Individualized, holistic support is the foundation of quality hospice care and this depends on a well-structured and continuously updated plan of care. Hospice Medicare Conditions of Participation (CoPs) and the Accreditation Commission for Health Care (ACHC) Hospice Standards together guide hospice providers in delivering high-quality, patient-centered care. Consistency in meeting and maintaining compliance with these regulations and best practices is also an effective quality and risk management strategy for hospice agencies.

Key Components of a Hospice Plan of Care

A hospice plan of care describes the medical, emotional, psychosocial, and spiritual care provided to a patient with a terminal illness. It is developed from an interdisciplinary perspective, meaning that it incorporates input from the patient’s attending physician (if there is one), the hospice medical director or physician, nurses, social workers, spiritual care providers, and other counselors to ensure a comprehensive approach. This interdisciplinary group (IDG) works together to meet the immediate needs of hospice patients and families facing bereavement and should be proactive by planning ahead for anticipated changes and needs.

Medicare CoPs at 42 CFR § 418.56 require that a hospice plan of care includes:

• Interventions to manage pain and symptoms.
• A detailed statement of the scope and frequency of visits from each discipline.
• Drugs and treatments necessary to meet to meet the patient’s needs.
• Measurable outcomes and updates.
• Medical supplies and appliances necessary to meet the patient’s needs.
• The interdisciplinary group’s documentation in the clinical record of the patient’s or their representative’s level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice’s own policies.

ACHC accredited hospices must also ensure that the plan of care meets ACHC standard HSP5-4A and includes documentation of:

• Start of care date.
• Certification period.
• Patient demographics.
• Principle diagnosis and other pertinent diagnoses.
• Family needs.
• Spiritual needs.
• End-of-life care preferences.
• Bereavement needs.
• Functional limitations.
• Diet and nutritional needs.
• Safety measures.

Developing the Plan

The plan of care begins with a thorough initial and comprehensive assessment. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Updated comprehensive assessments ensure that these services remain appropriate to current needs.

Setting Goals and Establishing Interventions

Once the initial and comprehensive assessments are complete, the hospice team collaborates with the patient and their family to establish clear, measurable goals and interventions based on the problems identified. Examples include:

• Pain and symptom management to enhance comfort.
• Emotional and spiritual support tailored to beliefs and values.
• Caregiver education and respite care to prevent burnout.
• Advanced care planning and end-of-life discussions.

Medicare and ACHC emphasize interdisciplinary collaboration, meaning all team members must contribute to the plan, ensuring a holistic and coordinated approach.

Implementing and Updating the Plan

A hospice plan of care is a living document that must be reviewed and updated regularly to reflect changes in the patient’s condition. Medicare CoP mandates reviews every 15 days, but adjustments should be made sooner if necessary. Regular interdisciplinary team meetings help ensure that care remains aligned with patient needs and preferences. Newly identified problems must be addressed through revision to the plan and resolved problems should be noted with corresponding interventions discontinued.

Compliance with Standards Serves Patients

Issues with the plan of care are among the most frequent deficiencies noted by ACHC Surveyors. By conducting thorough assessments, setting clear goals, maintaining interdisciplinary coordination, and ensuring continuous updates, hospice providers can deliver high-quality, compassionate care that aligns with both regulatory requirements and patient needs. This approach enhances comfort, dignity, and support for patients and families navigating end-of-life care.