Hospice Patients in Nursing Homes: Audit-Proof Documentation for Hospice-SNF Coordination

Many hospice patients live in nursing facilities. For these patients, two providers share responsibility for care: the nursing facility provides room, board, and 24-hour personal care, while the hospice provides the professional management of the patient's terminal illness and related conditions. When the two coordinate well, patients receive excellent end-of-life care. When they do not, reviewers may find gaps in care, duplication of services, or arrangements that raise compliance concerns.

Reviewers, surveyors, and investigators look closely at hospice care in nursing facilities for several reasons. Patients in facilities have historically had longer hospice stays. Facility staff already provide much of the daily care, so reviewers ask whether the hospice is providing the services Medicare pays for. And financial relationships between hospices and nursing facilities can create kickback risks.

This article explains the hospice Conditions of Participation for patients in nursing facilities, required written agreements, coordination and plan of care requirements, room and board, Medicare skilled nursing facility overlap, kickback risks, and how to build documentation that withstands audit. It is educational and does not replace legal or professional advice.

The Regulatory Framework

Hospice Requirements

Under 42 CFR 418.112, a hospice that provides care to residents of a skilled nursing facility, nursing facility, or intermediate care facility for individuals with intellectual disabilities must meet specific standards, in addition to all other hospice Conditions of Participation.

Facility Requirements

Long-term care facilities that arrange hospice services for residents must meet their own requirements under the long-term care facility regulations at 42 CFR Part 483, including requirements for written agreements with hospices and coordination of care.

Professional Management

Under 42 CFR 418.112(b), the hospice must assume responsibility for professional management of the resident's hospice services provided in accordance with the hospice Conditions of Participation and make any arrangements necessary for hospice-related inpatient care in a participating Medicare or Medicaid facility.

The Written Agreement

Under 42 CFR 418.112(c), the hospice and the facility must have a written agreement that specifies the provision of hospice services in the facility. The agreement must be signed by authorized representatives of both before hospice care is furnished to any resident and must include at least:

• The manner in which the facility and the hospice are to communicate with each other and document such communications to ensure that the needs of patients are addressed and met 24 hours a day.

• A provision that the facility immediately notifies the hospice if a significant change in the patient's physical, mental, social, or emotional status occurs; clinical complications suggest a need to alter the plan of care; a need to transfer the patient from the facility for any condition arises; or the patient dies.

• 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.

• An agreement that it is the facility's responsibility to continue to furnish 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 hospice care was elected.

• An agreement that it is the hospice's responsibility to provide services at the same level and to the same extent as those services would be provided if the facility resident were in his or her own home.

• A delineation of the hospice's responsibilities, which include, but are not limited to, providing medical direction and management of the patient; nursing; counseling, including spiritual, dietary, and bereavement; social work; providing 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 necessary for the care of the resident's terminal illness and related conditions.

• A provision that the hospice may use the facility's nursing personnel, where permitted by state law and as specified by the facility, 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 patient's family in implementing the plan of care.

• A provision stating that the hospice must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the facility administrator within 24 hours of the hospice becoming aware of the alleged violation.

• A delineation of the responsibilities of the hospice and the facility to provide bereavement services to facility staff.

The Plan of Care

Under 42 CFR 418.112(d), in addition to meeting the general plan of care requirements, the hospice plan of care must be established and maintained in consultation with representatives of the facility, and all hospice care provided must be in accordance with the hospice plan of care. The plan of care must identify the care and services needed and specifically identify which provider is responsible for performing the respective functions agreed upon and included in the plan. Any changes in the plan of care must be discussed with the patient or representative and facility representatives, and must be approved by the hospice before implementation.

Coordination of Services

Under 42 CFR 418.112(e), the hospice must:

• Designate a member of each interdisciplinary group that is responsible for a patient in the facility, who is responsible for providing overall coordination of the hospice care of the resident with facility representatives and communicating with facility representatives and other health care providers participating in the provision of care for the terminal illness, related conditions, and other conditions.

