A surveyor asks for your hospice–facility agreement. You hand it over. Ten minutes later, they’re asking questions you should know the answer to.
Suddenly, what felt like a routine document review becomes a compliance risk.
Contracts between hospices and Medicare-certified facilities (SNFs, NFs, and ICFs/IID) are one of the most frequently misunderstood parts of hospice compliance. The issue is rarely that care is not being provided. The issue is usually that the written agreement does not clearly define professional management, communication, and accountability the way Medicare expects.
*This article was written in consultation with Mariam Treystman.
At The Home Health Consultant (THHC), we work with Medicare-certified agencies nationwide on compliance infrastructure and survey readiness.
We’re writing this article to clarify what Medicare expects to see in these agreements, so agencies can evaluate whether their contracts support safe, compliant operations.
What Is a Hospice Facility Contract and Why Is It Required?
A hospice facility contract is a written agreement between the hospice and a Medicare-certified facility that allows hospice services to be provided to residents of that facility. The agreement must be signed by authorized representatives of both organizations before hospice services begin.
This agreement is not patient-specific. It does not need to be rewritten for each patient. However, it may be revised if operational improvements or clarifications are needed.
Regulators expect this agreement to define how hospice services will be delivered inside a facility where two separately regulated Medicare providers are operating simultaneously.
Who Is Responsible for Professional Management of Hospice Care in a Facility?
The hospice remains responsible for the professional management of the hospice portion of care, even when the patient resides in a facility.
Professional management includes but is not limited to:
- Assessing
- Planning
- Monitoring
- Directing
- Evaluating
…hospice care across settings. This responsibility is the same as if the patient were living in their own home.
Hospice must routinely provide substantially all core services directly through hospice staff. Core services cannot be delegated to facility personnel.
Because of this, the agreement between a hospice agency and facility should clearly address:
- What happens if facility staff must temporarily perform a hospice-related task in an emergency
- How hospice is immediately notified
- How crisis situations are escalated
- How 24-hour hospice access is ensured
Broad language about “collaboration” is not sufficient. Surveyors look for operational clarity.
How Should a Hospice and Facility Communicate 24/7?
The written agreement must clearly define how the hospice and facility communicate with one another and document that communication. This is required to ensure patient needs are addressed at all times.
This includes but is not limited to:
- Reporting significant changes in condition
- Escalating urgent concerns
- Accessing hospice’s on-call system
- Documenting communication in each entity’s records
What Must the Facility Immediately Report to Hospice?
The agreement must require the facility to immediately notify the hospice when specific events occur.
Those events include but are not limited to:
- A significant change in the patient’s physical, mental, social, or emotional status
- Clinical complications suggesting the plan of care must be altered
- The need for transfer from the facility
- The patient’s death
If a transfer becomes necessary, hospice remains responsible for arranging and managing any required continuous care or inpatient care related to the terminal illness and related conditions.
Clear triggers for notification should be written into the agreement to prevent delays in care coordination.
Who Determines the Level of Hospice Care?
The hospice determines the appropriate level of hospice care and any changes to that level of care.
The agreement must state that the hospice is responsible for deciding whether the patient requires…
- routine home care,
- continuous care,
- or inpatient care,
…and when those levels should change.
While coordination with the facility is required, authority over hospice services remains with the hospice.
Does the Facility Still Provide Room and Board When a Resident Elects Hospice?
The facility remains responsible for 24-hour room and board, personal care, and nursing services that would have been provided before hospice was elected.
A resident should not experience a reduction in facility services because of hospice election. The facility must continue furnishing services at the same level it provides to residents who have not elected hospice.
Each provider retains responsibility for the quality and appropriateness of the care it furnishes under its own regulatory requirements. The agreement should reflect this division of responsibility clearly.
What Services Must the Hospice Continue to Provide Inside the Facility?
Hospice must provide services at the same level and to the same extent as if the patient were residing at home.
