The Hospice Special Focus Program, which was finalized about a year ago, will select the list of participating hospices taking place in the program in November of 2024.
During the selection process, from the group identified as the bottom 10% of performers—those with the highest scores, which indicate poorer performance—a list will be published on the Special Focus Program website. Out of this group, 50 hospices will be chosen to begin participation in the program starting in January 2025.
As part of the Special Focus Program, you will undergo surveys every six months. Your participation will either end in graduation from the program or termination. To graduate, you must successfully complete at least two surveys without any Condition-Level Deficiencies and have no complaints under triage as Condition-Level or Immediate Jeopardy. Alternatively, you could also graduate by returning to full compliance with all requirements.
After graduating from the program, you will undergo a routine survey by either your accrediting body or the State survey office within 12 months. Following this, you will return to the regular survey schedule, which occurs every three years.
The bottom 10% of performers, or the highest 10% of scores, will be determined using an algorithm that factors in the Hospice Care Index scores, CAHPS Hospice Survey results, Condition-Level Deficiencies, and any substantiated complaints. While complaints may trigger surveys, only those that are validated during the survey process will count as substantiated complaints. If surveyors find no evidence to support a complaint, it won’t be considered substantiated.
Complaints and Condition-Level Deficiencies will be assessed based on those received over the past three consecutive years. Once the calculations are completed and the survey process begins, failing any two of the surveys will result in full termination from the Medicare program. Being terminated includes receiving a Condition-Level Deficiency in two surveys during this process or having any deficiencies considered immediate jeopardy or condition-level.
As mentioned earlier, the algorithm includes factors such as the Hospice Care Index, CAHPS Hospice survey results (using the bottom box scores), Condition-Level Deficiencies, and substantiated complaints. In this calculation, the CAHPS survey results are essentially weighted twice. If you don’t have CAHPS survey data, a different algorithm will apply. The only scenario where your CAHPS survey results would be excluded is if you served fewer than 50 patients during the specified period and applied for an exception.
Although the calculation is detailed, many in the hospice community consider it flawed. Nevertheless, CMS is firm in its decision to move forward. The process will identify the bottom 10% in November 2024, with 50 hospices selected to join the program starting in January 2025.
Please be aware that if you are accredited by an organization like CHAP, JCAHO, or ACHC, you will not hold “Deemed Status” during this period. Upon graduating from the program, you will regain Deemed Status, and your accrediting body will resume conducting surveys.
HPS stands ready to support you with any needs related to Hospice Medical Review, Hospice Survey Strategies, and more. Our consultants are certified in CAHPS and ACHC survey protocols, as well as survey for Medicare purposes in general. If you need help preparing for these surveys or responding to them, please feel free to reach out.
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