HOSPICE NURSING FACILITY SERVICES CHECKLIST (for Use With Agreements under which Nursing Homes Serve Hospice Patients Receiving the Hospice Routine Home Level of Care) The following Hospice-Nursing Facility Contracting Checklist (Checklist) is an excerpt from Reinhart Hospice and Palliative Care Practice Group's recently released Essential Hospice-Facility Contracting Resource: Inpatient, Respite, Nursing Home and Assisted Living Arrangements. The Checklist cites the federal hospice and nursing home regulatory requirements for contracts under which patients are receiving the routine home care level of hospice care, along with a brief description of the requirement. In addition, the Checklist includes in the third column a cross reference to the section where each obligation is addressed in the Template Hospice- Nursing Facility Services Agreement from The Essential Hospice-Facility Contracting Resource. For hospices that have purchased The Essential Hospice-Facility Contracting Resource, the Checklist can be used to assist in evaluating whether any changes made to the Template Hospice-Nursing Facility Services Agreement would impact compliance with the key legal requirements. The Checklist can also be used to verify that the regulatory requirements are addressed in another company's nursing facility services agreement that hospices may be provided and asked to sign. Specific Contract Terms Required for Hospice-Nursing Facility Agreements for the Routine Home Care Level of Care This section of the Checklist outlines those obligations that are specifically required to be addressed in written agreements between a hospice and nursing home under the federal Hospice Conditions of Participation (Medicare Hospice Regulations) and/or the Medicare Long Term Care Facility Regulations related to hospice services at 42 C.F.R. 483.75(t) (Medicare Facility Regulations). *Those obligations denoted with an asterisk (*) arguably apply only if the hospice is purchasing a hospice service from a third party. Since nursing home room and board services are not a covered hospice service, one could argue these obligations do not apply to the arrangement unless the contract includes Purchased Hospice Services. With that said, these obligations are generally addressed in the template agreement. Written Agreement 42 C.F.R. 418.112(c) 42 C.F.R. 483.75(t)(2)(ii) Manner of Communication 42 C.F.R. 418.112(c)(1) 42 C.F.R. 483.75(t)(2)(ii)(D) If hospice care is furnished in a nursing facility, the nursing facility and hospice must have a written agreement that is signed by authorized representatives of the hospice and nursing facility before the provision of hospice services and must include the provisions identified in 42 C.F.R. 418.112(c) and 483.75(t)(2)(ii). The written agreement must include the manner in which the nursing facility and the hospice are to communicate with each other to ensure the needs of the patient are addressed 24 hours per day, including how the communication will be documented between the nursing facility and hospice. Entire Agreement 2(e)(i) Reporting of Violations 42 C.F.R. 418.112(c)(8) 42 C.F.R. 483.75(t)(2)(ii)(J) Each party must report to the other party's administrator alleged violations involving mistreatment, neglect and verbal, mental, sexual and physical abuse, including injuries of unknown source and misappropriation of patient property. The hospice must report such violations by anyone unrelated to the hospice within 24 hours of becoming aware of the violation. The nursing facility must report such violations by hospice personnel immediately when it becomes aware of the alleged violation. 9(g)
Specific Contract Terms Required for Hospice-Nursing Facility Agreements for the Routine Home Care Level of Care Nursing Facility Services 42 C.F.R. 483.75(t)(2)(ii)(C) Notification of Change in Condition 42 C.F.R. 483.75(t)(2)(ii)(E) 42 C.F.R. 418.112(c)(2) 24-Hour Room and Board Care 42 C.F.R. 483.75(t)(2)(ii)(G) 42 C.F.R. 418.112(c)(4) Use of Nursing Facility Personnel 42 C.F.R. 483.75(t)(2)(ii)(I) 42 C.F.R. 418.112(c)(7) Bereavement Services to Nursing Facility Staff 42 C.F.R. 483.75(t)(2)(ii)(K) 42 C.F.R. 418.112(c)(9) The written agreement between the nursing facility and hospice must identify the services the facility will continue to provide, based on each resident's plan of care. The written agreement between the nursing facility and hospice must include a provision that the facility immediately notifies the hospice about the following: A significant change in the patient's physical, mental, social or emotional status; Clinical complications that suggest a need to alter the plan of care; A need to transfer the patient from the facility for any condition; and A patient's death. The written agreement between the nursing facility and hospice must set out an agreement that it is the nursing facility's responsibility to furnish 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 appropriately based on the individual resident's needs. The written agreement between the nursing facility and hospice must set out a provision that when facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, facility personnel may administer the therapies where permitted by state law and as specified by the facility. The written agreement between the nursing facility and hospice must set out a delineation of the responsibilities of the hospice and the facility to provide bereavement services to facility staff. 1(a) 2(a)(i) 2(e)(iv) 2(a)(i) 2(b) 2(a)(i) 2(k) Professional Management Responsibility 42 C.F.R. 418.100(e) and 418.112(b) The hospice must retain administrative and financial management and oversight of staff and services for all arranged hospice services to ensure the provision of quality care. For patients receiving hospice care in a nursing facility, the hospice must assume responsibility for the professional management of the resident's hospice services provided in accordance with the plan of care and the hospice conditions of participation and make any arrangements necessary for hospice related inpatient care. 3(b)(i) Exhibit A