This includes responsibility for but is not limited to:
- Medical direction and management
- Nursing services
- Social work
- Counseling (spiritual, dietary, bereavement)
- Hospice aide services when necessary to supplement facility aide services
- Medical supplies
- Durable medical equipment
- Medications and biologicals related to the terminal illness
Hospice also retains financial responsibility for hospice-related supplies, medications, and equipment.
The agreement must outline how supplies, medications, and DME are ordered, delivered, received, and administered 24 hours a day.
Can Hospice Use Facility Nursing Staff to Help Implement the Plan of Care?
Hospice may use facility nursing personnel, where permitted by state law, to assist with administering prescribed therapies included in the hospice plan of care.
However, this assistance is limited to the extent that hospice would routinely rely on family members in a home setting. The use of facility staff does not transfer professional management responsibility away from the hospice.
What Are the Abuse and Neglect Reporting Requirements?
The agreement must require hospice to report alleged violations involving:
- Mistreatment
- Neglect
- Abuse (verbal, mental, sexual, or physical)
- Injuries of unknown source
- Misappropriation of patient property by individuals unrelated to hospice
Hospice must report these allegations to the facility administrator within 24 hours of becoming aware of the issue.
Including this requirement in the contract reinforces accountability and protects patient safety.
How Must the Hospice Plan of Care Be Coordinated With the Facility?
A written hospice plan of care must be established and maintained in consultation with facility representatives.
The coordinated plan must:
- Identify needed care and services
- Clearly specify which provider is responsible for each function
- Reflect participation of hospice, facility, patient, and family (to the extent possible)
Strong coordinated plans typically involve but are not limited to:
- A shared problem list
- Palliative interventions
- Expected outcomes
- Responsible discipline
- Responsible provider
- Patient goals
Changes to the hospice portion of the plan must be discussed with the patient or representative and facility representatives and must be approved by hospice before implementation.
If physician orders affecting hospice care are received by the facility, hospice approval must occur prior to implementation of those changes.
Who Is Responsible for Coordinating Hospice Care With the Facility?
Hospice must designate a member of the interdisciplinary group to oversee coordination of care for each resident receiving hospice services.
This designated individual is responsible for:
- Facilitating communication between hospice and facility staff
- Ensuring plans of care are complementary
- Coordinating with physicians involved in the patient’s care.
The role may be filled by an RN, physician, social worker, or counselor, but the responsibility must be clearly defined.
What Information Must Hospice Provide to the Facility?
Hospice must provide the facility with patient-specific documentation necessary to ensure continuity of care. This documentation includes but is not always limited to:
- The most recent hospice plan of care
- Hospice election documentation
- Advance directives
- Physician certification and recertification
- Names and contact information for hospice personnel
- Instructions for accessing 24-hour on-call services
- Medication information
- Hospice and attending physician orders
There must be a clear process for exchanging updates as care evolves.
What Training Is Required for Facility Staff Caring for Hospice Patients?
Hospice and facility share responsibility for ensuring that facility staff caring for hospice patients are oriented to hospice philosophy and care principles.
Training should include:
- Pain and symptom management
- Comfort measures
- Principles of death and dying
- Patient rights
- Documentation requirements
Training frequency should take facility staff turnover rates into account to ensure ongoing competency.
How Do You Know If Your Hospice Facility Contract Is Survey-Ready?
A compliant hospice–facility agreement should function as an operational blueprint rather than a generic vendor contract.
Hospice compliance is interconnected. Your facility agreement supports, and must align with, how you manage:
- Eligibility
- Certification
- Recertification
- Interdisciplinary group oversight
If you’re having trouble staying on top of what contracts need what, and making sure your administrative paperwork holds up during survey, we can help. That’s exactly why we created our Administrative Compliance Program.
Check out Our Services, or Request a Free Strategy Call to learn how we can help your agency stay survey-ready year-round.
If you’re looking for more hospice resources, you might find this article helpful:
*Disclaimer: The content provided in this article is not intended to be, nor should it be construed as, legal, financial, or professional advice. No consultant-client relationship is established by engaging with this content. You should seek the advice of a qualified attorney, financial advisor, or other professional regarding any legal or business matters. The consultant assumes no liability for any actions taken based on the information provided.
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