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Hospice Plan of Care

Medicare Benefit Policy Manual (CMS Pub. 100-02) Ch. 9 §40External PDF

For hospice care to be covered, in addition to the election of services and the written certification of terminal illness, a plan of care (POC) must be established. The POC is developed from the initial and comprehensive assessments, and is a road map for the beneficiary's care.  The POC must include all services necessary for the palliation and management of the terminal illness, and related conditions. The POC may include problems, interventions and goals. The POC must be established before services are provided.

All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. The hospice must ensure that each patient and the primary care giver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care.

The POC:

  • Must be reviewed and updated by the IDG at intervals specified in the POC, but no less frequently than every 15 calendar days.
  • Should continually be assessed to ensure that the care the beneficiary receives meets their conditions and needs.
  • When revised, must include information from the patient's updated comprehensive assessment and must note the patient's progress toward outcomes and goals specified in the POC.
  • Should be updated if the beneficiary's condition improves or deteriorates, and when the level of care changes.
  • Will include an assessment of the individual's needs and identification of the services, including the management of discomfort and symptom relief.
  • Must state in detail the scope and frequency of services needed to meet the beneficiary's and family's needs.
  • Acts as a road map for the IDG to provide consistent, cohesive care, and will support the medical necessity of hospice care.

Reviewed: 12.08.21


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