The world of hospice care is deeply personal and profoundly compassionate. As a hospice clinician, your primary focus is providing compassionate care to your patients and their families during their most vulnerable moments. But the intimate nature of home-based care can sometimes expose you to unexpected risks of workplace violence.
The Growing Concern of Workplace Violence
In recent years, workplace violence has emerged as a critical issue in healthcare, particularly for homecare professionals. A survey conducted by Transcend Strategy Group (https://transcend-strategy.com/insights-workforce-safety/) revealed that over 50% of healthcare workers have witnessed or experienced a violent event.
Workplace violence extends far beyond physical assault. It encompasses a broad spectrum of threatening behaviors including verbal abuse, psychological harassment, and intimidation. These experiences can have devastating consequences — not just physically — but emotionally and professionally.
There are some steps that you can take to help reduce your risk of experiencing workplace violence including pre-visit preparation, situational awareness, and setting boundaries. Let’s explore these further.
Pre-Visit Preparation is Key
Effective safety starts with thorough preparation. Before entering a home, confirm who will be present during your visit. Don’t hesitate to ask about potential safety concerns, ask to have pets restrained, and ensure no weapons are visible. Clear communication with patients and their families can prevent many potential incidents.
On visiting a patient’s home, situational awareness is a key preventative action. Situational awareness begins before you even step into a patient’s home. As you approach, take a moment to observe your surroundings. Notice changes in the in the environment – are things different from the previous times you visited the patient’s home? Are there more or fewer cars? Did something change in appearance? This isn’t about paranoia – it’s about being prepared and alert.
When you enter the patient’s home and say hello to the patient and family members, ask the patient or caregiver to introduce you to anyone else in the room if there are new people there. As you look around the room, note potential exit routes in case you need to quickly exit.
Setting Boundaries and Maintaining Professionalism
Your personal safety is paramount. While providing compassionate care is your mission, it should never come at the expense of your well-being. If a situation feels uncomfortable or threatening, you have the absolute right to remove yourself. Engage with management immediately if you feel that your safety is compromised.
Reporting and Documentation: A Critical Process
If you experience workplace violence, it is important that you report the event and that the event is documented. Unfortunately, clinicians are often hesitant to report the experience, citing reasons such as:
Workplace violence is “part of the job” (acceptance)
It wasn’t really a big deal… (acceptance)
Nothing can be done about it anyway (acceptance)
What will management think if I say something (fear of job loss)
I want to avoid conflict with the patient/patient’s family (fear of job loss)
I don’t want to be labeled as incompetent (fear of job loss)
I was in the wrong place at the wrong time” (blame)
Although you may hesitate to report an incident, it is important that every incident of workplace violence is documented.
Documenting incidents is not just a procedural requirement – it’s a crucial step in preventing future occurrences and in protecting fellow clinical staff. Detailed, confidential reports help agencies identify patterns, implement preventive measures, and create safer working environments. It is important that fellow staff members are aware of potentially problematic situations that may arise when they visit the patient.
Contact Information / Buddy System
Make sure that you have provided your management with emergency contact information for so that someone can be contacted in the case of an emergency. Avoid after dark visits. If after dark visits cannot be avoided, use the “buddy system.” Make sure that someone knows where you are going and is anticipating your return or is anticipating contact from you and will either go out to look for you or call 911 if they do not hear from you.
Wrapping it Up
In summary, workplace violence is a real concern for home healthcare workers but here are steps that you can take to protect yourself:
Conduct a home assessment to identify potential risks in the home. Be sure to act on those potential risks.
Establish boundaries: Set your personal safety boundaries. Your personal safety is most important.
Emergency contact: Ensure your management knows whom you would like to have contacted in case of emergency
Avoid after dark visits: Try not to visit patient homes after dark.
Buddy system: Make sure someone knows where you are going, knows when to expect to hear from you, and will go look for you or will call 911 if they do not hear from you by the predesignated time.
Early termination of visit: If you feel that a situation has escalated or that you are feeling threatened, terminate the visit and engage with management to notify them of the situation.
The hospice interdisciplinary group (IDG) creates a patient’s plan of care and provides holistic care to the patient, caregiver, and family. Hospice Conditions of Participation require the IDG to “review, revise, and document the individualized plan as frequent as the patient’s condition requires, but no less frequently than every 15 calendar days.”
As such, the IDG meet at a minimum every 15 days. In many hospice organizations, the interdisciplinary group meets weekly to review patient status and to determine if changes are required to a patient’s plan of care. It is important that during the IDG meeting patients’ care plans are reviewed and updated based upon patients’ assessments. Timely and accurate documentation is critical; this documentation may be reviewed by surveyors and by CMS to ensure compliance with regulations.
