Hospice

On October 22, 2010, the Centers for Medicare & Medicaid Services (CMS) issued the long-awaited companion regulations to the June 5, 2008 final rule entitled “Medicare and Medicaid Program: Hospice Conditions of Participation.” The 2008 hospice care final rule set forth new requirements that a Medicare-certified hospice provider must meet when it provides services, including the provision of hospice care to residents of a long-term care facility (LTCF) who elect the hospice benefit. In the proposed rule’s Overview section, the agency states that the proposed rule was crafted to mirror the hospice final rule as much as possible.

The rule entitled “Medicare and Medicaid Programs; Requirements for Long Term Care Facilities; Hospice Services” proposes several new requirements including specifications for a written agreement between a Medicare-certified hospice provider and a long-term care facility. The specifications are designed to provide a clear delineation of each provider’s responsibility for maintaining continuity of care. A signed agreement would be required even if the Medicare-certified hospice and long-term care facility were under common control or ownership.

When AMDA and the National Hospice and Palliative Care Organization met with CMS in September 2008, AMDA expressed concerns about how the regulations would consider the provision of joint care. The hospice condition of participation state that the nursing facility is responsible for those “conditions unrelated to hospice care”. The proposed rule addresses the issue. Under the agreement, “the hospice would be responsible for making decisions related to a resident’s care for the palliation and management of the terminal illness and related conditions…The LTC facility would be responsible for making decisions that were not related to a resident’s terminal illness.” The proposed rule adds that the long-term care facility would be responsible for ensuring the hospice provider was informed about changes made to the resident’s care plan.

The rule also proposes that LTCFs that decline to arrange for the provision of hospice services through an agreement with a Medicare-certified hospice provider would be required to assist a resident in transferring to a facility that would arrange for the provision of these services when the resident requested such a transfer. The request for transfer could be written or verbal and would have to be documented in the resident’s record.

Excerpted Provisions:

The written agreement would have to include, at the very least, the following provisions:

• The services the hospice will provide;
• The hospice’s responsibilities for determining the appropriate hospice plan of care;
• The services the LTC facility will continue to provide, based on each resident’s care plan; and
• A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.

Additionally, the agreement contains a provision that the LTC facility must notify the hospice provider immediately regarding

• A significant change in the resident’s physical, mental, social, or emotional status;
• Any clinical complication(s) that would suggest a need to alter the plan of care;
• A condition unrelated to the terminal condition that might require transfer of the resident from the facility; or
• The resident’s death.

The hospice must assume responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.

The LTC facility must continue to provide 24-hour room and board care, meet the resident’s personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriate based on the individual resident’s needs.

The written agreement includes a delineation of additional hospice responsibilities, which include, but are not limited to:

• Providing medical direction and management of the patient.
• Nursing.
• Counseling (including spiritual, dietary, and bereavement).
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• Social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions.
• All other hospice services that are necessary for the care of the resident’s terminal illness and related conditions.

The agreement includes a provision that the hospice may use LTC facility personnel, where permitted by State law and as specified by the LTC facility, to assist in the administration of prescribed therapies included in the hospice plan of care.

The written agreement contains a provision that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation. CMS proposes that the agreement also must include a delineation of the responsibilities of the hospice to offer bereavement services to LTC facility staff.

The LTC facility that arranges for the provision of hospice care under a written agreement must designate a member of the facility’s interdisciplinary team to be responsible for working with hospice representatives to coordinate care provided by the LTC facility and hospice staff to the resident. This individual must be responsible for:

Each LTC facility providing hospice care under a written agreement must ensure that each resident’s written plan of care includes both the hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being.

AMDA is reviewing the proposed rule, particularly the sections that discuss the roles of the LTC facility’s medical director and attending physician in providing hospice services. CMS’ comment period on the proposed rule closes December 21, 2010.

1. Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services;
2. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions to ensure quality of care for the patient and family;
3. Ensuring that the LTC facility communicates with the hospice medical director, the patient’s attending physician, and other physicians participating in the provision of care to the patient as needed to coordinate the hospice care of the hospice patient with the medical care provided by other physicians;
4. Obtaining pertinent information from the hospice (that is, the most recent hospice plan of care specific to each patient; hospice election form and any advance directives specific to each patient; physician certification and recertification of the terminal illness specific to each patient; names and contact information for hospice personnel involved in hospice care of each patient; instructions on how to access the hospice’s 24-hour on-call system; hospice medication information specific to each patient; and hospice physician and attending physician (if any) orders specific to each patient); and
5. Ensuring that the LTC facility staff provide orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.