CMS SOM App. M, Tag L775

SNF/NF or ICF/IID, and the patient and family to the extent possible.

Interpretive Guidelines §418.112(d)(2)

The hospice and the facility must develop a coordinated plan of care for each patient that

guides both providers. When a hospice patient is a resident of a facility, that patient’s

hospice plan of care must be established and maintained in consultation with

representatives of the facility and the patient/family (to the extent possible). The hospice

portion of the plan of care governs the actions of the hospice and describes the services

that are needed to care for the patient. In addition, the coordinated plan of care must

identify which provider (hospice or facility) is responsible for performing a specific

service. The coordinated plan of care may be divided into two portions, one of which is

maintained by the facility and the other, which is maintained by the hospice. The facility

is required to update its plan of care in accordance with any Federal, State or local laws

and regulations governing the particular facility, just as hospices need to update their

plans of care according to §418.56(d) of these CoPs. The hospice plan of care must

specifically identify/delineate the provider responsible for each

function/service/intervention included in the plan of care.

NOTE: The providers must have a procedure that clearly outlines the chain of

communication between the hospice and facility in the event a crisis or

emergency develops, a change of condition occurs, and/or changes to the

hospice portion of the plan of care are indicated.

Based on the shared communication between providers, both providers’ portion of the

plan of care should reflect the identification of:

• A common problem list;

• Palliative interventions;

• Palliative outcomes;

• Responsible discipline;

• Responsible provider; and

• Patient goals.