Current through Reg. 49, No. 38; September 20, 2024
(a)
Types of Documentation Required. A hospice must maintain the following
information on each individual receiving Medicaid hospice services.
(1) Signed hospice election and discharge
forms.
(2) Signed Physician's
Certification of Terminal Illness.
(3) Physician narratives.
(4) Documentation of each face-to-face
assessment.
(5) Patient history and
physical exams before and during the provision of hospice services, including
previous and new diagnoses, emergency room visits, and ability to perform
activities of daily living.
(6)
Physician consultation reports, orders, and progress notes.
(7) Hospital admission and discharge
reports.
(8) Plans of care covering
all periods during which the hospice provides services to the
individual.
(9) Nursing assessments
and nursing notes.
(10) IDT meeting
notes.
(11) Medication
administration records, including doses, frequency, and routes.
(12) Signs and symptoms, anthropometric
measurements, weights, oral intake, and laboratory and diagnostic testing
results supporting the conclusion that the individual's condition is
terminal.
(13) Other documentation
supporting the plan of care, service delivery, and outcome of
services.
(14) Summary of
circumstances surrounding the death, including date, time, family in
attendance, and hospice staff in attendance.
(b) Requirements for Physician's Orders. A
hospice must have a signed physician's order that:
(1) covers the time period for which hospice
services were provided; and
(2)
documents the terminal illness and related medical need for skilled nursing
care, as provided.
(c)
Requirements for the Plan of Care. A hospice must maintain a plan of care for
each individual receiving Medicaid hospice services. The plan of care must meet
the following criteria.
(1) The plan of care
must relate to the identified terminal illness.
(2) The plan of care must be updated every 15
days, or when the individual's condition changes if sooner than 15 days, and
include any change in the individual's status.
(3) The plan of care must include the
following:
(A) a description of the
individual's service needs and how the hospice plans to meet those
needs;
(B) the baseline condition
of the individual at the beginning of the election period including symptoms
documented with location, severity, and frequency;
(C) identification of the specific
interventions and services necessary for the management of the symptoms
including the intensity, frequency, duration, and scope of services;
(D) physician orders for the specific
interventions and services necessary; and
(E) the measurable outcomes anticipated from
implementing the plan of care and reasonable timeframes expected for achieving
those measurable outcomes.
(d) Requirements for Physician Services on
the Day of Discharge. To request payment for physician services on the day of
discharge, the hospice must submit to HHSC proof that:
(1) the physician is a hospice employee;
and
(2) the physician provided
direct services to the patient on the day of discharge.
(e) Requirements for all documentation. All
documentation must be:
(1) clearly labeled to
indicate what type of documentation it is;
(2) legible to a reader other than the
author; and
(3) signed and
dated.
