is the belief of the task force that these changes should not alone trigger a change-of-condition MDS. 2. EXAMPLES Exhibit A: Subject:   Nursing Home Setting Title:   Plan of Care Policy:   Hospice and nursing home will establish one individualized Plan of Care for the hospice patient/family in the Nursing Home Setting. Purpose:   To plan for quality hospice care. Special Instructions: Upon admission to hospice, the initial Plan of Care will be developed by hospice and charted. Nursing home resident to hospice: Hospice will do assessment and gather information from existing Plan of Care and nursing home staff. Hospice and nursing home will jointly establish the Plan of Care. Nursing home staff will initiate change-of-condition MDS/RAP as care changes focus from curative/maintenance to palliative. Hospice patient to nursing home: Hospice/nursing home will develop a Plan of Care. Nursing home will initiate change-of-care focus MDS/RAP and gather information from hospice. At initial interdisciplinary team conference after nursing home admission, hospice will address the RAP problem areas and document anticipated potential patient outcomes based on terminal disease progression and dying process on form NH 021. A copy will be placed on nursing home chart. At interdisciplinary team meeting following MDS/RAP review, the triggered RAP areas will be addressed by hospice interdisciplinary/nursing home team meeting with problems opened or rationale for not opening documented on form NH 021 with copy on nursing home chart. When a new problem is opened, hospice will document on interdisciplinary team minutes form if anticipated and related to terminal illness