Who is required to attend an IDG Meeting
Required members of the IDG meeting include:
A doctor who is an employee or under contract with the hospice agency
Registered nurse
Social worker
Pastoral or other counselor
These four individuals are minimum participants in the IDG meeting. If one of these members i missing from the IDG meeting, the meeting does not meet Medicare regulations and it is considered as if the meeting did not take place. . Care must be taken to ensure that the minimum requirement – IDG meeting with the participation of at least these four individuals at a minimum of once every 15 days – is met.
Additionally, a staff member is typically identified to serve as the scribe for the IDG meeting. The scribe captures any changes to a patient’s plan of care that are agreed upon during the meeting.
What activities occur during the IDG meeting?
When the meeting begins, all participants sign the meeting sign-in sheet. These sheets serve as documented proof that the hospice has met the Medicare Conditions of Participation – that the required members of IDG participated in the meeting. Sign in sheets are stored in a place that is accessible for review upon the request of auditors or surveyors.
Prior to the IDG meeting, a list is drawn up of the patients who will be reviewed during the meeting. For each of these patient’s members of the care team provide an update on the patient’s current condition, highlighting any concerns. The team then discusses the plan for the upcoming two weeks.
Patients may be ordered for discussion as follows:
Deaths
Admissions
Recertifications
Evaluation
Let’s review each of these in detail.
Deaths
Each death since the prior IDG meeting is reviewed. The team discusses whether bereavement has been requested or declined. In the case where bereavement has been requested, the individuals who will be receiving bereavement services are identified. Any further details or concerns on the services that will be provided are discussed.
Admissions
The RN Case manager discusses any new admissions since the prior IDG meeting, including patient diagnosis and hospice eligibility criteria. Visit frequency is discussed, hospice aide services, and patient psychosocial needs. Typically, all team members partake in this discussion including a discussion about patient medications and prognostic indicators.
Recertifications
At this stage in the IDG the team discusses all patients who are the end of their benefit period and need to be recertified. Any face-to-face visits that were conducted will be discussed and any that are still pending will need to be scheduled. For patients who were evaluated and are found not to meet criteria, the team discusses how to notify the family and details on how to transition the patient off of hospice care.
Evaluations
All remaining patients on the list are reviewed by the members of the IDG. The team discusses whether any changes to the plan of care are needed, whether any medications need to be changed or if any additional support is required (e.g., chaplain, volunteer). The plan of care may be updated if the team agrees that a change in visit frequency is required.
Updating patients’ plan of care
While each patient is discussed, any changes to the patient’s plan of care are entered into the patient’s chart, which is signed by the medical director.
Hospice care is patient- and family-centered, where the patient’s and family’s preferences and needs drive the care plan.
The hospice interdisciplinary group (also referred to as Hospice IDG or IDG), also referred to as the interdisciplinary team (IDT) is a team of healthcare professionals who work together to create a plan tailored to the needs of hospice patients. The IDG is crucial because it reflects the fundamental principle of hospice care: a multidisciplinary and holistic approach to treating a patient. Hospice care is not just about managing medical symptoms; it involves addressing the physical, emotional, social, and spiritual needs of the patient and their family. This comprehensive care model requires combined expertise of different healthcare professionals working together as a cohesive team.
Multidisciplinary and 360-degree approach
The idea of a multidisciplinary approach is central to hospice care because a single healthcare professional cannot fully address the complex needs of a patient at the end of life. Hospice patients often experience pain, emotional distress, social isolation, and spiritual concerns, all of which need to be treated so that the patient has a peaceful and dignified end of life experience. Each of the members of the IDG can address different aspects of hospice patient needs.
Physical needs: Managed by the physician and nurse. The physician provides medical direction and oversees patient care while the nurse manages the patient’s medical needs such as pain control and symptom management.
Emotional and social needs: The social worker provides emotional and social support, caring for emotional health, caregiver stress, and family dynamics. Consideration is also given to connecting the family with community resources
Spiritual needs: These are managed by the chaplain, who offers spiritual care and counseling, based on the patient’s and family’s beliefs. The chaplain helps patients and families explore spiritual concerns, questions of meaning, or religious beliefs in the context of their journey.
Daily living needs: Hospice aides assist with personal care like bathing, dressing, and grooming. They ensure dignity and comfort in activities of daily living like bathing, dressing, and grooming.
