38594 Federal Register / Vol. 78, No. 124 / Thursday, June 27, 2013 / Rules and Regulations 

regulatory requirements or costs on any 

tribal government. It does not have 

substantial direct effects on tribal 

governments, on the relationship 

between the Federal government and 

Indian tribes, or on the distribution of 

power and responsibilities between the 

Federal government and Indian tribes. 

Thus, Executive Order 13175 does not 

apply to this rule. 

G. Executive Order 13045 (Protection of 

Children From Environmental Health 

and Safety Risks) 

This action is not subject to Executive 

Order 13045 (62 FR 19885, April 23, 

1997) because it is not economically 

significant as defined in Executive 

Order 12866, and because the Agency 

does not believe the environmental 

health or safety risks addressed by this 

action present a disproportionate risk to 

children. 

H. Executive Order 13211 (Actions 

Concerning Regulations That 

Significantly Affect Energy Supply, 

Distribution, or Use) 

This action is not subject to Executive 

Order 13211 (66 FR 28355, May 22, 

2001), because it is not a significant 

regulatory action under Executive Order 

12866. 

I. National Technology Transfer and 

Advancement Act 

Section 12(d) of the National 

Technology Transfer and Advancement 

Act of 1995 (‘‘NTTAA’’), Public Law 

104–113, 12(d) (15 U.S.C. 272 note) 

directs the EPA to use voluntary 

consensus standards in its regulatory 

activities unless to do so would be 

inconsistent with applicable law or 

otherwise impractical. Voluntary 

consensus standards are technical 

standards (e.g., materials specifications, 

test methods, sampling procedures, and 

business practices) that are developed or 

adopted by voluntary consensus 

standards bodies. NTTAA directs the 

EPA to provide Congress, through the 

Office of Management and Budget, 

explanations when the Agency decides 

not to use available and applicable 

voluntary consensus standards. 

This action does not involve technical 

standards. Therefore, the EPA did not 

consider the use of any voluntary 

consensus standards. 

J. Executive Order 12898 (Federal 

Actions To Address Environmental 

Justice in Minority Populations and 

Low-Income Populations) 

Executive Order 12898 (59 FR 7629, 

February 16, 1994) establishes Federal 

executive policy on environmental 

justice. Its main provision directs 

Federal agencies, to the greatest extent 

practicable and permitted by law, to 

make environmental justice part of their 

mission by identifying and addressing, 

as appropriate, disproportionately high 

and adverse human health or 

environmental effects of their programs, 

policies, and activities on minority 

populations and low-income 

populations in the United States. 

The EPA has determined that this 

final rule will not have 

disproportionately high and adverse 

human health or environmental effects 

on minority or low-income populations 

because it does not affect the level of 

protection provided to human health or 

the environment. This action merely 

removes the 2006 NPDES Pesticides 

Rule from the CFR which was vacated 

by the U.S. Court of Appeals. 

K. Congressional Review Act 

The Congressional Review Act, 5 

U.S.C. 801 et seq., as added by the Small 

Business Regulatory Enforcement 

Fairness Act of 1996, generally provides 

that before a rule may take effect, the 

agency promulgating the rule must 

submit a rule report, which includes a 

copy of the rule, to each House of the 

Congress and to the Comptroller General 

of the United States. Section 808 allows 

the issuing agency to make a rule 

effective sooner than otherwise 

provided by the CRA if the agency 

makes a good cause finding that notice 

and public procedure is impracticable, 

unnecessary or contrary to the public 

interest. This determination must be 

supported by a brief statement. 5 U.S.C. 

808(2). As stated previously, the EPA 

has made such a good cause finding, 

including the reasons therefore, and 

established an effective date of June 27, 

2013. The EPA will submit a report 

containing this rule and other required 

information to the U.S. Senate, the U.S. 

House of Representatives, and the 

Comptroller General of the United 

States prior to publication of the rule in 

the Federal Register. This action is not 

a ‘‘major rule’’ as defined by 5 U.S.C. 

804(2). 

V. Statutory Authority 

This rule is issued under the authority 

of sections 101, 301, 304, 306, 308, 402, 

and 501 of the CWA. 33 U.S.C. 1251, 

1311, 1314, 1316, 1317, 1318, 1342, and 

1361. 

List of Subjects in 40 CFR Part 122 

Environmental protection, 

Administrative practice and procedure, 

Confidential business information, 

Hazardous substances, Reporting and 

recordkeeping requirements, Water 

pollution control. 

Dated: June 21, 2013. 

Bob Perciasepe, 

Acting Administrator. 

For the reasons set out in the 

preamble, 40 CFR part 122 is amended 

as follows: 

PART 122—EPA ADMINISTERED 

PERMIT PROGRAMS: THE NATIONAL 

POLLUTANT DISCHARGE 

ELIMINATION SYSTEM 

■ 1. The authority citation for part 122 

continues to read as follows: 

Authority: The Clean Water Act, 33 U.S.C. 

1251 et seq. 

§ 122.3 [Amended] 

■ 2. Section 122.3 is amended by 

removing and reserving paragraph (h). 

[FR Doc. 2013–15445 Filed 6–26–13; 8:45 am] 

BILLING CODE 6560–50–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

42 CFR Part 483 

[CMS–3140–F] 

RIN 0938–AP32 

Medicare and Medicaid Programs; 

Requirements for Long Term Care 

Facilities; Hospice Services 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Final rule. 