• Ensure that the hospice interdisciplinary group communicates with the facility medical director, the patient's attending physician, and other physicians participating in the care to ensure quality of care for the patient and family.

• Provide the facility with the following information: the most recent hospice plan of care specific to each patient; the hospice election form and any advance directives; physician certification and recertification of the terminal illness; names and contact information for hospice personnel involved in hospice care of each patient; instructions on how to access the hospice's 24-hour on-call system; hospice medication information specific to each patient; and hospice physician and attending physician, if any, orders specific to each patient.

Orientation and Training

Under 42 CFR 418.112(f), the hospice must assure orientation of facility staff furnishing care to hospice patients in the hospice philosophy, including hospice policies and procedures regarding methods of comfort, pain control, symptom management, principles about death and dying, individual responses to death, patient rights, appropriate forms, and record keeping requirements.

Room and Board

Medicare does not pay for room and board in a nursing facility for hospice patients. For patients eligible for Medicaid, the state Medicaid program generally pays the hospice an amount for room and board, which the hospice passes through to the facility, under state Medicaid rules. Payments to the facility should be consistent with the room and board amount and the written agreement. Payments above that amount, or payments for services the facility would provide anyway, may raise Anti-Kickback concerns.

Medicare Skilled Nursing Facility Coverage and Hospice

A patient who elects hospice waives Medicare coverage for services related to the terminal illness and related conditions, other than through the hospice. A Medicare-covered skilled nursing facility stay for a condition related to the terminal illness is not available while the patient is on hospice. A covered skilled nursing facility stay for a condition unrelated to the terminal illness may be possible in limited circumstances, but documentation must clearly establish that the skilled care is unrelated. Reviewers look closely at overlapping claims.

What Reviewers Look For

The Hospice Is Providing Hospice Care

• Hospice visits by nurses, aides, social workers, chaplains, and other disciplines consistent with the plan of care.

• Hospice documentation distinct from facility documentation.

• Hospice management of symptoms and medications.

• Hospice physician involvement.

Eligibility

• Clinical documentation supporting terminal prognosis, using measurable indicators drawn from both hospice and facility records.

• Facility records, such as weights and intake, that are consistent with hospice narratives.

Coordination

• A signed written agreement in place before care began.

• A coordinated plan of care that identifies who does what.

• Documentation of communication between hospice and facility staff.

• Facility notification of significant changes and the hospice's response.

No Duplication or Gaps

• Services not billed by both the hospice and the facility.

• No reliance on facility staff to perform hospice functions beyond what would be expected of a family.

Financial Relationships

• Room and board payments consistent with Medicaid requirements and the agreement.

• No free services, staff, or other benefits provided to the facility to obtain referrals.

Common Audit Problems

• Missing, expired, or incomplete written agreements.

• Plans of care that do not identify responsibilities of each provider.

• Hospice visit frequencies that are low or inconsistent with the plan of care.

• Hospice documentation copied from facility charts.

• Lack of documentation of communication with the facility.

• Missing documentation provided to the facility, such as the current plan of care or medication information.

• Facility staff performing hospice aide functions without proper arrangement.

• Eligibility documentation that does not reflect facility data, such as stable weights.

• Long lengths of stay without documented decline.

• Overlapping skilled nursing facility claims without clear unrelated documentation.

• Financial arrangements suggesting inducements.

Building Audit-Proof Documentation

Contracts and Communication

• Maintain a current, signed written agreement with every facility, executed before the first patient is served.

• Track agreement renewal dates.

• Use a communication log for each patient documenting calls, visits, and messages with facility staff.

The Coordinated Plan of Care

• Hold care planning discussions with facility representatives and document them.

• List specific responsibilities for the hospice and the facility.

• Update the plan when needs change, and document facility input and hospice approval.

Providing Information to the Facility

• Deliver the plan of care, election, certifications, contact information, on-call instructions, medication information, and orders to the facility.

