Best Practices for Updating The Hospice Care Plan

The Hospice Plan of Care: Part Two

In Part One, we explored how maintaining an up-to-date and compliant hospice Plan of Care (POC) is crucial for a successful survey, accurate reimbursement, and delivering individualized care that meets regulatory standards.

This issue focuses on best practices for real-time documentation, ongoing training, and practical tools to make POC updates easier and more effective. Accurate care plans not only enhance patient outcomes but also support compliance—improving survey performance and strengthening revenue stability.

Real-Time Documentation

• Update the plan of care with discussion and changes during or immediately after patients are assessed and interdisciplinary group (IDG) meetings.
• Leverage Technology: Firenote Hospice EMR (my personal favorite) has an intuitive informed intelligence model built in that helps clinicians reflect changes in condition, including decline and eligibility, as well as the patient’s progress towards goals! This helps avoid deficiencies related to the plan of care and IDG meeting.

Regular Training and Education

• Provide ongoing training for clinicians on documentation practices and the importance of regularly updating the care plan. 
• The RN Case Manager is primarily responsible for updating the POC during every visit and at least every 15 days in alignment with IDG meetings. 
• Ongoing education ensures clinicians understand the importance of these updates in maintaining compliance, improving care coordination, and optimizing reimbursement.

What to Monitor for Updates in the Plan of Care

These questions may help with assessing if the care plan needs updating:

Level of Care and Frequencies:

• Has there been an increase or decrease in acuity?
• Are there changes in visit frequencies?
• Is a different level of care needed?

Changes in Condition:

• Are there any new symptoms or changes in cognition?
• Is there a decline in functional status or ADLs (activities of daily living)?
• Has there been a change in mobility or increased dependence on caregivers?

Medication and Treatment Changes

• Are there new prescriptions, discontinued medications, or dose adjustments ordered?
• If you see an antibiotic ordered - Acute conditions like infections that require a care plan!
• Was any new equipment or supplies ordered? Was oxygen ordered?

Incidents and Falls

• Have there been any incidents, falls, injuries, or other safety concerns?
• Are there new interventions or prevention plans needed following a fall?

Spiritual and Psychosocial Needs

• Are there changes in the patient’s spiritual or psychosocial needs, especially as they near end-of-life?
• Is there a dynamic affecting the patients current living situation or family dynamics?
• Is the patient moving to a nursing facility or planning for respite?

Make plan of care updates a priority in your operational workflow. The POC is not a "set it and forget it", but a living breathing document. It requires frequent updates to reflect changes in a patient’s condition, medication, symptoms, and level of care. 

An out-of-date care plan can have ripple effects that impact compliance, survey outcomes, and even affect revenue through external audit results.

Do you need expert guidance on accreditation, survey readiness, or audit preparation? Schedule a consultation, and let’s discuss how we can support your needs! https://harthealthcarescheduling.as.me/discovery 

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