| (a) Types of Documentation Required. A hospice must
maintain the following information on each individual receiving Medicaid
hospice services.
(1) Signed hospice election and discharge forms.
(2) Signed Physician's Certification of Terminal Illness.
(3) Physician narratives.
(4) Documentation of each face-to-face assessment.
(5) Patient history and physical exams before and during
the provision of hospice services, including previous and new diagnoses,
emergency room visits, and ability to perform activities of daily
living.
(6) Physician consultation reports, orders, and progress
notes.
(7) Hospital admission and discharge reports.
(8) Plans of care covering all periods during which
the hospice provides services to the individual.
(9) Nursing assessments and nursing notes.
(10) IDT meeting notes.
(11) Medication administration records, including doses,
frequency, and routes.
(12) Signs and symptoms, anthropometric measurements,
weights, oral intake, and laboratory and diagnostic testing results
supporting the conclusion that the individual's condition is terminal.
(13) Other documentation supporting the plan of care,
service delivery, and outcome of services.
(14) Summary of circumstances surrounding the death,
including date, time, family in attendance, and hospice staff in attendance.
(b) Requirements for Physician's Orders. A hospice
must have a signed physician's order that:
(1) covers the time period for which hospice services
were provided; and
(2) documents the terminal illness and related medical
need for skilled nursing care, as provided.
(c) Requirements for the Plan of Care. A hospice must
maintain a plan of care for each individual receiving Medicaid hospice
services. The plan of care must meet the following criteria.
(1) The plan of care must relate to the identified
terminal illness.
(2) The plan of care must be updated every 15 days,
or when the individual's condition changes if sooner than 15 days,
and include any change in the individual's status.
(3) The plan of care must include the following:
(A) a description of the individual's service needs
and how the hospice plans to meet those needs;
(B) the baseline condition of the individual at the
beginning of the election period including symptoms documented with
location, severity, and frequency;
(C) identification of the specific interventions and
services necessary for the management of the symptoms including the
intensity, frequency, duration, and scope of services;
(D) physician orders for the specific interventions
and services necessary; and
(E) the measurable outcomes anticipated from implementing
the plan of care and reasonable timeframes expected for achieving
those measurable outcomes.
(d) Requirements for Physician Services on the Day
of Discharge. To request payment for physician services on the day
of discharge, the hospice must submit to HHSC proof that:
(1) the physician is a hospice employee; and
(2) the physician provided direct services to the patient
on the day of discharge.
(e) Requirements for all documentation. All documentation
must be:
(1) clearly labeled to indicate what type of documentation
it is;
(2) legible to a reader other than the author; and
(3) signed and dated.
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