Completing a Comprehensive Assessment for a Hospice Patient
By: Lisa Meadows, MSW
Senior Manager, Clinical Operations
Posted: August 5, 2025
The April 2025 article, Excellence in Hospice Care: The Plan of Care, touched on comprehensive assessment as the critical first step in developing an individualized plan of care for hospice patients. This piece explores in greater detail the expectations for that assessment as it relates to accreditation.
The Medicare Conditions of Participation (CoPs) and ACHC Standards drive assessments that are thorough, timely, and person-centered. These standards guide hospice providers in evaluating the physical, emotional, psychosocial, and spiritual needs of patients and their families.
According to the CoPs, the initial assessment must be completed within 48 hours after the election of hospice care. The comprehensive assessment must be completed within five calendar days of the election of hospice care.
The patient and their family must be included in the assessment process, with the goal of understanding their goals, preferences, and expectations. All members of the hospice interdisciplinary group (IDG) are also involved with completing the comprehensive assessment. This includes a hospice physician, a registered nurse, a social worker, mental health counselor, or marriage and family therapist, a spiritual counselor, and other relevant clinicians. This collaborative approach ensures that care remains aligned with the patient’s values throughout their hospice journey.
IDG members represent disciplines engaged with specific elements of the comprehensive assessment.
The registered nurse must document the physical assessment; diagnoses, current symptoms, medication profile, pain levels, imminence of death, complications that will affect care planning, and the patient’s ability to perform activities of daily living. Pain and symptom management are priorities in hospice care.
Psychosocial factors are assessed to determine the need for social work services, including the needs of the patient and caregiver for emotional support, the caregiver capabilities, and the family dynamics. This portion of the assessment should also identify any legal or financial concerns and ensure that advance directives and other legal documents are in place.
Assessment of spiritual factors determines the need for spiritual care services. Here, the evaluation includes how terminal illness is impacting the patient’s and family’s belief system. It explores their values and spiritual practices to identify how these can be best supported through the plan of care.
The bereavement risk assessment must include an evaluation of the needs of the patient’s family and others close to the patient, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death.
Once complete, the assessment findings are used to develop a patient-specific plan of care that addresses all identified needs. The plan must be reviewed and updated regularly—at least every 15 calendar days, or more often as the patient’s condition changes.
Interdisciplinary cooperation, patient and family involvement, and timely review work together to ensure patient-centered hospice care. The CoPs and ACHC Standards require these qualities in a comprehensive hospice assessment. Through collaboration, clear documentation, and consistent reassessment, hospice providers can ensure high-quality, compassionate care that supports the patient and family at every stage of the end-of-life experience.
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Read more articles about Hospice Accreditation here.