Have you reviewed end-of-life care plans with your staff?

On September 27, 2012, CMS published a Memo: Ref: S&C 12-48-NH, to the State Survey Agency Directors on F-Tag 309 — Quality of Care. These revisions were to be implemented no later than November 30, 2012.

CMS made changes to the surveyor guidance for End of Life in Appendix PP of the State Operations Manual. This was to provide clarification to nursing home surveyors when determining compliance with the regulatory requirements for End-of-Life. The regulatory language remains unchanged.

This memo can be accessed here.

Upon review of the information, there may be a few questions we ask ourselves:

1.     Are our systems consistent with appropriate assessment and management of care at end of life?

2.     Do we need to update our policies and procedures?

3.     Do we need to educate our interdisciplinary team?

4.     Do the resident choices for end of life coincide with the plan of care?

5.     Do we have a system for collaboration with hospice if elected, for a coordinated plan of care?


Let’s take a look at the facility policies and procedures to ensure that they include how the facility will ensure the necessary care and services to attain or maintain the resident’s highest level of physical, mental and psychosocial well-being for palliative care in accordance with the resident choices, assessment and care plan consistent with standards of practice? 


What is our protocol/procedure for collaboration with hospice for care planning? Is there a binder on the unit for hospice care plans/documentation and the facility has their own care plans and never the two shall meet? Are the goals and interventions consistent or do they conflict? Who is managing the oversight? Do these areas need to be tightened up?



Next, we will want to educate the facility staff in the policies and procedures as well as a system to evaluate staff compliance with the policies and procedures. 


Other opportunities for education include:

  • Care for a resident approaching end of life consistent with resident wishes, Advance Directives and individualized plan of care based on comprehensive assessment.
  • Hospice Services: What services are provided, expectations of both entities —hospice and facility — communication, documentation, notifications and collaboration in the plan of care as well as the location of all documentation for reference.



1.    Is there evidence of comprehensive assessment in the medical record?

2.    Does the care plan coincide with resident choices and comprehensive assessment?

3.    If hospice is elected, is there evidence of collaboration in the plan of care, identifying each entity’s responsibilities?



Is there a system in place to communicate with hospice?:

1.     Assessment information – including pain management (pharmacological and non-pharmacological)

2.     Changes of Condition

3.     Notifications

4.     Need for Transfer

5.     Supply and Equipment needs

6.     Responsibilities for writing orders



Do we have a system in place to review the care plans, communication, problem solving and education?



If there are identified areas that need to be updated in our system, we can develop an Action Plan to address:

  •                   The specific areas that need to be updated (i.e. policies, education, documentation etc.)
  •                   Your recommended plan of action
  •                   Responsible discipline/position
  •                   Date this will be completed.


The action plan can then be discussed and worked on by the interdisciplinary team during the next Quality Assurance Committee for review and recommendations.


Once our system is in place, we can audit on a regular basis to ensure that we are in compliance with F309!


Susan LaGrange, RN, BSN, NHA, is the national education coordinator at Pathway Health Services.