• Document what was provided and when.

• Update facility copies when documents change.

Hospice Visit Documentation

• Document each hospice visit separately from facility notes.

• Describe hospice-specific assessments and interventions.

• Use measurable indicators, and note facility data used, such as weights.

• Record communication with facility staff during each visit.

Responding to Facility Notifications

• Document facility notifications of significant changes.

• Document the hospice's assessment and response, including plan of care changes.

Training Facility Staff

• Document orientation sessions, attendees, and topics.

• Provide refresher training as needed.

Visit Expectations for Facility Patients

Medicare does not set specific minimum visit frequencies for hospice patients in facilities, but the hospice must provide services at the same level and to the same extent as if the patient were at home, consistent with the plan of care. Reviewers may question low visit frequencies, especially near the end of life. Hospices should:

• Set visit frequencies based on each patient's needs.

• Make sure visits occur as planned, and document missed visits and reasons.

• Increase visits as the patient declines.

• Provide skilled visits in the last days of life when appropriate.

Hospice Aide Services in Facilities

Hospice aide services in facilities should be part of the hospice plan of care and should supplement, not replace, the facility's personal care. Hospices should:

• Define aide duties in the plan of care.

• Make sure aide visits are documented separately.

• Avoid using hospice aides to perform the facility's general duties.

Kickback and Inducement Risks

Hospice relationships with nursing facilities can raise Anti-Kickback Statute concerns. Risky practices include:

• Paying facilities more than the room and board amount.

• Providing free staff, such as aides or nurses, to perform facility duties.

• Providing free supplies or services unrelated to hospice care.

• Paying facility staff or discharge planners for referrals.

• Arrangements that encourage facilities to steer residents to one hospice.

Facilities must respect residents' choice of hospice. Hospices should review arrangements with counsel and train staff on these risks.

Auditing Nursing Facility Hospice Care

Step 1: Inventory Facilities and Agreements

List every facility served, the agreement date, renewal date, and signatures.

Step 2: Review a Sample of Patients

For each patient, review:

• Eligibility documentation and facility data.

• The coordinated plan of care.

• Hospice visit documentation.

• Communication logs.

• Information provided to the facility.

• Any overlapping claims.

Step 3: Review Financial Arrangements

Review room and board payments and any other payments or services provided to facilities.

Step 4: Correct and Educate

Update agreements, documentation templates, and staff training. Evaluate overpayment obligations under 42 CFR 401.305 when audits find unsupported claims.

Long Stays in Facilities

Facility-based hospice patients, especially those with dementia, often have long stays. Hospices should:

• Use facility data, such as weights and intake records, to document decline.

• Coordinate with facility staff to obtain consistent measurements.

• Review facility-based long-stay patients regularly for continued eligibility.

• Discharge patients who no longer meet eligibility.

Surveys and Inspections

Both the hospice and the facility may be surveyed for compliance with their own Conditions of Participation and requirements. Surveyors may review the written agreement, coordinated plan of care, communication records, and staff training. CMS's State Operations Manual includes surveyor guidance for hospices, and surveyors may also review the facility's compliance with long-term care requirements for hospice coordination.

A Nursing Facility Coordination Checklist

• Signed written agreement with all required provisions, executed before services began.

• Coordinated plan of care developed with facility input, identifying each provider's responsibilities.

• Designated interdisciplinary group coordinator for each patient.

• Plan of care, election, certifications, contact information, on-call instructions, medication information, and orders provided to the facility.

• Documented communication with facility staff.

• Documented response to facility notifications.

• Hospice visits consistent with the plan of care, documented separately.

• Eligibility supported by measurable data.

• Facility staff orientation documented.

• Room and board payments consistent with requirements.

• No free services or inducements to the facility.

A Hypothetical Example

A hospice serving several nursing facilities audits 20 facility-based patients. It finds that two agreements had expired, plans of care did not specify which provider was responsible for personal care and medications, and hospice nurse notes for several patients repeated facility vital signs without hospice assessments. It also finds that the hospice had been sending a part-time aide to one facility to help with general resident care, not just hospice patients.

