Caring for patients nearing the end of life or in the advanced stage of a serious illness should address needs in the areas of physical comfort and practical life tasks, as well as spiritual and emotional needs. This blog overviews Hospice and Palliative Care services in nursing homes, and discusses common oversight and deficiency risks related to integration of these services in the SNF/NF setting.

Hospice vs. Palliative Care

Hospice services are only used if a resident is terminally ill. In order to qualify for hospice services, a resident must have a life expectancy of less than six months and their condition must be certified by a hospice physician.  Any treatments aimed to cure the terminal illness are stopped when a resident is on Hospice.

Palliative care is specialized medical care to improve quality of life for individuals living with a serious illness.  A resident does not need to be terminally ill to receive palliative care. Residents in palliative care may receive medical care for their symptoms, or palliative care, along with treatment intended to cure their serious illness (NIH, 2021).

Services & Items Included in the Medicare Hospice Benefit

      • Medical, nursing, and social services
      • Medical equipment and supplies
      • Medications for pain and symptom management
      • Hospice aide and homemaker services
      • Bereavement support and resources for families
      • Other services and items in the resident’s plan of care that are offered and arranged by the hospice program

Goals of Hospice Services

      • Hospice services enable the resident to have the best quality of life possible during the last months of life by providing care, comfort, and support to the resident and their family. Hospice services provide a holistic resident focused care plan, and may also include spiritual and emotional support for the resident’s family, nursing home staff, and other residents who are close with the resident.

Hospice Services in Nursing Homes

Nursing homes and long-term care facilities generally have small hospice units or utilize external hospice services for their residents. Approximately 80% of nursing homes offered hospice services in 2016 according to the U.S. Department of Health and Human Services.  Hospices providing services to residents of a SNF/NF must meet the Hospice Conditions of Participation including but not limited to:

      • Meeting Medicare hospice eligibility criteria
      • The hospice must assume responsibility for professional management of the hospice services provided
      • A written agreement (Memo of Understanding) must be signed by the hospice and SNF/NF prior to the provision of services. The MOU should address the responsibilities of each party including that the hospice assumes responsibility for determining the appropriate course of hospice care and providing medical care, nursing, counseling, social work , supplies, DME and drugs related to pain management and symptoms associated with the terminal illness with services maintained at the same level and extent as those services would have been provided if the resident were at home, while the SNF/NF continues to furnish 24 hour room and board care, personal care and nursing needs that would have been provided by a primary caregiver at home at the same level of care provided prior to the election of the hospice benefit

SNF/NF Integration with the Hospice Team

A resident’s hospice team may include the resident and their family, doctors, nurses, counselors, social workers, spiritual supports, pharmacists, physical therapists, occupational therapists, speech-language pathologists, hospice aides, homemakers, and volunteers. This interdisciplinary team of specialists work to help the resident accomplish their goals, provide a comforting and supportive environment for the resident and their family, maintain the resident’s dignity, and is available 24 hours a day. The hospice team will develop a plan of care that meets the resident’s needs emotionally, spiritually, and medically.

Oversight and Survey Deficiency Trends

The most common deficiencies noted in hospice surveys involve poor care planning, mismanagement of aide services, and inadequate assessments.  High risk areas for integrating hospice services in the SNF/NF include:

      • Effective documentation and record keeping related to hospice election, advance directives, physician certification and recertification of the terminal illness for each patient
      • Orientation and training of SNF/NF staff on required topics including but not limited to rendering care to patients on hospice, pain control, comfort care and symptom management, the hospice philosophy and principles of death and dying, as well as record keeping requirements
      • Maintaining the patient specific hospice plan of care and coordination of care to ensure quality service provision, involvement of the SNF/NF, patient and family to the extent possible and reflecting changes as necessary
      • Effective communication with the SNF/NF medical director and other involved physicians

Best Practices for Effective Integration

The Hospice and End of Life Care and Services Critical Element Pathway that surveyors use for residents identified as receiving end of life care or hospice care is a great tool to use to assess your compliance with hospice and end of life requirements. This pathway can be used as an audit tool or checklist when a resident is placed on hospice or end of life care to ensure that you are addressing all areas.


Join us October 19 or 20, 2021 for the Standards of Care series session End of Life Care—Hospice and Palliative Services.  Learn more and register.