SUMMARY: This final rule will revise the 

requirements that an institution will 

have to meet in order to qualify to 

participate as a skilled nursing facility 

(SNF) in the Medicare program, or as a 

nursing facility (NF) in the Medicaid 

program. These requirements will 

ensure that long-term care (LTC) 

facilities (that is, SNFs and NFs) that 

choose to arrange for the provision of 

hospice care through an agreement with 

one or more Medicare-certified hospice 

providers will have in place a written 

agreement with the hospice that 

specifies the roles and responsibilities 

of each entity. This final rule reflects the 

Centers for Medicare and Medicaid 

Services’ (CMS’) commitment to the 

principles of the President’s Executive 

Order 13563, released on January 18, 

2011, titled ‘‘Improving Regulation and 

Regulatory Review.’’ It will improve 

quality and consistency of care between 

hospices and LTC facilities in the 

provision of hospice care to LTC 

residents. 


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Federal Register / Vol. 78, No. 124 / Thursday, June 27, 2013 / Rules and Regulations 38595 

DATES: These regulations are effective 

on August 26, 2013. 

FOR FURTHER INFORMATION CONTACT: Lisa 

Parker, (410) 786–4665. 

SUPPLEMENTARY INFORMATION:

I. Background 

A. Overview 

Sections 1819(b)(4)(A)(i) and 

1919(b)(4)(A)(i) of the Social Security 

Act (the Act) state that, to the extent 

needed to fulfill all plans of care 

described in sections 1819(b)(2) and 

1919(b)(2) of the Act, a skilled nursing 

facility (SNF) or nursing facility (NF) 

must provide, or arrange for the 

provision of, nursing and related 

services and specialized rehabilitative 

services to attain or maintain the highest 

practicable physical, mental, and 

psychosocial well-being of each 

resident. The Omnibus Budget 

Reconciliation Act (OBRA) of 1986 

permitted States to add a hospice 

benefit to their State Medicaid plans, 

and specified that such care could be 

provided to an individual while such 

individual was a resident of a SNF or 

intermediate care facility (Pub. L. 99– 

272 (1986), section 9505(a)(2)). 

Additionally, eligible residents of longterm care (LTC) facilities may elect to 

receive services under the Medicare 

hospice benefit. 

Medicare does not have a separate 

payment rate for routine hospice 

services provided in a nursing home. 

Because hospice services are typically 

provided to patients in their homes, the 

routine home care hospice rate does not 

include any payment for room or board. 

For routine home care services provided 

to patients in LTC facilities, hospices 

receive the Medicare routine home care 

rate, which is a fixed amount per day for 

the services provided by the hospice, 

regardless of the volume or intensity of 

the services provided. Accordingly, 

when the hospice patient resides in an 

LTC facility, the patient generally 

remains responsible for payment of the 

LTC facility’s room and board charges. 

If, however, a patient receiving 

Medicare hospice benefits in an LTC 

facility is also eligible for Medicaid, 

Medicaid will pay the hospice at least 

95 percent of the State’s daily LTC 

facility rate, and the hospice is then 

responsible for paying the LTC facility 

for the beneficiary’s room and board. 

The specific services included in the 

daily rate payment are determined by 

the State’s Medicaid program and may 

vary from State to State. In addition to 

the room and board payment, a hospice 

may contract with the nursing home for 

the nursing home to provide non-core 

hospice services (that is, those services 

which the hospice is not required by 

law to provide itself) to its hospice 

patients. 

LTC facilities and hospices are 

required to provide many of the same 

services to residents who have elected 

to receive the hospice benefit. The LTC 

facility regulations clearly specify what 

services the facility is required to 

provide to residents. Those services 

include nursing services (including aide 

services), dietary services, physician 

services, dental services, pharmacy 

services, specialized rehabilitative 

services if appropriate, laboratory 

services, and social services. Similarly, 

if a resident chooses to elect the hospice 

benefit, hospice providers are required 

to provide many of the same services as 

the LTC facility. As required at 42 CFR 

418.100(c), a hospice must provide 

certain specified care and services and 

must do so in a manner that is 

consistent with accepted standards of 

practice. Those services include nursing 

services (including aide services), 

medical social services, physician 

services, counseling services (spiritual, 

dietary, and bereavement), volunteer 

services, therapy services as 

appropriate, short-term inpatient care, 

and medical supplies. 

Due to so many of the same services 

being provided by both LTC facilities 

and hospice providers, there is a clear 

potential for residents to receive 

duplicative and/or conflicting services. 

The Department of Health and Human 

Services’ Office of Inspector General 

(OIG) has recently raised a number of 

concerns about Medicare hospice care 

for nursing facility residents. OIG found 

that 31 percent of Medicare hospice 

beneficiaries resided in nursing 

facilities in 2006 and that 82 percent of 

hospice claims for these beneficiaries 

did not meet Medicare coverage 

requirements. (OIG, Medicare Hospice 

Care: Services Provided to Beneficiaries 

Residing in Nursing Facilities, OEI–02– 

06–00223, September 2009). 

Additionally, OIG reported that, unlike 

private homes, nursing facilities are 

staffed with professional caregivers and 

are often paid by third-party payers, 

such as Medicaid. These facilities are 

required to provide personal care 

services, which are similar to hospice 

aide services that are paid for under the 

hospice benefit. (OIG, Medicare 

Hospices that Focus on Nursing Facility 

Residents, OEI–02–10–00070, July 

2011). To address this issue, we are 

establishing a requirement that will 

ensure LTC facilities that choose to 

arrange for the provision of hospice care 

through an agreement with one or more 

Medicare-certified hospice providers 

will have in place a written agreement 

with the hospice that will specify the 

roles and responsibilities of each entity. 

