation, assessment of skills and competency, and in-service training was provided to all employees, contracted staff and volunteers furnishing care/services to hospice patients and families.

Regarding advance directives, hospices are required to provide for education of staff concerning its policies and procedures on advance directives and provide for community education regarding issues concerning advance directives. Hospices may do this either directly or in concert with other providers and organizations. Emergency preparedness must be part of the orientation. The CMS Emergency Preparedness Interpretive Guidelines require that each hospice develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, risk assessment, policies and procedures, and the communication plan. The training and testing program must be reviewed and updated at least annually.

Hospices must also abide by all other applicable laws and regulations, and there are some that require staff orientation and/or training such as HIPAA Privacy and Security. Also, Accrediting Organizations (AOs) such as The Joint Commission require additional orientation and training.

The requirements from CMS cover only a fraction of the topics that hospice staff should be oriented to or receive education and training about, and they focus on staff providing direct patient care. Healthcare Provider Solutions, Inc. recommends that all staff, regardless of position, at least be oriented to the items listed below and that the hospice maintain evidence of this orientation in the staff member’s personnel file.

  • Hospice philosophy and the interdisciplinary team approach
  • Scope of care for each of the following:
    • Nursing
    • Dietary
    • Social Work
    • Bereavement
    • Therapies
    • Chaplain
    • Aide/Homemaker
    • Volunteer
  • Medicare Hospice Benefit/Medicaid Hospice Benefit overview
  • Hospice Organization’s Philosophy, Mission, Goals and Objectives
  • Organizational Chart
  • Employee’s specific job duties (this can be in the form of a job description)
  • HIPAA Privacy and Security
  • Quality Program
    • Employee’s role in program
    • Patient outcome measures
    • Current PIPs
  • Definition and Identification of Adverse Events
  • Patient/Family Complaint and Resolution Process
  • Employee Complaint and Resolution Process
  • Incident Reporting for Employees
  • Conflict of Interest
  • Compliance Plan and Program
  • Professional Boundaries
  • Staff Safety – Office and Field
  • Emergency Preparedness
  • Cultural Diversity
  • All Other Applicable Policies and Procedures

Questions have arisen regarding the duration of staff orientation. It is up to each hospice to determine this for all of its staff – paid, contracted, and volunteer. The hospice should ensure that each of its staff members is competent to carry out assigned duties and responsibilities. There are some specific training and competency requirements for hospice aides found at 418.76. While they do not specify the duration of the orientation and training, they do get very specific on the areas that a hospice aide must be competent in, how that competency is determined, and ongoing education requirements for the aides.

There is no specific requirement on the duration of volunteer training. Rather the hospice is to have an orientation and training program that is consistent with industry standards and all required volunteer training should be consistent with the specific tasks that volunteers perform. It is common for the hospice volunteers that are providing direct patient care to have more hours of training than those not having any patient/family contact and for that training to cover such areas as:

  • Patient rights
  • Abuse, neglect and exploitation
  • Communication with the terminally ill patient/family
  • Ethical issues – identification, reporting and resolution
  • Signs and symptoms of approaching death
  • Disease and culture specific issues pertinent to the population served by the hospice
  • Recognition and acceptance of one’s own mortality
  • Training specific to the tasks assigned to the volunteer
  • Any quality initiatives that would include the volunteer

It is possible to utilize volunteers in the provision of bereavement services provided they are competent in this area. These volunteers usually go through even more orientation and training. Volunteers assisting in one-time events, such as a walk-a-thon or hospice open house, usually receive training in the hospice philosophy and specific to the duties they’ll be fulfilling at the event.

It is important for hospices to remember that CMS considers volunteers unpaid staff. Therefore, whatever orientation and training requirements a hospice has implemented for its paid staff should be implemented with unpaid staff performing in the same role/carrying out the same duties.

This article does not address job qualifications or requirements nor does it address applicant/employee screenings such as physicals or drug testing. Note that CMS does not require hospice staff to have physicals or submit to drug testing although there are very good reasons why they are commonly required by hospices.