Chapter 2 of the MDS 3.0 RAI manual provides SNF facilities with instruction on how to handle the RAI process for a patient who elects care from a hospice program. The manual states, when a SNF is a hospice patient's residence for purposes of the hospice benefit, the facility must comply with the Medicare or Medicaid participation requirements. The resident must be assessed using the RAI, have a care plan and be provided with the services required under the plan of care. 

 

If a terminally ill resident enrolls in a hospice program (Medicare Hospice or other structured hospice) but remains a resident at the nursing home, a SCSA should be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure that a coordinated plan of care between the hospice and nursing home is put into place. Because a Medicare-certified hospice must also conduct an assessment at the initiation of its services, this is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving his/her highest practicable well-being at whatever stage of the disease process the resident is experiencing. 

 

If a resident elects the Medicare Hospice program, it is important that the two separate entities (nursing home and hospice program staff) coordinate their responsibilities and develop a care plan reflecting the interventions required by both entities. The nursing home and hospice plans of care should be reflective of the current status of the resident.