These clarifications will increase 

coordination of care for patients as well 

as help foster a stronger channel of 

communication between the two 

providers assisting patients and their 

families. We believe that a clear division 

of responsibilities and increased 

communication required by this rule 

will help eliminate duplication of and/ 

or missing services. 

This final rule sets forth requirements 

consistent with requirements in the June 

5, 2008 final rule (73 FR 32088) titled 

‘‘Medicare and Medicaid Program: 

Hospice Conditions of Participation.’’ 

The hospice care final rule set forth new 

requirements that a Medicare-certified 

hospice provider must meet when it 

provides services, including the 

provision of hospice care to residents of 

an LTC facility who elect the hospice 

benefit. In regulations at 42 CFR 

418.112(c), we specify what must be 

included in a written agreement 

between a Medicare-certified hospice 

provider and an LTC facility. In this 

final rule, we have made the 

requirements for LTC facilities 

consistent with the June 2008 final rule. 

This final rule also supports current 

LTC requirements that protect a 

resident’s right to a dignified existence, 

self-determination, and communication 

with, and access to, persons and 

services inside and outside the facility. 

B. Relevance to Existing Hospice 

Requirements 

Our intent in finalizing these 

requirements for LTC facilities is to 

ensure they are in accord with our 

existing requirements at § 418.112 for 

hospices that provide services to 

residents of LTC facilities. Our 

requirements for LTC facilities to have 

agreements with hospices and to 

collaborate and communicate with 

hospices to provide care for LTC facility 

residents largely parallels the language 

and intent of the hospice requirements. 

There are, however, instances where 

employing the same language will not 

reflect the distinct roles of each entity 

or where we believe it is important to 

provide clarity and detail without 

disturbing the substance or the proper 

interpretation of the requirements. In 

some instances, we are finalizing 

different requirements because we 

believe they are in the best interests of 

the residents of LTC facilities. For 

instance, we are requiring at 

§ 483.75(t)(2)(ii)(E)(3) that the LTC 

facility notify the hospice about a need 

to transfer the resident from the facility 

for any condition. As a slight variation, 

the hospice is currently required at 


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§ 418.112(c)(2)(iii) to provide in an 

agreement with a SNF/NF or ICF/IID 

that the SNF/NF or ICF/IID will notify 

the hospice of a need to transfer a 

patient from the SNF/NF or ICF/IID, and 

the hospice makes arrangements for, 

and remains responsible for necessary 

continuous care or inpatient care related 

to the terminal illness and related 

conditions. While these provisions are 

similar, the hospice regulations also 

highlight the hospice’s continued 

responsibility for care related to the 

terminal illness. We believe that these 

provisions, which are tailored to the 

unique needs and circumstances of each 

provider type, will promote higher 

quality of care and safety for the 

resident. 

The rationale for both of these rules 

is to require a written agreement 

between the hospice and the LTC 

facility, which will help ensure safe and 

quality care if provided to the residents. 

(See § 418.112 (c)(1) through (9) for 

hospice and § 483.75(t)(2)(ii) (A) 

through (K) finalized in this rule for 

LTC facilities.) While the rules have 

slight differences in language, 

substantively, the requirements are the 

same. We believe it is appropriate for 

the remainder of the rule, including the 

coordination of care requirements at 

§ 483.75(t)(3)(i) through (v) for LTC 

facilities and § 418.112(e) for hospice, to 

reflect the difference in the roles 

between these two providers in 

delivering resident care. Therefore, we 

are finalizing requirements for 

communication and collaboration 

specific to the LTC facility that do not 

entirely mirror the language in the 

hospice requirements. Rather, the final 

rule for LTC facilities will complement 

the hospice requirements, and together, 

these rules will allow for better 

coordination of care and quality of care 

for LTC facility residents who elect to 

receive the hospice benefit. 

This final rule reflects the Centers for 

Medicare and Medicaid Services’ 

(CMS’) commitment to the principles of 

the President’s Executive Order 13563, 

released on January 18, 2011, titled 

‘‘Improving Regulation and Regulatory 

Review.’’ It will improve quality and 

consistency of care between hospices 

and LTC facilities in the provision of 

hospice care to LTC residents. 

II. Provisions of the Proposed Rule and 

Response to Comments 

We published a proposed rule in the 

Federal Register on October 22, 2010 

(75 FR 65282). In that rule, we proposed 

to revise the requirements that an 

institution would have to meet in order 

to qualify to participate as a skilled 

nursing facility (SNF) in the Medicare 

program, or as a nursing facility (NF) in 

the Medicaid program. 

We provided a 60-day public 

comment period, during which we 

received approximately 30 timely 

comments from individuals, advocacy 

organizations, and industry 

associations. Summaries of the 

proposed provisions, as well as the 

public comments and our responses, are 

set forth below. We originally proposed 

the standard regarding LTC facility/ 

Hospice cooperation at § 483.75(r); 

however, during the process of 

finalizing this rule, CMS published a 

separate interim final rule, titled 

‘‘Requirements for Long-Term Care 

(LTC) Facilities; Notice of Facility 

Closure’’ (76 FR 9503). The interim final 

rule added separate standards at 

§§ 483.75(r) and (s). Since the 

designations (r) and (s) are now in use, 

we are finalizing this standard at 

§ 483.75(t). However, in this discussion, 

we will continue to refer to the 

proposed regulations text at § 483.75(r). 

