Scope of Service: Matching Resident Needs and Provider Capabilities

ECRI Institute and Annals of Long-Term Care: Clinical Care and Aging (ALTC) have joined in collaboration to bring ALTC readers periodic articles on topics in risk management, quality assurance and performance improvement (QAPI), and safety for persons served throughout the aging services continuum. ECRI Institute is an independent nonprofit that researches the best approaches to improving health care.

What do the following situations—which are based on actual events, lawsuits, or questions from ECRI Institute members—have in common?

A continuing care retirement community (CCRC) determines that an independent-living resident requires transfer to assisted living. The resident wants to stay in independent living and retain private care, but her care needs exceed that which state law allows to be provided in independent living.

In accordance with a preferred provider agreement, the hospital sends a referral for postacute care. Although the person could benefit from rehabilitation, the prospective patient has multiple comorbidities as well—including a recent history of suicidal ideation. Occupancy in the short-stay unit has been low for several weeks.

Although these situations raise a variety of risk management concerns, from lawsuits to resident or family dissatisfaction to regulatory or licensure problems, the common theme is scope of service.

When processes are in place to harmonize the needs of persons served with the capabilities of the delivery system, a greater likelihood exists to fulfill duty-of-care obligations. But when the needs of the person served and the capabilities of the service line and level of care do not align, risk and the potential for harm can emerge. Organizational processes that lead to mismatches are potential root causes that can manifest as many different types of problems throughout any care and service delivery system. 

Having a well-defined scope of service for each service line offers benefits such as the following to aging services organizations:

It provides a framework for making decisions about admissions, transfers, and discharges of individual residents that helps to ensure they are able to meet residents’ and patients’ needs.

It supports decision makers when they determine that the service line cannot meet the individual resident’s needs.

It facilitates evaluation and implementation of management decisions, such as expansion of services, entering into contracts for additional services, and other issues.

What Is Scope of Service?

The prevalence of scope-of-service documents varies among health care and aging services settings. For example, acute care hospitals and home health agencies that participate in Centers for Medicare & Medicaid Services programs are required to develop and maintain scope-of-service documents. Licensing regulations may require a licensed provider organization to develop and maintain a scope of service, sometimes referred to as a “description of services.” Scope-of-service requirements can exist in either federal or state regulations, depending on the aging services sector or service line.

Aging services organizations should ensure familiarity with applicable regulations and guidance addressing scope of service, including those addressing supporting documentation, for all current and proposed service lines. For example, Pennsylvania law requires personal care homes to have a “current written description of services and activities that the home provides,” including the scope and a description of services, admission and discharge criteria, and services the personal care home will coordinate but does not itself provide.¹ A regulatory compliance guide describes the requisite components in more detail, outlines inspection procedures, and discusses the rationale for and benefits of the requirement. For example, the compliance guide states, in part:

Compliance with this regulation is critical to ensuring that homes serve only those residents whose needs can be met in the home. Homes must be very careful about admitting residents who have dangerous behaviors, who need extensive medical care, or who have personal care/supervision needs that require additional staffing.² 

The compliance guide also notes that, by reducing the risk of admitting residents whose needs cannot be met, the description of services protects both prospective residents and personal care homes and reduces disputes over denials of admission and discharges.²

Joint Commission standards for nursing care centers and home care characterize scope of service as key to providing services in a way that optimizes quality and safety—and a central responsibility for leaders. The overview for the “Provision of Care, Treatment, and Services” chapter states that the standards in the chapter “center around the integrated and cyclical process that allows care to be delivered according to patient or resident needs and the organization’s scope of services.”³ Joint Commission also requires organizations to describe, in writing, the scope and nature of services provided pursuant to a contractual arrangement (leadership standard LD.04.03.09). An element of performance for the Joint Commission standard holding governance accountable for quality and safety (LD.01.03.01) requires governance to approve the written scope of service. An element of performance for the nursing care centers standard requiring medical directors to oversee care and services (LD.01.06.01) calls on medical directors to advise governance, administrators, and others regarding “the degree to which the organization’s scope of service, its medical equipment, and its professional and support staff meet patients’ and residents’ needs.”³

Risks of Poorly Designed or Inconsistent Scopes of Service 

Scope of service helps to draw a picture of the many types of care and services a delivery system provides to care for and support the ongoing health and needs of persons served throughout the aging services continuum, from stand-alone provider organizations to CCRCs and life plan communities. Defining and understanding scope of service helps provider organizations and persons served in many ways, acting as a template for daily operational decision-making about admissions, discharges, and transitions in care. In an ideal situation, a resident’s needs neatly fall within the scope of service within a service line. In such situations, the care environment can respond to the needs of persons served 24 hours a day, 365 days a year.

Risk develops when the organization admits a person whose needs fall outside the capabilities of a delivery system, because those needs cannot be met consistently (Figure 1). This can be caused by many factors: the delivery system was never designed to meet needs at that acuity level, staffing levels do not safely or consistently allow those needs to be met, or care-critical competencies do not exist to the degree necessary to deliver those services (eg, intravenous medications, management of peripherally inserted central catheters). Thus, when a person is admitted to a care setting where these mismatches occur, an area of risk related to unmet needs can exist from the start. 

However, care delivery systems must also be aware of the ever-changing needs of persons served within the scope of service. Because a person’s needs tend to change over time, risk can develop as those needs drift beyond what the scope of service is capable of meeting (Figure 2). Thus, delivery systems determine the needs of the person served prior to admission and over time, during the person’s residency in the service line.

Furthermore, the provider organization must have processes in place to recognize risky situations, take appropriate action when they are identified, and then either add to the services provided within the service line based on the scope of service or begin a care transition process if the needs fall outside of the capabilities of the scope of service.

Recommendations for creating thorough and effective scope-of-service documents can be found in Box 1. 

Conclusion

Once developed and operationalized, scope-of-service documents can serve as internal organizational guidelines for developing other key operational documents like marketing materials, preadmissions policies and guidelines, admissions appropriateness criteria, discharge policies and guidelines, and residency agreements.

To read more practical aging services risk, quality, and safety suggestions about scope of service processes including how to develop them, and the expanded role they can play in day-to-day delivery operations, download Scope of Service and Delivery Design: Matching Needs and Capabilities at www.ecri.org/systems-thinking. This white paper includes additional guidance and legal case reviews that help to clarify this and related issues.⁴

To contact ECRI Institute directly for more information about their tools and services, please email ECRI’s Continuing Care Risk Management at ccrm@ecri.org. 

References

1. Commonwealth of Pennsylvania. The Pennsylvania Code. Chapter 2600. Personal Care Homes. 55 Pa. Code § 2600.233(a) (2018).

2. Pennsylvania Department of Public Welfare. Regulatory compliance guide: a tool for personal care home regulators, operators, and stakeholders. https://dhs.pa.gov/cs/groups/webcontent/documents/report/p_013038.pdf. Published April 1, 2013. Accessed September 19, 2018. 

3. Joint Commission. Comprehensive Accreditation Manual for Nursing Care Centers. Oakbrook Terrace, IL: Joint Commission Resources; 2018.

4. ECRI Institute. Scope of Service and Delivery Design: Matching Needs and Capabilities. www.ecri.org/systems-thinking. Published October 2018.