Specific Contract Terms Required for Hospice-Nursing Facility Agreements for the Routine Home Care Level of Care Hospice Services 42 C.F.R. 483.75(t)(2)(ii)(A) Hospice Plan of Care 42 C.F.R. 483.75(t)(2)(ii)(B) The written agreement between the hospice and the nursing facility must set out the services the hospice will provide. The written agreement between the hospice and the nursing facility must set out the hospice's responsibilities for determining the appropriate hospice plan of care as specified in 42 C.F.R. 418.112(d). 1(f) Course of Hospice Care 42 C.F.R. 418.112(c)(3) 42 C.F.R. 483.75(t)(2)(ii)(F) Delineation of Hospice's Responsibilities 42 C.F.R. 418.112(c)(6) 42 C.F.R. 483.75(t)(2)(ii)(H) The written agreement between the hospice and the nursing facility must include a provision that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided. The written agreement between the hospice and nursing facility must include a delineation of the hospice's responsibilities, including, but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary and bereavement); 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; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions. 1(f) Level of Hospice Care 42 C.F.R. 418.112(c)(5) The written agreement between the hospice and the nursing facility must include a provision that it is the hospice's responsibility to provide services at the same level and to the same extent as those services would be provided if the facility resident were in his or her own home. Criminal Background Checks 42 C.F.R. 418.114(d) Hospice contracts must require that all contracted entities obtain criminal background checks on their contracted employees who have direct patient contact or access to patient records. Criminal background checks must be obtained in accordance with state requirements. If there are no state requirements, criminal background checks must be obtained within three months of the date of employment for all states in which the individual has lived or worked in the past three years. 2(c)(ii)[b]
Specific Contract Terms Required for Hospice-Nursing Facility Agreements for the Routine Home Care Level of Care Inspection of Records by Government* 42 C.F.R 420.300 The facility shall make available until the expiration of five years from the termination of the agreement, upon written request, to the Secretary of Health and Human Services, and upon request, to the Comptroller General of the United States, or any of their duly authorized representatives, the agreement and any of the provider's books, documents and records necessary to certify the nature and costs of Medicare reimbursable services provided under the agreement. If and to the extent the facility carries out any of its duties under this agreement through a subcontract with a related organization having a value or cost of $10,000 or more over a 12-month period, the facility shall ensure the subcontract contains a clause comparable to the clause above. 6(d) Authorization by Hospice* 42 C.F.R. 418.100(e) Services must be authorized by the hospice. 2(a)(iii) 3(b)(i) Exhibit A Safe and Effective Services* 42 C.F.R. 418.100(e)(2) Services must be furnished in a safe and effective manner by qualified personnel. 3(b)(ii) Exhibit A Plan of Care* 42 C.F.R. 418.100(e)(3) Services must be delivered in accordance with the patient's plan of care. 2(a)(i) Exhibit A
General Obligations of Hospices and Nursing Facilities The following obligations from the Medicare Hospice Regulations and the Medicare Facility Regulations are not explicitly required to be included in a written agreement. Note that many of the hospice obligations are not specific to hospice-nursing facility relationships. However, it can be helpful to address some or all of these obligations in the contract so that the parties have a clear understanding of each party's obligations. Hospice Plan of Care 42 C.F.R. 418.112(d) In accordance with 418.56, a written hospice plan of care must be established and maintained in consultation with SNF/NR or ICF/MR representatives. All hospice care provided must be in accordance with this hospice plan of care. 1(e) 3(b)(i) 3(b)(ii) Identification of Hospice Services 42 C.F.R. 418.112(d)(1) The hospice plan of care must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Participation in Plan of Care 42 C.F.R. 418.112(d)(2) The hospice plan of care reflects the participation of the hospice, the nursing facility, and the patient and family to the extent possible. 1(e) Approval of Plan of Care 42 C.F.R. 418.112(d)(3) Responsible IDG Member 42 C.F.R. 418.112(e)(1) Communication from IDG 42 C.F.R. 418.112(e)(2) Any changes in the hospice plan of care must be discussed with the patient or representative, and nursing facility representatives, and must be approved by the hospice before implementation. The hospice must designate a member of each interdisciplinary group that is responsible for a patient who is a resident of a nursing facility. The designated interdisciplinary group member is responsible for: Providing overall coordination of the hospice care of the nursing facility resident with nursing facility representatives. Communicating with nursing facility representatives and other health care providers participating in the provision of care for the terminal illness and related conditions and other conditions to ensure quality of care for the patient and family. The hospice must ensure that the hospice IDG communicates with the nursing facility 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. 2(e)(iii) 3(d) 3(d) 3(e)