Companionship and support: The hospice volunteer offers companionship and practical help, like errands or respite for family caregivers.
By involving individuals from different disciplines, hospice care can take a 360-degress approach to a patient’s needs. It means that every aspect of care – physical, emotional, social, and spiritual – is addressed by someone with the expertise to manage that particular dimension. This all encompassing approach is what makes hospice care unique and effective.
Are all member of the IDG required per CMS regulations?
Per CMS regulations, only core members must always be part of the IDG to ensure that hospice care addresses every critical aspect of the patient’s experience. Four disciplines are considered core required members of the team. These include:
Physician
Registered nurse
Social worker
Chaplain
Some professional members may be included in the IDG as needed, depending upon patient’s individual circumstances. These include:
Hospice Aide
Volunteer
Therapists
Bereavement Counselor
How is the IDG aligned with regulatory standards?
CMS requires that hospice care involve an interdisciplinary approach because it reflects the need to treat the “whole” patient, not just their medical condition. The IDG ensures that the care plan is tailored to the patient’s evolving needs and that it incorporates feedback from multiple disciplines to achieve the best outcomes. The interdisciplinary model is also a regulatory requirement under the hospice Conditions of Participation (CoPs). As such, surveyors will review the functioning of the IDG during inspections to ensure compliance. A well coordinated interdisciplinary team ensures regulatory compliance and quality patient care.
Why is the interdisciplinary hospice team essential?
Hospice care is patient and family centered, meaning that the patient’s and family’s preferences and needs drive the care plan. The IDG works collaboratively to ensure that the care plan remains flexible and responsive to changes in the patient’s condition. As hospice patients often experience rapid changes in health, having professionals from different disciplines ensures that all aspects of care can be addressed promptly and effectively.
In summary, the IDG reflects hospice’s holistic, multidisciplinary approach to care by ensuring that all dimensions of the patient’s well-being are addressed. Required team members focus on medical, emotional, and spiritual care, while optional members can be added to meet unique or additional needs. This alignment ensures that hospice remains flexible and patient-centered.
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Caregivers play a critical role in hospice care, where the focus is on providing comfort and support to individuals nearing the end of life. These unsung heroes, often family members or close friends, offer physical, emotional, and spiritual support to their loved ones during one of life’s most challenging transitions. However, the demands of caregiving can take a toll, leading to burnout and reduced well-being. Recognizing and addressing caregiver burnout is essential for ensuring ongoing support for patients and their families.
Understanding Caregiver Burnout:
Caregiver burnout is a multifaceted phenomenon that is characterized by physical, emotional, and mental exhaustion. It can manifest as feelings of overwhelming stress, compassion fatigue, depression, and a sense of hopelessness. According to the Mayo Clinic, symptoms of burnout may include fatigue, irritability, withdrawal from social activities, and a lack of motivation or interest in caregiving tasks. If caregiver burnout is not addressed, it can have a negative impact on the quality of care provided to patients and negatively impact caregivers’ own health and well-being.
Research conducted by the Ann & Robert Lurie Children’s Hospital of Chicago and the University of Pittsburgh sheds light on the prevalence and impact of caregiver burnout in hospice settings. Dr. Michael Certo, assistant professor of pediatrics at Lurie, emphasizes the high risk of emotional, social, and financial consequences for caregivers. The study found that caregiver burnout is alarmingly common among those providing end-of-life care, underscoring the need for targeted interventions and support mechanisms.
Assessing Caregiver Distress:
To effectively address caregiver burnout, healthcare providers must first identify individuals at risk. The research team implemented a standardized method for assessing caregiver distress, recognizing the importance of early intervention in mitigating burnout. The caregiver self-assessment questionnaire, developed by the American Geriatric Society, emerged as a valuable tool for screening caregivers’ well-being. This brief yet comprehensive metric enables clinicians to identify signs of burnout and tailor support interventions accordingly.
Supporting Caregivers:
Once caregiver distress is identified, healthcare providers can offer a range of supportive measures to promote resilience and well-being. These may include encouraging caregivers to prioritize self-care, providing access to respite care services, facilitating peer support groups, and connecting caregivers with community resources. Additionally, caregivers may benefit from educational programs aimed at enhancing coping skills, stress management techniques, and communication strategies.
The Impact of Caregiver Burnout on Hospice Care:
Caregiver burnout not only affects individual caregivers but also has broader implications for hospice care delivery. Research has shown that patients who do not have adequate caregiver support may be less likely to choose hospice care, leading to delayed referrals and suboptimal end-of-life experiences. Moreover, caregiver burnout can strain healthcare resources and contribute to caregiver turnover, compromising the continuity and quality of care provided to patients and families.
