Understanding Hospice and Palliative Care in Long-Term Care
Hospice and palliative care have become a routine part of skilled nursing facility operations as a growing share of residents spend their final months in long-term care. Although the terms are often used interchangeably, they carry distinct clinical and regulatory meanings. Federal hospice regulations define palliative care as patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering, addressing physical, intellectual, emotional, social, and spiritual needs. Palliative care may be provided at any stage of a serious illness and may be delivered alongside curative or disease-modifying treatment.
Hospice is a specific Medicare benefit for individuals certified as terminally ill, with a life expectancy of six months or less if the illness runs its normal course, who elect comfort-focused care in place of curative treatment for the terminal condition. For the facility, the distinction has practical consequences. Palliative approaches fall within the facility’s own obligation to manage pain, provide quality care, and honor resident preferences regardless of hospice status. Hospice introduces a second Medicare-certified provider into the resident’s care, creating shared responsibilities that must be defined in writing and coordinated every day.
Federal Requirements for Hospice Services in the SNF
Under 42 CFR 483.70(n), a long-term care facility may either arrange for hospice and palliative care services through an agreement with one or more Medicare-certified hospices or decline to arrange hospice services and instead assist residents who request hospice in transferring to a facility that provides it. Facilities that arrange hospice services are evaluated by surveyors under F849, which addresses the written agreement, care coordination between hospice and the facility, and integration of the hospice plan of care into the resident’s comprehensive care plan.
The written agreement must be signed by authorized representatives of both the hospice and the facility before hospice care is furnished to any resident. At a minimum, the agreement must address the following elements:
- The services the hospice will provide and the services the facility will continue to provide under each resident’s plan of care.
- The hospice’s responsibility for the hospice plan of care and for determining the course of hospice care, including changes in level of care.
- A documented communication process that ensures resident needs are addressed and met 24 hours a day.
- Immediate facility notification to the hospice of a significant change in status, clinical complications, a need to transfer the resident, or the resident’s death.
- The facility’s responsibility for 24-hour room and board, personal care, and nursing care in coordination with the hospice.
- Authorization for facility staff to administer hospice-prescribed therapies where permitted by state law and as specified by the facility.
- Immediate reporting by the facility of alleged mistreatment, neglect, abuse, or misappropriation of resident property by hospice personnel to the hospice administrator.
- A delineation of hospice and facility responsibilities for bereavement services offered to facility staff.
Agreements should be reviewed periodically and whenever services, staffing contacts, or ownership change for either party. An agreement that exists on file but does not reflect day-to-day practice offers limited protection during a survey.
Reciprocal Hospice Responsibilities
Hospices operate under their own Conditions of Participation, and 42 CFR 418.112 sets out requirements that mirror those placed on the facility. The hospice retains professional management of hospice services and must provide services at the same level and to the same extent as if the resident were living at home. The facility continues to provide room and board and personal and nursing care at the level provided before hospice election, and facility nursing staff may assist with hospice-prescribed therapies only to the extent the hospice would routinely rely on a family caregiver.
The hospice must report alleged abuse, neglect, or misappropriation of property by facility personnel to the facility administrator within 24 hours of becoming aware of it. The hospice is also responsible, in coordination with the facility, for orienting facility staff to the hospice philosophy, comfort and pain control measures, symptom management, death and dying, patient rights, and hospice forms and record-keeping requirements. When hospice visits occur less often than the plan of care specifies, or when hospice-covered supplies and medications are delayed, the issue should be escalated through the communication process established in the agreement rather than quietly absorbed by facility staff.
Integrating the Care Plan and Documentation
Federal regulations require that the resident’s comprehensive care plan includes the most recent hospice plan of care and a description of the services the facility provides. A common survey concern arises when the facility and the hospice maintain separate plans that are never reconciled. Examples include a hospice medication change that does not appear on the facility’s medication administration record, a hospice aide schedule unknown to unit staff, or conflicting repositioning or nutrition instructions.
The integrated plan should identify which provider is responsible for each service, intervention, and supply. Changes to the hospice plan of care must be discussed with the resident or resident representative and facility staff and approved by the hospice before implementation. On the MDS, hospice care is captured in Section O, and the RAI Manual generally requires a Significant Change in Status Assessment when a resident elects or revokes the hospice benefit, or changes hospice providers.
Palliative Care Obligations Beyond the Hospice Benefit
Residents who are not enrolled in hospice remain entitled to palliative approaches as part of the facility’s quality of care and resident rights obligations. The State Operations Manual, Appendix PP, directs surveyors to evaluate pain management, end-of-life care consistent with resident goals, and each resident’s right to formulate advance directives and to request, refuse, or discontinue treatment. Hospice and palliative care principles apply equally to residents who decline hospice, who do not meet eligibility criteria, or whose prognosis is uncertain.
Goals-of-care conversations should be documented, revisited at quarterly care conferences, and updated after any significant change in condition. When consistent with a resident’s documented wishes, comfort-focused care plans can reduce burdensome transfers and hospitalizations near the end of life. Social services and nursing leadership should ensure that the advanced directive and physician order documentation are consistent, accessible to all shifts, and are reflected in the care plan.
Medicare Coverage and Recent Regulatory Updates
The Medicare hospice benefit does not pay for room and board in the nursing facility, except during short-term inpatient respite or general inpatient care. Room and board for hospice residents is paid privately, through long-term care insurance, or through Medicaid for eligible residents, typically with payment passing from the state Medicaid program to the hospice and then to the facility under the terms of the agreement. A resident may receive the Medicare Part A skilled nursing facility benefit for a condition unrelated to the terminal illness while also electing hospice; skilled care related to the terminal condition is the responsibility of the hospice.
Federal oversight of hospice program integrity continues to increase. The FY 2027 Hospice Final Rule makes the hospice election statement addendum, which lists items, services, and drugs the hospice has determined are unrelated to the terminal illness and will not be covered, mandatory for all beneficiaries electing hospice. Facilities should request a copy of the addendum for each hospice resident, as it clarifies which medications and supplies remain the responsibility of the facility, the resident, or another payer.
Staff Training, Oversight, and QAPI Integration
Effective hospice and palliative care in the skilled nursing facility depends on consistent staff preparation and ongoing oversight of contracted hospice services. Training should address hospice philosophy, recognition of pain and symptoms in residents with cognitive impairment, communication with grieving families, cultural and religious practices surrounding death, post-mortem care, and bereavement support for staff.
Hospice coordination should be incorporated into the facility’s QAPI program. Useful monitoring measures include the following:
- Hospice visit frequently compared with the hospice plan of care
- Timeliness of notification and communication between providers
- Hospital transfers and emergency department visits among hospice residents
- Pain assessment results and response to interventions
- Grievances and family feedback related to end-of-life care
Hospice agreements, designee assignments, and orientation records should be reviewed at least annually. The facility assessment should also account for the needs of residents receiving end-of-life care, including staffing competencies and equipment. Treating hospice coordination as an ongoing quality process, rather than a contractual formality, supports compliance and helps ensure each resident’s final months reflect personal goals and preferences.