Working with counsel, the hospice ends the aide arrangement, renews and updates all agreements, revises its plan of care template to list responsibilities, retrains nurses on hospice-specific documentation, and implements communication logs. It evaluates whether any claims were affected and addresses overpayment obligations.

Common Myths

• "The facility's chart is enough." The hospice must maintain its own documentation of hospice services.

• "Facility staff can do the hospice aide's work." Only to the extent the hospice would rely on a family caregiver, and as permitted by state law and the agreement.

Key Takeaways

• A signed written agreement with all required provisions must be in place before hospice care begins in a facility.

• The plan of care must be coordinated with the facility and identify each provider's responsibilities.

• The hospice must provide specific information to the facility and coordinate care through a designated interdisciplinary group member.

• Hospice visits and documentation must show the hospice's distinct role.

• Room and board arrangements and other financial relationships must avoid inducements.

Questions Leadership Should Ask

• Do we have current signed agreements with every facility we serve?

• Do our plans of care clearly identify hospice and facility responsibilities?

• Can we show hospice visits and interventions distinct from facility care?

• Are our room and board payments and other arrangements reviewed by counsel?

Frequently Asked Questions

Is a written agreement required before serving nursing facility residents?

Yes. It must be signed by both parties before hospice care is furnished to any resident.

Who is responsible for room and board?

The facility provides room and board. Medicare does not pay for it. Medicaid may pay for eligible patients, generally through the hospice.

Can facility staff provide hospice services?

The hospice may use facility nursing staff, where permitted by state law and as specified by the facility, only to the extent the hospice would use a family caregiver.

What must the hospice provide to the facility?

The plan of care, election form and advance directives, certifications, contact information, on-call instructions, medication information, and orders.

Can a hospice patient have a Medicare-covered SNF stay?

Not for conditions related to the terminal illness. A stay for an unrelated condition may be possible in limited circumstances with clear documentation.

Conclusion

Hospice care in nursing facilities depends on close coordination between two providers. Medicare's requirements for written agreements, coordinated plans of care, communication, information sharing, and staff orientation are designed to make that coordination real. Hospices that maintain complete agreements, document their distinct role, communicate consistently, support eligibility with measurable data, and avoid inducements will be well prepared for audits and surveys.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that helps hospices strengthen nursing facility coordination through agreement reviews, plan of care and documentation audits, communication process design, staff training, and support for counsel in reviewing facility arrangements. If you serve patients in nursing facilities, please get in touch with us. We will be happy to help you with this topic.

References

• Electronic Code of Federal Regulations. 42 CFR 418.112, Condition of Participation: Hospices That Provide Hospice Care to Residents of a SNF/NF or ICF/IID. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-D/section-418.112

• Electronic Code of Federal Regulations. 42 CFR 418.56, Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-C/section-418.56

• Electronic Code of Federal Regulations. 42 CFR Part 483, Requirements for States and Long Term Care Facilities. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483

• Electronic Code of Federal Regulations. 42 CFR Part 418, Subpart B (Election and Certification). https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-B

• Electronic Code of Federal Regulations. 42 CFR 401.305, Requirements for Reporting and Returning of Overpayments. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-A/part-401/subpart-D/section-401.305

• Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 9, Coverage of Hospice Services Under Hospital Insurance. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf

• Centers for Medicare & Medicaid Services. State Operations Manual, Appendix M, Guidance to Surveyors: Hospice. https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/som107ap_m_hospice.pdf

• Office of the Law Revision Counsel. 42 U.S.C. 1320a-7b, Criminal Penalties for Acts Involving Federal Health Care Programs. https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1320a-7b&num=0&edition=prelim

• U.S. Department of Health and Human Services, Office of Inspector General. Reports and Publications. https://oig.hhs.gov/reports/all/