Comments Regarding Possible Barrier 

Creation 

Notwithstanding our analysis that this 

rule and 2008 final hospice rule are 

complimentary and substantively 

similar, and in view of the slight 

differences between these rules, we 

requested public comment on whether 

the differences found in the proposed 

rule would create a barrier to forming 

agreements between LTC facilities and 

hospices, or interfere in coordination of 

residents’ care between LTC facilities 

and hospices. We received a few 

comments regarding the differences 

between the two rules. Those comments 

and our response are set forth below. 

Comment: Several commenters had 

concerns that the proposed rule, as 

written, has the potential of creating a 

barrier to agreements between LTC 

facilities and hospice providers. 

Commenters noted that this requirement 

imposes responsibility and liability on 

the LTC facilities to make decisions 

regarding whether or not a hospice 

provider is meeting professional 

standards and principles. Those duties 

and responsibilities are the province of 

the State licensing agency and CMS, and 

should not be placed on LTC facilities. 

Response: The requirements in the 

final rule will ensure that LTC facilities 

that chose to arrange for the provision 

of hospice care through an agreement 

with one or more Medicare-certified 

hospice providers will have in place a 

written agreement with the hospice that 

specified the roles and responsibilities 

of each entity. If an LTC facility is 

establishing an agreement for the 

provision of services, the LTC facility 

should be monitoring the delivery of the 

services to a resident in order to assure 

that professional standards and 

principles are followed in the provision 

of the services within their facility. The 

LTC facility is responsible for assuring 

that services and care provided meet the 

assessed needs of each resident. 

General Comments 

Comment: The majority of 

commenters support the rule. Several 

commenters stated that having a 

mandated set of written expectations 

between LTC facilities and hospice 

providers would help clarify specific 

responsibilities of each entity. The 

commenters also stated that 

clarifications will increase coordination 

of care for patients as well as help foster 

a stronger channel of communication 

between the two providers assisting 

patients and their families. With a clear 

division of responsibilities and 

increased communication, this rule will 

help eliminate duplication of and/or 

missing services. 

Response: We appreciate the support 

from the commenters on this proposal. 

We believe that having a consistent set 

of regulatory requirements that establish 

the expectations for both hospices 

(§ 418.112(e)) and LTC facilities 

(§ 483.75(t)) will help both entities 

clarify their specific patient/residentcare roles and responsibilities. The 

regulatory clarity will also help to 

eliminate duplication of and/or missing 

services. 

Comment: One commenter suggested 

extending the deadline for the 

implementation of the rule to allow 

hospices and LTC facilities more time to 

develop agreements to be reached, 

reviewed, and signed along with 

training of LTC and hospice staff to be 

conducted. 

Response: The rule will be effective 

on August 26, 2013. We believe this is 

an adequate timeframe since hospices 

already have to meet this requirement. 

Comment: Several commenters 

suggested the final rule should include 

the creation of a liaison position. 

Commenters suggested the on-staff, 

clinically trained professional should 

serve as a point of contact and mediator 

collaborating directly with hospice and 

LTC facility staff members to coordinate 

effective patient care. Some commenters 

suggested that the point of contact 

person be on the LTC facility’s staff, 

while other commenters suggested the 

position be filled by a member of the 

hospice staff. Commenters suggested 

that the liaison position should help to 

eliminate division of services and 

ensure that all appropriate medical care 


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safety precautions were being observed 

and provided. 

Response: We believe the requirement 

that we are finalizing, which designates 

a member of the LTC facility’s 

interdisciplinary team as a point of 

contact who will directly collaborate 

with hospice to coordinate effective 

patient care sufficiently, addresses the 

commenter’s suggestion. Likewise, 

current hospice regulations 

(§ 418.112(e)(1)) require the designation 

of a person who is responsible for 

coordinating the care of the resident 

provided by the LTC facility and 

hospice staff. 

Comment: One commenter stated that 

SNFs and NFs should provide hospice 

services to residents in their facilities 

and there should be reimbursement for 

the care. 

Response: The current regulations do 

not prohibit an LTC facility from 

providing palliative care to its residents 

with its own staff. However, we do not 

have the statutory authority to modify 

LTC facility payments to include the 

full range of hospice services. In 

addition, in order to receive Medicare 

payment for hospice services, the 

hospice provider must meet Medicare 

hospice requirements, including the 

statutory requirement that a hospice be 

primarily engaged in providing the 

hospice care and services set out at 

section 1861(dd)(1) of the Act. 

Therefore, under the above statutory 

requirements an LTC facility could not 

receive Medicare hospice benefit 

payments because it is not primarily 

engaged in providing hospice services 

and does not meet the definition of a 

hospice. If a provider does not meet the 

definition of a ‘‘hospice’’ it cannot be 

Medicare-certified and therefore, cannot 

receive payment under the Medicare 

hospice benefit. 

Comment: One commenter mentioned 

that they disagreed with the increased 

responsibility that the proposed rule 

placed on LTC facilities. Another 

commenter suggested that the focus of 

the proposed rule was incorrect. Rather 

than the expense and additional 

regulation that the proposed rule would 

generate, the commenter would like 

each State to provide the guidance for 

facilities desiring to provide hospice 

services. 