Addressing the Financial Burden:
In addition to the emotional and physical toll, caregiving often imposes a significant financial burden on families. According to AARP, unpaid family caregivers in the United States collectively spend billions of dollars annually on caregiving-related expenses. These costs may include medical bills, prescription medications, home modifications, and lost wages due to missed workdays. Recognizing the financial challenges faced by caregivers is essential for implementing policies and programs aimed at alleviating economic strain and promoting financial security.
In conclusion, caregiver burnout poses a significant challenge in hospice care, impacting both caregivers and the patients they serve. By implementing comprehensive assessment tools, providing targeted support interventions, and addressing the financial burdens associated with caregiving, healthcare providers can foster resilience and well-being among caregivers. Nurturing caregivers not only enhances the quality of care provided but also ensures that patients and families receive the compassionate support they need during life’s final journey.
Where Can you Get Additional Information:
Mayo Clinic. (n.d.). Job burnout: How to spot it and take action. Retrieved from Mayo Clinic
National Institute on Aging. (n.d.). Taking Care of Yourself as a Caregiver. Retrieved from National Institute on Aging
AARP Public Policy Institute. (2021). Family Caregiving and Out-of-Pocket Costs: 2016 Report. Retrieved from AARP Public Policy Institute
American Geriatrics Society. (n.d.). Caregiver Self-Assessment Questionnaire. Retrieved from American Geriatrics Society
Hospice Foundation of America. (n.d.). Caregiving at the End of Life: Finding Resilience. Retrieved from Hospice Foundation of America
Morrison, R.S. et al. (2009). Palliative Care Consultation Teams Cut Hospital Costs for Medicaid Beneficiaries. Health Affairs, 28(3), w450-w460. Retrieved from Health Affairs
The False Claims Act (FCA) was established in 1863 during the Civil War to combat fraud and abuse perpetrated by suppliers of the federal government. At that time, the law was referred to as “Lincoln’s Law.”
The FCA has evolved significantly in recent years and is now one of the main tools used by the government to fight fraud. The FCA penalizes individuals or entities that submit fraudulent claims to the government, cause fraudulent claims to be submitted, or conspire to submit fraudulent claims.
One of the noteworthy provisions of the FCA is the qui tam provision, also known as the whistleblower provision. The qui tam provision allows private citizens, also referred to as “relators”, to report details of alleged fraud to the government. The whistleblower “stands in the shoes” of the government to prosecute the claim. This action benefits the government and the taxpayer as well as potentially the relator, who may receive a share of what is recovered.
How does the FCA relate to a hospice agency?
The False Claims Act allows hospice agency employees, patients, families of patients, or any individuals with alleged knowledge of fraud or abuse by the agency to report the behavior. Under the qui tam provision of the FCA, the relator may be entitled to a percentage of recovered funds.
What are different types of false claims?
A claim is a request for money made to the government. A false claim is money that is obtained from the government due to false or fraudulent claims. False claims include claims where the service
Has not been provided
Is already included as part of a different claim (i.e., double billing)
Is not coded correctly
Is not supported by the patient’s medical record
Claims may also be false and are covered under the FCA if they result from a referral made in violation of the Federal Anti-kickback statue (Stark Law).
The False Claims Act also includes payment from the government based upon false certification.
False claims include claims that the hospice agency should have known were false or fraudulent.
What is a claim that a hospice agency “should have known” is false?
The FCA expressly includes claims that a hospice agency “should have known” were false or fraudulent. “Should have known” means deliberate ignorance or reckless disregard of truth. As such, a hospice agency cannot avoid liability by simply ignoring inaccuracy in their claims. Examples of “should have known” include:
Ignorance of billing rules, i.e., lack of knowledge of the rules
Failure to act on consistent trends that are indicative of inaccurate billing
Failure to act on inaccuracies or system errors identified by outside or internal auditing teams
Failure to correct inaccurate billing (impacting either past or future claims)
A hospice agency must understand the rules and take proactive measures — such as conducting internal audits within the organization — to ensure compliance and accurate billing.
How can False Claims Act matters be initiated?
There are two ways that FCA matters can be initiated:
Initiated by the government: When a FCA matter is initiated by the government, this type of matter typically starts with an audit or an investigation by the government. The government would determine that there is a false claim made to it and would initiate a matter, usually by a subpoena or civil investigative demand (CID). The government would issue the CID directly to the hospice agency. CID is a form of subpoena that requires the hospice agency to engage in one-sided discovery. That is, the hospice agency is required to produce documents demanded, respond to interrogatories, and provide sworn oral testimony. However, the hospice agency may not conduct any discovery.
