Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices. The Intent of this regulation is to ensure that the care and services provided meet professional standards of practice as well as meet each resident’s physical, mental and psychosocial needs.

Surveyors are directed to use guidance at F684 for review of concerns which have caused or have a potential to cause a negative outcome to a resident’s physical, mental, or psychosocial health or well- being that is not specifically addressed by any other tag at §483.25. F684 also contains the following guidance for end of life and hospice care.

Care Planning for the Resident at or Approaching End of Life and/or Receiving Hospice Care & Services

The resident must receive a comprehensive assessment to provide direction for the development of the resident’s care plan to address the choices and preferences of the resident who is nearing the end of life. In addition, to promote the physical, mental, and psychosocial well-being of a resident who is approaching the end of life, the facility and the resident’s attending physician/practitioner, should, to the extent possible:

      • identify the resident’s prognosis and the basis for that prognosis; and
      • Initiate discussions/considerations regarding advance care planning and resident choices to clarify goals and preferences regarding treatment including pain management and symptom control, treatment of acute illness, and choices regarding hospitalization.

The care plan must be based upon the resident assessment, choices and advance directives, if any. As the resident’s status changes, the facility, attending practitioner and the resident representative, to the extent possible, must review and/or revise care plan goals and treatment choices. Based upon the resident’s assessment, the care plan may include, but is not limited to addressing

      • Oral Care
      • Skin Integrity –
      • Medical Treatment/Diagnostic Testing –
      • Symptom Management –
      • Nutrition and Hydration nutrition/hydration; and/or
      • Activities/Psychosocial Needs –

In order to provide continuity of care, the hospice, nursing home, and resident/representative must collaborate in the development of a coordinated care plan which includes, but is not limited to, the following:

      • Resident/representative choices regarding care;
      • The hospice philosophy of care and all services necessary for the palliation and management of the terminal illness and related conditions;
      • Measurable goals and interventions based on comprehensive and ongoing assessments;
      • Interventions that address, as appropriate, the identification of timely, pertinent non-pharmacologic and pharmacological interventions to manage pain and other symptoms of discomfort;
      • The hospice portion that governs the actions of the hospice provider and describes the services that are needed to care for the resident;
      • Identification of the services the nursing home will continue to provide; and
      • The identification of the provider responsible for performing specific services/functions that have been agreed upon.

The Critical Element Pathway (CEP) for Hospice and End of Life Care and Services is a helpful resource for the facility to be familiar with and recognize that during survey an evaluation will be completed to determine if there are signs of psychosocial distress or harm. It is important to validate that the contracted hospice services identified are provided in accordance with the care plan as well as the agreement. Communication between the facility IDT, medical director, hospice provider and resident/responsible party is essential to providing quality of care and avoiding negative outcomes.

To learn more about the Quality of  Care  regulatory requirements, action steps for compliance and survey trends in this area, please plan to join our June 13, 2023 Deep Dive into Federal Regulations session where we will review the Quality of Care regulatory requirements, survey procedures for assessing compliance with Quality of Care requirements, examples of how Quality of Care requirements are commonly cited, and strategies for incorporating survey preparedness related to Quality of Care into facility QAPI processes.



Written By: Christine Twombly, RN-BC, RAC-MT, RAC-MTA, HCRM, CHC
Clinical Consultant

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