General Obligations of Hospices and Nursing Facilities Orientation and Training of Nursing Facility Staff 42 C.F.R. 418.112(f) Hospice staff must assure orientation of nursing facility staff furnishing care to hospice patients in the hospice philosophy, including hospice policies and procedures regarding methods of comfort, pain control, symptom management, as well as principles about death and dying, individual responses to death, patient rights, appropriate forms and record keeping requirements. 3(c) Standards for Hospice Services 42 C.F.R. 483.75(t)(2)(i) A nursing facility that contracts with a hospice must ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of services. 3(b)(ii) Provision of Information from Hospice to Nursing Facility 42 C.F.R. 418.112(e)(3) 42 C.F.R. 483.75(t)(3)(iv) The hospice must provide the below information to the nursing facility. The facility must designate a member of its interdisciplinary group pursuant to 42 C.F.R. 483.75(t)(3) responsible for obtaining the below information: The most recent hospice plan of care specific to each patient. The hospice election form and any advance directives specific to each patient. The physician certification and recertifications of the terminal illness specific to each patient. The 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. Hospice physician and attending physician (if any) orders specific to each patient. 3(e)
General Obligations of Hospices and Nursing Facilities Designation of Facility Interdisciplinary Team Member 42 C.F.R. 483.75(t)(3) Each nursing facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their state scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident. The designated interdisciplinary team member is responsible for the following: Collaborating with Hospice 42 C.F.R. 483.75(t)(3)(i) Collaborating with hospice representatives and coordinating nursing facility staff participation in the hospice care planning process for those residents receiving these services. Communicating with Providers 42 C.F.R. 483.75(t)(3)(ii) 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. Communicating with Physicians 42 C.F.R. 483.75(t)(3)(iii) Obtaining Information from Hospice 42 C.F.R. 483(t)(3)(iv) Ensuring that the nursing facility communicates with the hospice medical director, the patient's attending physician and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians. Obtaining the information listed at 42 C.F.R. 483.75(t)(3)(iv). 3(e) Orientation for Hospice 42 C.F.R. 483.75(t)(3)(v) Ensuring that the nursing facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms and record keeping requirements, to hospice staff furnishing care to nursing facility residents. Facility Care Plan 42 C.F.R. 483.75(t)(4) Each nursing facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the nursing facility to attain or maintain the resident's highest practicable physical, mental and psychosocial wellbeing, as required at 483.25.
Training 42 C.F.R. 418.100(g) and 418.60(c) General Obligations of Hospices and Nursing Facilities The hospice must provide orientation about the hospice philosophy to all contracted staff that have patient and family contact. The hospice must assess the skills and competence of all individuals furnishing care and, as necessary, provide in-service training and education programs where required. The hospice must have written policies and procedures describing methods of assessment of competency. The hospice must provide infection control education to contracted providers. 3(c) Coordinating Care 42 C.F.R. 418.56(e) The hospice must develop and maintain a system of communication and integration to: Ensure that the IDG maintains responsibility for directing, coordinating and supervising the care and services provided; Ensure that the care and services are provided in accordance with the plan of care; Ensure that the care and services provided are based on all assessments of the patient and family needs; and Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. 2(e) 3(b)(i) 3(b)(ii) 3(d)3(e) Availability of Hospice Services 42 C.F.R. 418.100(c)(2) Licensed Professional Services 42 C.F.R. 418.62 Nursing services, physician services, and drugs and biologicals must be made routinely available on a 24-hour basis, 7 days per week. Other covered services must be available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family. Licensed professionals must actively participate in the coordination of all aspects of the patient's hospice care, in accordance with current professional standards and practice, including participating in ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, and contributing to patient and family counseling and education. Licensed professionals must participate in the hospice's quality assessment and performance improvement program and hospice sponsored in-service training. 1(f) 3(b) 3(d) 1(f) 3(b) 3(d)
Standards of Practice 42 C.F.R. 418.70 General Personnel Qualifications 42 C.F.R. 418.114(a) and (c) General Obligations of Hospices and Nursing Facilities Services must be provided in a manner consistent with current standards of practice. All professionals who furnish services directly, under an individual contract or under arrangements with a hospice, must be legally authorized (licensed, certified or registered) in accordance with applicable federal, state and local laws, and must act only within the scope of his or her state license or state certification, or registration. All personnel qualifications must be kept current at all times. 2(c)(i) 2(c)(ii)[b] Compliance with Laws 42 C.F.R. 418.116 Services must be furnished in compliance with all applicable federal, state and local laws and regulations related to the health and safety of patients. 2(c)(i) Licensed Professional Services 42 C.F.R. 418.62 Patient Grievances 42 C.F.R. 418.52(b)(1)(iii) Licensed professional services must be authorized, delivered and supervised only by health care professionals who meet the appropriate qualifications specified under 418.114 and who practice under the hospice's policies and procedures. The hospice must be notified of patient grievances regarding treatment or care that is (or fails to be) furnished and the lack of respect for property by anyone who is furnishing services on behalf of the hospice. 2(c)(ii)[b] 2(g) QAPI 42 C.F.R. 418.58 The hospice's quality assessment and performance improvement program (QAPI) must involve all hospice services, including those services furnished under contract. 2(d)