Response: We do not believe that the 

written agreement and resident care 

requirements increase an LTC facility’s 

responsibilities. An LTC facility’s 

responsibilities for the care of its 

residents already exist in regulation at 

§ 483.25, which states that ‘‘each 

resident must receive and the facility 

must provide the necessary care and 

services to attain or maintain the highest 

practicable physical, mental, and 

psychosocial well-being, in accordance 

with the comprehensive assessment and 

plan of care.’’ The requirements of this 

final rule simply clarify the roles and 

responsibilities of LTC facilities when 

they choose to contract with hospices to 

serve their residents. For more than a 

decade, States have regulated the 

overlapping relationship between LTC 

facilities and hospice providers. As we 

explained in the proposed rule, there is 

clear and consistent evidence of a lack 

of care coordination and persistent 

ambiguities in care responsibilities 

when LTC residents are also hospice 

patients. Both a 2002 Department of 

Health and Human Services’ (DHHS) 

Advisory Committee Report (http:// 

regreform.hhs.gov/finalreport.htm) and 

a 2003 Hastings Center Report (True 

Ryndes, Linda Emanuel, The Hastings 

Center Report, Hastings-on-Hudson: 

March/April 2003, page S45) addressed 

the need for more care coordination. We 

believe it is in the best interest of the 

patients to regulate this overlapping 

relationship in order to improve the 

safety and quality of care provided to 

LTC residents who receive hospice 

services. Information gathered from 

surveys in both LTC facilities and 

hospice providers has informed our 

policy making for this rule. 

Furthermore, as this regulation is a 

companion rule to the current hospice 

CoPs, the industry has voiced support 

for this rule because it clarifies the 

responsibilities of both providers. 

Comment: One commenter questioned 

how this rule affects hospice provision 

in other types of facilities in which an 

individual may reside (for example, 

Intermediate Care Facilities for 

Individuals with Intellectual Disabilities 

(ICFs/IID), formerly referred to as ICFs/ 

MR). The commenter asked if the 

exclusion of other facilities, for example 

ICFs/IID, implies that a State could not 

provide the hospice benefit, or does it 

imply that a State has the option to 

provide hospice? 

Response: This regulation specifically 

clarifies the responsibilities of LTC 

facilities and hospice providers that 

choose to have in place a written 

agreement for hospice services. 

Therefore, the requirements in this rule 

will only apply to LTC facilities. 

However, we believe the commenters 

concerns regarding hospice services in 

ICFs/IID are addressed in the current 

hospice regulations. Section 418.112(c) 

‘‘Written agreement,’’ sets forth the 

requirements for a written agreement 

between hospice and ICFs/IID. Since 

this regulation only affects LTC facilities 

we did not intend to imply anything 

regarding the State’s ability to provide 

hospice services. 

Notice of Availability of Hospice 

Services 

We proposed a new standard at 

§ 483.75(r), titled ‘‘Hospice services.’’ At 

§ 483.75(r)(1), we proposed that LTC 

facilities could either arrange for the 

provision of hospice services through an 

agreement with one or more Medicarecertified hospice providers or not 

arrange for such services and assist a 

resident in transferring to a facility that 

would arrange for the provision of these 

services when the resident requested 

such a transfer. 

Comment: Some commenters believed 

LTC facilities should be required to 

provide notice to residents upon 

admission as to whether hospice care 

will be available at the facility along 

with the names of the Medicare-certified 

hospice providers with which the 

facility has agreements. Additionally, 

commenters suggested that LTC 

facilities should also be required to give 

notice to their residents should 

substantial changes occur regarding 

their agreements with Medicarecertified hospice programs. If the facility 

has no agreement for the provision of 

hospice care, commenters suggested that 

the admission notice should explain to 

the resident that hospice care is not 

available at the facility and include 

information regarding the facility’s 

responsibility to assist with transfer 

should the resident become terminally 

ill and wish to elect the hospice benefit. 

Response: We agree with the 

commenters that notifying residents of 

services that an LTC facility provides is 

important. However, we believe that the 

current requirements at § 483.10(b)(6) 

sufficiently address this issue. Section 

483.10(b)(6) currently requires an LTC 

facility to inform each resident before, 

or at the time of admission, and 

periodically during the resident’s stay, 

of all services available in the facility. 

From past experience with LTC 

facilities, we would assume that 

information regarding available hospice 

services would be discussed at the time 

in which the resident wishes to utilize 

the hospice benefit. 

Additionally, while it is uncommon 

for residents to enter an LTC facility and 

have need of hospice services right 

away, it can sometimes occur. A 

resident transferring into an LTC facility 

with the intention of using his or her 

hospice benefit right away is more than 

likely either being discharged from a 

hospital, or already receiving hospice 

care at home and in need of care in an 

LTC facility because the caregiver can 

no longer meet the individual’s 


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custodial care needs. In the event that 

the resident is being discharged from a 

hospital and entering an LTC facility 

opting to use their hospice benefit, the 

hospital would be responsible for 

developing an appropriate discharge 

care plan to an LTC facility that 

provides hospice services. If the 

resident is already receiving hospice 

services at home and chooses to move 

to an LTC facility, the hospice, through 

its medical social services, would assist 

the individual and family in selecting 

an appropriate LTC facility with a 

hospice agreement. 

Timeliness of Service 

At § 483.75(r)(2)(i) and (ii), we 

proposed specific requirements for LTC 

facilities choosing to have hospice care 

provided by a Medicare-certified 

hospice in their facility. The LTC 

facility would be required to ensure that 

the hospice services met professional 

standards and principles that would 

apply to individuals providing services 

in the facility, and the timeliness of the 

services. We also proposed requiring 

that, before any hospice care was 

provided to a facility resident, a written 

agreement would have to be signed by 

both an individual authorized by the 

hospice administration and an 

individual authorized by the LTC 

facility administration. 

Comment: Seven commenters 

recommended that we clarify the 

meaning of ‘‘timeliness of services.’’ 

Commenters also suggested that the 

interdisciplinary team be responsible for 

ensuring that the hospice provider is 

meeting the requirements. Another 

commenter suggested that the proposed 

requirement was duplicative of existing 

conditions of participation (CoPs) for 

LTC facilities and should be deleted 

from the final rule. 

