Do Hospice Facilities Need Own Rules?

There are separate requirements for all kinds of health-related places — nursing homes, skilled nursing facilities, congregate living health facilities –  so should there be separate definitions and requirements for hospice facilities? Since end-of-life care differs from extending-of-life care, should separate facilities be built just for hospice?

Those are some of the questions taken on last week in a Senate appropriations committee special hearing on AB 950 by Ed Hernandez (D-West Covina), and the legislative answers are not simple.

“The basic question is: Is there a need for a specific hospice license category?” hearing chair Elaine Alquist (D-Santa Clara) said.

“We have a huge group of Baby Boomers coming, and they will need expanded hospice services. This is a question, for many of them, of staying human till the end. This is too important a bill not to do it right.”

But Charlene Harrington, formerly of UCSF Medical Center, said that establishing a new license category for hospice could be opening up a can of administrative chaos.

“I have serious concerns about this legislation,” Harrington said. “In theory, it’s nice to have a separate category, but I think it just creates more confusion, because there are so many choices and options now.”

New hospice facilities would be costly and unnecessary, she said, because of the amount of time and money it would take to work out new building requirements, and how little all of that would accomplish, given the wide variety of hospice services currently being offered. More important, Harrington said, is the cost and effort needed to keep tabs on how a new category of hospice facilities are run. If they operate under their own rules, the state would need to set up a structure to monitor a new type of facility.

“It would require new licensing resources,” she said. “According to the CMS, California can’t even meet its requirement of inspecting nursing facilities now. Considering how vulnerable the people are who are needing hospice services, oversight is a critical issue.”

Cost is a specious argument, Peter Kelleson of California Hospice and Palliative Care said. “Hospice is not a cost increase, it is a cost saver,” he said. By getting people out of hospitals and other medical care facilities and into their homes or proposed hospice centers, a lot of the high cost of health care diminishes.

“The dividing line here is, every health care building now is designed for those to live. This is an entirely different modality.”

For instance, he said, SNF units have requirements to have recreation services and a set number of nutritious meals that are not so important to dying patients.

So setting up hospice facilities in SNF or CLHF units means meeting a lot of expensive requirements that are superfluous to end-of-life care, according to Holly Swiger of VITAS Hospice.

“There is difficulty when hospices have tried to be at SNFs or CLHFs, and when hospices try to build small facilities [and are faced with the need to fulfill unnecessary requirements] it’s untenable,” she said.

“We want to create legislation that allows hospice in all communities. We’d like the ability for hospice to go into an existing facility and provide hospice care,” she said, “in a safe, effective, affordable way.”

One of those requirements is for a registered nurse to be on hand for hospice patients, in the same way they’re available at skilled nursing facilities, for instance.

“A registered nurse has the kind of firsthand knowledge that makes sure that patients get safe and appropriate standards,” Kelly Green of the California Nurses Association said.

“[Licensed Vocational Nurses] don’t have the authority, training or expertise to properly assess, for example, pain management goals,” she said. “Pain meds are important to hospice patients, and an RN can assess when someone is over- or under-medicated. An LVN is not trained for this.

Brenda Klutz of the Health Management Association said that an informal poll by her staff showed that 35 other states do have a specific category for hospice.

The bill, passed by the Assembly, remains in the Senate Committee for Appropriations.