CMS SOM App. M, Tag L781

(i) The most recent hospice plan of care specific to each patient;

(ii) Hospice election form and any advance directives specific to each

patient;

(iii) Physician certification and recertification of the terminal illness

specific to each patient;

(iv) Names and contact information for hospice personnel involved in

hospice care of each patient;

(v) Instructions on how to access the hospice’s 24-hour on-call system;

(vi) Hospice medication information specific to each patient; and

(vii) Hospice physician and attending physician (if any) orders specific to

each patient.

Interpretive Guidelines §418.112(e)(3)

The hospice and facility must have a process by which information from the hospice IDG

plan of care reviews, updated assessments, and the facility team and the patient and

family (to the extent possible) will be exchanged when developing and updating the plan

of care and evaluating outcomes of care to assure that the patient receives the necessary

care and services.