Response: The term, ‘‘timeliness of 

services’’ means that the LTC facility 

will be required to ensure that the 

Medicare-certified hospice will provide 

services to the resident in a way that 

meets their needs in a timely manner, 

for example, by increasing the resident’s 

pain medication to ensure an optimal 

comfort level. We anticipate that LTC 

facilities will address timeliness of 

services in their agreements with 

hospices, based on resident needs. 

Although the existing LTC facility 

standard at § 483.75(h)(2)(ii) requires 

the facility to assure the timeliness of 

the current services that an LTC facility 

provides, this provision does not 

specifically apply to the content of 

written agreements for hospice services. 

Therefore, the requirement at 

§ 483.75(t)(2)(i) is not duplicative. We 

are finalizing the language as proposed. 

Services and Responsibilities of Hospice 

Plan of Care 

We proposed under 

§ 483.75(r)(2)(ii)(A) through 

§ 483.75(r)(2)(ii)(D) that the written 

agreement include, at least, descriptions 

of the services the hospice will provide; 

the hospice’s responsibilities for 

determining the appropriate hospice 

plan of care as specified in § 418.112(d); 

the services the LTC facility would 

continue to provide, based on each 

resident’s care plan; and a 

communication process, including how 

the communication will be documented 

between the LTC facility and the 

hospice provider, to ensure that the 

needs of the resident were addressed 

and met 24 hours per day. 

Comment: One commenter suggested 

that it would be helpful if there was a 

standardized communication form that 

hospice providers and LTC facilities 

could use to inform each other of new 

orders and changes, and if it indicated 

whether or not the primary physician 

and family member had been notified. 

Another commenter suggested that the 

facility document family engagement, 

consent, acknowledgement of an 

agreement with the patient’s care plan, 

and any changes requested by the 

patient or their family in the patient’s 

medical record. This would assist the 

family and the caregivers in identifying 

when there was a deviation from the 

plan of care. 

Response: The written agreements 

between the hospice and the LTC 

facilities require communication 

between the two entities regarding the 

provision of care to the resident 

receiving hospice services. The LTC 

facility and hospice must collaborate on 

how they will communicate information 

regarding the resident’s care and staff 

must be aware of the system and/or 

form for communication that will be 

used. The development of a system and/ 

or form for communication is the 

responsibility of the hospice and LTC 

facility. Additionally, we believe that 

the commenter’s suggestion regarding 

documentation in the resident’s medical 

record is sufficiently addressed at 

§ 483.75(l)(5). That requirement sets 

forth the information LTC facility 

clinical records must contain. 

Comment: One commenter suggested 

that CMS update the instructions used 

by the State Agencies responsible for 

LTC facility survey and certification to 

ensure that sufficient emphasis is 

placed on surveyor review of a facility’s 

clinical and administrative 

documentation. The commenter stated 

that this update would assure proper 

communication between all caregivers, 

regardless of their employer, and that 

issues of concern expressed in that 

documentation would be appropriately 

addressed by the LTC facility and other 

providers serving the facility’s residents. 

Response: We appreciate the 

commenter’s suggestion regarding 

updates for surveyors. We expect 

shortly after the publication of the rule 

that updates to the State Operations 

Manual (SOM), which among other 

things provides interpretive guidelines 

for our surveyors, will be made 

regarding the new requirements. The 

instructions to surveyors for reviewing 

the care of a resident receiving hospice 

services are found in the interpretive 

guidelines for § 483.25, ‘‘Quality of 

Care.’’ (TAG #F309 in Appendix PP of 

the SOM). This guidance provides 

instruction for the surveyor for the 

review and observation of the delivery 

of care, and for the review of the 

collaboration of the services between 

the hospice and the nursing home, 

including the coordination of care, the 

plan of care and the communication 

between the two entities. 

Notifying Hospice of Change in Patient 

Status 

Under § 483.75(r)(2)(ii), we proposed 

the inclusion of other duties and 

responsibilities that must be delineated 

by the LTC facility and the hospice in 

their written agreement. Under 

§ 483.75(r)(2)(ii)(E), we proposed that 

the agreement contain a provision that 

the LTC facility notify the hospice 

provider immediately regarding a 

significant change in the resident’s 

physical, mental, social, or emotional 

status, any clinical complication(s) that 

suggests a need to alter the plan of care, 

a condition unrelated to the terminal 

condition that might require transfer of 

the resident from the facility, or the 

resident’s death. 

Comment: A few commenters stated 

that hospice providers should be 

notified of any transfer of a resident 

receiving hospice services, regardless of 

whether it was related to the terminal 

illness or not. Therefore, commenters 

suggested amending the rule to read, ‘‘a 

need to transfer the resident from the 

facility for any condition.’’ 

Response: We agree with the 

commenters and have revised the 

regulation at § 483.75(t)(2)(ii)(E)(3) to 

remove the phrase ‘‘that is not related to 

the terminal condition’’ in order to 

clarify that the LTC facility immediately 

notifies the hospice regarding a need to 

transfer the resident from the facility for 

any condition. 


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Appropriate Level of Hospice Services 

We proposed at § 483.75(r)(2)(ii)(F) 

that the hospice assume responsibility 

for determining the appropriate course 

of hospice care, including the 

determination to change the level of 

services provided. 

