Hospice Plan of Care

The Hospice Plan of Care (POC) serves as a crucial roadmap for addressing the complex needs of a patient facing terminal illness and the needs of their family. However, data from the Centers for Medicare and Medicaid Services (CMS) reveals continued concerns about incomplete or incorrectly enacted POCs. This underscores the necessity for a comprehensive and individualized approach to care planning in hospice settings.

The primary objective of hospice care is to address the holistic needs of patients and their caregivers when curative care is no longer viable or desired. An Interdisciplinary Group (IDG) overseen by a Registered Nurse (RN) coordinates and develops the individualized POC. This plan, created in collaboration with the patient, attending physician, and primary caregiver, should align with patient and family goals.

The POC must encompass all services essential for the care and comfort of the patient. It is imperative to document needs and provide education to patient and caregivers. It contains interventions for pain and symptom management, specifies the scope and frequency of services, outlines measurable outcomes, and addresses necessary medications, treatments, and medical supplies. Care documentation of the patient’s understanding and agreement with the POC is essential.

The IDG works collaboratively to address physical, emotional, social, and spiritual needs. Continuous updates to the POC occur throughout the patient’s hospice benefit period, ensuring adaptability to evolving needs. Hospices also should provide bereavement support to the caregiver/family.

CMS data continues to identify common deficiencies related to POC implementation, such as lack of individualization, missed visits, inadequate documentation, and inconsistent updates during IDG meetings. Addressing these issues is paramount for ensuring quality care and compliance.

CMS further underscores the importance of the RN to coordinate POC implementation. The RN, as an integral part of the IDG, ensures the POC remains updated, individualized, and relevant. The RN plays a crucial role in continuous assessment, timely documentation, communication within the IDG, and monitoring the successful implementation of the POC.

Some key points to remember include:

• All hospice care and services must adhere to an individualized POC.
• The POCs should reflect the patient and family’s goals based on comprehensive assessments.
• The RN is instrumental in ensuring the relevant and individualization of the POC.
• Documenting of deviations from the POC is crucial and updates to the POC should align with the evolving patient needs.

In conclusion, with continued rising regulatory scrutiny in hospice, ensuring that that plan of care is accurate, specific and the patient record is complete is critical for providing quality care and meeting regulatory requirements. Hospices are encouraged to focus efforts on improving documentation especially in relation to individualized Plans of Care for patients to avoid frequently cited survey deficiencies.