Qui tam matter: this type of matter is initiated by a whistleblower, also known as a “relator,” typically through the filing of a sealed lawsuit in a federal district court. The hospice agency does not know about the qui tam lawsuit since the lawsuit is initially served on the government. The case remains under seal while it is investigated by the government.
What is the qui tam process?
Qui tam actions are initially filed under seal. That is, only the US Attorney and some members of the Department of Justice (DOJ) have knowledge of and access to documents related to the case. The relator serves the complaint on the government together with a written disclosure of all material evidence.
The purpose of the sealed qui tam action is to allow the DOJ time to evaluate the relator’s allegations and for the DOJ to decide whether it would like to take over primary responsibility for prosecuting the case. If the DOJ decides to take over primary responsibility for the case, the DOJ is said to “intervene.”
The complaint remains under seal for 60 days during which time the DOJ investigates the relator’s allegations. This 60-day period can be (and typically is) extended. In fact, the government may spend months – or even years – investigating the case.
While the DOJ conducts its investigation, it may issue a Civil Investigative Demand (CID). This form of subpoena requires the defendant (the hospice agency) to engage in one-sided discovery where the hospice agency must produce documents, respond to interrogatories, and provide sworn oral testimony, as demanded. The CID is “one-sided discovery” because the hospice agency may not conduct any discovery.
If the government decides to intervene, the government is then responsible for litigating the case and files its own complaint instead of the complaint that was filed by the relator. The relator remains a party to the complaint.
If the government declines to intervene, the relator may proceed in her own name subject to the government’s right to dismiss the claim or to intervene at a later date.
Whether or not the government decides to intervene, the government remains the real party of interest. (As a reminder, the relator is only “standing in the shoes” of the government.) As such, the government must agree to any decisions on the case. The relator may not agree to dismiss or settle the case without the government’s approval.
What are the key phases in a False Claims Act investigation?
Phase 1: FCA investigation is triggered. Triggers may include:
Qui tam (whistleblower) lawsuit
Call to OIG hotline
Information identified during audit or claim review
Complaints
Data mining
Phase 2: Formal investigation launches. Investigation may involve:
Review of corporate filings
Interview current or former employees
Review financial records
Electronic surveillance
Physical surveillance of employees or of company premises
DOJ civil investigative demand (CID), or the like
Government search warrant or raid
Phase 3: Litigation or resolution
Who are common whistleblowers?
Anyone can be a whistleblower and anyone may report alleged fraudulent activity to the government. The most common relators are:
Business partners
Current or former employees
Competitors
Patients
Individuals who mine CMS data to identify anomalies/FCA claims
How can a hospice agency reduce the chance of qui tam lawsuits?
Any complaints or concerns that are raised – by employees, vendors, patients, or competitors, or any other individuals should be investigated and treated with concern as these have the potential to reveal compliance issues that need to be resolved by the hospice agency.
Employee complaints – whether from departing or active employees – are often an excellent source of information on potential compliance issues. A hospice agency should have a clearly established method – that is clearly and often communicated to employees – for employees to raise concerns. It should also have an organized process to diligently investigate and address any concerns raised by employees.
Internal complaints:
There must be an organized process – that is communicated regularly to employees – for employees to raise concerns
All concerns must be investigated
Have a plan to address any issues that are identified
Take any necessary corrective actions
Follow up with the individual who raised the complaint
Provide training, as needed
Departing employees
Treat employees fairly as they leave
Conduct exit interviews to identify any potential compliance concerns – investigate any issues that may be identified
Potential releases (e.g., recovery from FCA claims)
Employees must feel that there is a process for raising concerns and that their concerns are heard. Employees should not fear retaliation for raising concerns. A hospice agency should be diligent and careful to respond to all employee complaints that are raised internally or to any complaints that are raised when employees leave the organization.
What are the financial benefits of avoiding FCA violations?
False claims act matters can be quite costly for a hospice organization. In addition to returning the payments associated with the false claims identified and incurring the costs associated with attorney fees to defend the matter, the hospice agency potentially faces the following significant costs:
Treble damages: The FCA has a treble damages provision which provides that a hospice agency that is found to have violated the FCA statute may be liable to pay three times the amount of the actual false claim amount
Penalty per claim: Under the FCA, a civil penalty may be assessed for each false claim that is submitted. The civil penalty dollar amount per claim has increased with inflation and currently may be as much as $23,000 per claim.