Comment: One commenter stated that 

there was often disagreement between 

hospice staff and LTC facility staff due 

to hospice providers changing orders 

unrelated to the terminal diagnosis and/ 

or palliative care. In addition, the 

commenter stated that hospice 

providers did not always provide 

rationale for changed orders. Another 

commenter expressed difficulty 

receiving information from local 

hospice providers in a timely manner; 

therefore, the commenter thought that 

this requirement would be difficult to 

fulfill. 

Response: In accordance with the 

hospice regulations at § 418.112(c)(3), 

the hospice is responsible for 

establishing and updating the hospice 

plan of care, which encompasses all 

issues related to the terminal illness and 

all related conditions. We encourage 

LTC facilities and hospices to establish 

procedures for communicating patient 

care between both providers, more 

specifically to determine which 

provider is responsible for the care 

planning. For example, both hospice 

staff and LTC facility staff need to be 

aware of conditions related to the 

resident’s terminal illness, which are 

handled under the hospice’s care 

planning. Additionally, they need to be 

aware of conditions not related to the 

resident’s terminal illness, which are 

handled under the LTC facility’s care 

planning. Effective communication 

among both LTC facilities and hospices 

is, we believe, the most appropriate way 

for both providers to address this issue. 

The regulations for the written 

agreements for the hospice regulations 

at § 418.112(c)(1) and the LTC facility 

regulations at § 483.75(t)(2)(ii)(D) 

require both entities to establish, in 

writing, the manner in which they are 

to communicate with one another, and 

the method(s) that will be used to 

document such communications. 

Continuation of Appropriate Resident’s 

Needs 

We proposed at § 483.75(r)(2)(ii)(G) 

that the LTC facility must continue to 

provide 24-hour room and board care, 

meet the resident’s personal care and 

nursing needs in coordination with the 

hospice representative, and ensure that 

the level of care provided is appropriate 

based on the individual resident’s 

needs. 

Comment: A commenter stated that 

most hospice care, whether in the home 

or in an LTC facility, is provided at the 

routine level of care. If an LTC resident 

elects the Medicare hospice benefit and 

is receiving a routine level of care, 

Medicare does not pay for the resident’s 

room and board. This billing caveat 

frequently creates a great deal of 

confusion for Medicare beneficiaries 

and their families. One commenter 

suggested that before the start of hospice 

care in the LTC facility and the 

consequent financial liability of the 

Medicare beneficiary for the cost of the 

room and board, the LTC facility should 

be required by regulation to provide 

notice to the beneficiary clearly 

explaining the liability for room and 

board and the estimated cost of that 

liability. 

Response: At § 418.52(c)(7) of the 

hospice CoPs, hospice providers are 

required to ensure that residents receive 

information about the services covered 

under the hospice benefit. Likewise, 

§ 483.10(b)(6) of the LTC facility 

regulations, require LTC facilities to 

inform each resident before, or at the 

time of admission, and periodically 

during the resident’s stay, of services 

available in the facility and of charges 

for those services, including any charges 

for services not covered under Medicare 

or by the facility’s per diem rate. 

Therefore, we believe that the current 

LTC and hospice regulations address the 

concerns of the comments. 

Additional Hospice Responsibilities 

At § 483.75(r)(2)(ii)(H), we proposed 

that the written agreement include a 

delineation of additional hospice 

responsibilities, which would include, 

but not be limited to, providing medical 

direction and management of the 

patient; nursing; counseling (including 

spiritual, dietary, and bereavement); 

social work; and the provision of 

medical supplies, durable medical 

equipment, and drugs necessary for the 

palliation of pain and symptoms 

associated with the terminal illness and 

related conditions. In addition, the 

written agreement would delineate all 

other hospice services that would be 

necessary for the care of the resident’s 

terminal illness and related conditions. 

Comment: Several commenters had 

concerns with the lack of clarity as to 

whether the LTC facility or the hospice 

provider would take the lead as the 

primary decision maker. Two 

commenters suggested that the 

attending physician maintain oversight 

of care of the resident and ensure that 

the care providers are in compliance 

with the documented plan in the 

patient’s medical record. One 

commenter also stated that the hospice 

medical director should serve as a 

consultant and advisor to correct 

problems with the delivery of hospice 

services by LTC facility personnel. 

Another commenter suggested that only 

one physician should approve or 

disapprove all documented orders for 

patient care and that doctor must be 

credentialed in the LTC facility. 

Response: There is no Federal 

regulation precluding the LTC staff from 

taking orders for care from the hospice 

physician regarding a resident’s 

terminal illness and related condition. 

The written agreement should identify 

how the LTC staff communicate and 

receive orders from the hospice 

physician in relation to the terminal 

care. 

The hospice regulations at 

§ 418.112(c)(3) through § 418.112(c)(7) 

describe the role of the hospice in caring 

for an LTC resident. The hospice is 

responsible for all decisions related to 

the care provided for the terminal 

illness and related conditions. The LTC 

facility maintains responsibility for all 

other care decisions. In accordance with 

the requirements at § 418.56(c)(2), 

hospices are responsible for 

communicating with the patient/ 

resident, family members, and attending 

physician at all points during the 

decision-making process to develop and 

update the content of the hospice plan 

of care. The hospice medical director, as 

the individual responsible for the 

medical component of the hospice’s 

patient care program, is available to 

provide expertise in all necessary cases. 

In addition, hospices are required to 

provide physician services (§ 418.64(a)) 

in conjunction with the patient’s 

attending physician to manage the 

patient’s hospice care and to provide 

additional non-hospice physician 

services when the patient’s attending 

physician is not available. Therefore, we 

believe care coordination is explicit in 

the regulation. 

