CMS SOM App. M, Tag L536

coordination of services

The hospice must designate an interdisciplinary group or groups as specified in

paragraph (a) of this section which, in consultation with the patient's attending

physician, must prepare a written plan of care for each patient. The plan of care

must specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the

terminal illness and related conditions.

Interpretive Guidelines §418.56

The physician member of the IDG may be the hospice medical director or another

hospice physician who is employed by or under contract with the hospice. The nurse,

social worker and counselor members of the IDG must be hospice employees or

employees of the agency or organization of which the hospice is a sub-division (e.g., a

hospital) who are appropriately trained and assigned to the hospice.

There should be a direct link between the needs identified in the patient/family

assessment and the plan of care developed by the hospice. Hospices may identify needs

in the comprehensive assessment that are not related to the terminal illness and related

conditions, and should document that they are aware of these needs and note who is

addressing them. Hospices are not required to provide direct services to meet needs

unrelated to the terminal illness. Hospices are responsible for including services and

treatments in the plan of care that address how they will meet the patient and family-specific needs related to the terminal illness and related conditions.

The medical director and/or other hospice physician is responsible for meeting the

medical needs of the patient according to §418.64(a)(3) per the patient’s attending

physician’s request or when the hospice is unable to contact the attending physician to

address the patient’s medical needs.