| (a) Professional management. A hospice must assume
responsibility for professional management of the hospice services
it provides to a resident of a skilled nursing facility (SNF), nursing
facility (NF), or an intermediate care facility for individuals with
an intellectual disability or related conditions (ICF/IID), in accordance
with the hospice plan of care. The hospice must make arrangements,
as necessary for hospice-related inpatient care in a participating
Medicare or Medicaid facility, in accordance with §558.850 of
this subchapter (relating to Organization and Administration of Hospice
Services) and §558.863 of this subchapter (relating to Hospice
Short-term Inpatient Care).
(b) Written contract. A hospice and SNF, NF, or ICF/IID
must have a written contract that allows the hospice to provide services
in the facility. The contract must be signed by an authorized representative
of the hospice and the SNF, NF, or ICF/IID before hospice services
are provided. In addition to the requirements in §558.289 of
this chapter (relating to Independent Contractors and Arranged Services),
the written contract must include:
(1) the way the SNF, NF, or ICF/IID and the hospice
are to communicate with each other and document such communications
to ensure that the needs of a client are addressed and met 24 hours
a day;
(2) a provision that the SNF, NF, or ICF/IID immediately
notifies the hospice of:
(A) a significant change in the client's physical,
mental, social, or emotional status;
(B) clinical complications that suggest a need to alter
the plan of care;
(C) the need to transfer the client from the SNF, NF,
or ICF/IID; or
(D) the death of a client;
(3) a provision stating that if the SNF, NF, or ICF/IID
transfers the client from the facility that the hospice arranges for,
and remains responsible for, any necessary continuous care or inpatient
care related to the terminal illness and related conditions;
(4) a provision stating that the hospice assumes responsibility
for determining the appropriate course of hospice care, including
the determination to change the level of services provided;
(5) an agreement that the SNF, NF, or ICF/IID is responsible
for furnishing 24-hour room and board care, meeting the personal care
and nursing needs that would have been provided by the primary caregiver
at home at the same level of care provided before the client elected
hospice care;
(6) an agreement that the hospice is responsible for
providing services at the same level and to the same extent as those
services would be provided if the SNF, NF, or ICF/IID resident were
in his or her own home;
(7) a delineation of the hospice's responsibilities,
which include providing medical direction and management of the client;
nursing; counseling, including spiritual, dietary and bereavement
counseling; social work; 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;
(8) a provision that the hospice may use the SNF, NF,
or ICF/IID nursing personnel where permitted by State law and as specified
by the SNF, NF, or ICF/IID to assist in the administration of prescribed
therapies included in the plan of care, only to the extent that the
hospice would routinely use the services of a hospice client's family
in implementing the plan of care;
(9) a provision stating that the hospice must report
an alleged violation involving mistreatment, neglect, or verbal, mental,
sexual, and physical abuse, including injuries of unknown source,
and misappropriation of client property by non-hospice personnel to
the SNF, NF, or ICF/IID administrator within 24 hours after the hospice
becomes aware of the alleged violation;
(10) a delineation of the responsibilities of the hospice
and the SNF, NF, or ICF/IID to provide bereavement services to SNF,
NF, or ICF/IID staff; and
(11) a provision regarding management and disposal,
in compliance with applicable law, of drugs, including controlled
substance prescription drugs and biologicals.
(c) Hospice plan of care. In accordance with §558.821
of this subchapter (relating to Hospice Plan of Care), a written hospice
plan of care must be established and maintained in consultation with
SNF, NF, or ICF/IID representatives. Hospice care must be provided
in accordance with the hospice plan of care.
(1) A hospice plan of care must identify the care and
services needed to care for the client 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.
(2) A hospice plan of care must reflect the participation
of the hospice, representatives of the SNF, NF, or ICF/IID, and the
client and family to the extent possible.
(3) Any changes in the hospice plan of care must be
discussed with the client or the client's LAR, and SNF, NF, or ICF/IID
representatives, and must be approved by the hospice before implementation.
(d) Coordination of services. In addition to the requirements
in §558.288 of this chapter (relating to Coordination of Services)
and §558.823 of this subchapter (relating to Coordination of
Services by the Hospice), a hospice must:
(1) designate a member of each interdisciplinary team
(IDT) that is responsible for a client who is a resident of a SNF,
NF, or ICF/IID who is responsible for:
(A) providing overall coordination of the hospice care
of the SNF, NF, or ICF/IID resident with SNF, NF, or ICF/IID representatives;
and
(B) communicating with SNF, NF, or ICF/IID 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 client and family; and
(2) ensure that the hospice IDT communicates with the
SNF, NF, or ICF/IID medical director, the client's attending practitioner,
and other physicians participating in the provision of care to the
client as needed to coordinate hospice care with medical care provided
by other physicians; and
(3) provide the SNF, NF, or ICF/IID with:
(A) the most recent hospice plan of care specific to
the client;
(B) the hospice election form and any advance directives
specific to the client;
(C) physician certification and recertification of
the terminal illness specific to the client;
(D) names and contact information for hospice personnel
involved in hospice care of the client;
(E) instructions on how to access the hospice's 24-hour
on-call system;
(F) hospice medication information specific to the
client; and
(G) hospice physician and, if any, attending practitioner
orders specific to the client.
(e) Orientation and training of staff. Hospice personnel
must ensure that SNF, NF or ICF/IID staff who provide care to the
hospice's clients have been oriented and trained in the hospice philosophy,
including the hospice's policies and procedures regarding methods
of comfort, pain control, and symptom management, as well as principles
about death and dying, how a person may respond to death, the hospice's
client rights, the hospice's forms, and the hospice's record keeping
requirements.
(f) Management and disposal of drugs and biologicals.
The policies and procedures of the hospice may not impede the SNF,
NF, or ICF/IID from adhering to state, federal, and local law applicable
to the disposal of drugs and biologicals in a facility.
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