Comment: One commenter suggested 

that the reference to ‘‘all other hospice 

services that are necessary . . .’’ in 

§ 483.75(r)(2)(ii)(H) of the proposed rule 

should be elaborated to include ‘home 

health aide/nursing assistant services 

and therapy.’ The commenter noted that 

these services have posed the biggest 

challenges regarding determination of 

responsibility. For example when the 

hospice plan of care has included 

placement of a home health aide/ 

nursing assistant in the facility, the 

entities have been confused regarding 

their obligations for personal care. 

Response: We understand the 

commenter’s concern with the 

abbreviated list not including all 


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possible services that the hospice would 

provide. We do not view those services 

not listed as less important, however, 

the list of services provided is an 

abbreviated list; we did not intend it to 

be all-inclusive. Hospice is responsible 

for providing all hospice services 

including the provision of hospice aide 

services, if these services are 

determined necessary by the 

Interdisciplinary Group (IDG) to 

supplement the nurse aide services 

provided by the facility. In entering into 

a written agreement with each other, 

each provider clearly delineates 

responsibilities for the quality and 

appropriateness of the care it provides 

in accordance with their respective laws 

and regulations. Both providers must 

comply with their applicable conditions 

or requirements for participation in the 

Medicare and/or Medicaid programs. 

The facility’s services must be 

consistent with the plan of care 

developed in coordination with the 

hospice, and the facility must offer the 

same services to its residents who have 

elected the hospice benefit as it 

furnishes to its residents who have not 

elected the hospice benefit. Therefore, 

the hospice patient residing in a facility 

should not experience any lack of 

services or personal care because of his 

or her status as a hospice patient. 

Administration of Prescribed Therapies 

We proposed at § 483.75(r)(2)(ii)(I) 

that the agreement include a provision 

that the hospice may use LTC facility 

personnel, where permitted by State law 

and as specified by the LTC facility, to 

assist in the administration of 

prescribed therapies included in the 

hospice plan of care. We did not receive 

any comments on this proposal. 

Therefore, we are adopting it in this 

final rule without change. 

Abuse 

We proposed at § 483.75(r)(2)(ii)(J) 

that the written agreement contain a 

provision that the LTC facility report all 

alleged violations involving 

mistreatment, neglect, or verbal, mental, 

sexual, and physical abuse, including 

injuries of unknown source, and 

misappropriation of patient property by 

hospice personnel, to the hospice 

administrator immediately when the 

LTC facility becomes aware of the 

alleged violation. 

Comment: One commenter believed 

that the proposed rule lacked direction 

in reporting alleged abuse and what the 

LTC facility’s liability would be if the 

situation was not corrected and 

documented within the patient’s 

records. The commenter suggested that 

the final rule require that a resolution 

process be documented in the patient’s 

care plan, enabling those who are 

accountable for the care of the patient to 

be aware of their roles and 

responsibilities as well as increasing 

patient safety and improving quality of 

care. 

Response: The written agreement 

specifies that the LTC facility must 

report alleged violations by hospice 

personnel to the hospice administrator 

immediately when the LTC facility 

becomes aware of the alleged violation. 

This is to assure that the hospice 

administrator is not only aware of the 

alleged violation, but also begins an 

investigation as required in the hospice 

CoPs at § 418.52(b)(4). We disagree with 

the commenter’s suggestion regarding 

reporting alleged abuse in the resident’s 

plan of care. The plan of care is a 

treatment plan that is developed 

according to the needs of the residents 

upon admission. Changes to the plan of 

care are made according to changes in 

the resident’s condition and treatment 

needs. Moreover, the LTC facility must 

follow our regulations at § 483.13(c), 

‘‘Staff Treatment of Residents,’’ which 

require the facility to protect its 

residents from abuse; to identify, 

investigate, and report any alleged 

violations; and to take appropriate 

corrective action. Additionally, 

§ 483.13(c) currently includes 

requirements for abuse documentation; 

therefore it would be duplicative to 

include an additional requirement in 

this final rule. 

Bereavement Services 

We proposed at § 483.75(r)(2)(ii)(K) 

that the agreement also include a 

delineation of the responsibilities of the 

hospice and the LTC facility to provide 

bereavement services to LTC facility 

staff. 

Comment: Several commenters had 

concerns with this requirement in the 

proposed rule. One commenter 

suggested that the requirement should 

be removed, stating that the hospice 

agency should not be held responsible 

for providing bereavement counseling 

for LTC facility staff. It was suggested 

instead that LTC facilities should be 

held responsible for providing 

bereavement counseling for their own 

staff members. A few commenters 

requested additional information to be 

added regarding the duration and 

location of the services and whether 

one-on-one or group services would be 

acceptable. Additionally, commenters 

requested information clarifying which 

hospice would be responsible for 

providing the services in an LTC facility 

in the event that the facility contracts 

with more than one hospice for services. 

Response: We understand the 

concerns expressed by the commenter 

regarding the removal of the 

bereavement requirement for hospices. 

However, this requirement is consistent 

with hospice requirements at 

§ 418.112(c)(9) and changes to the 

hospice regulations are beyond the 

scope of this regulation. The agreement 

between the hospice and the LTC 

facility should detail how the services 

will be coordinated and provided by the 

hospice provider for the LTC staff. The 

bereavement services are based upon 

the relationship between the care 

provider and the hospice resident. The 

hospice and the LTC facility should 

collaborate and communicate in order to 

determine which LTC staff will benefit 

from the bereavement services. In the 

cases of several hospices offering 

services in a facility, the individual 

hospice and the facility, as noted above, 

should review and identify those LTC 

staff who will benefit from the 

bereavement services. This should be 

individualized based on the resident 

involved and the staff involvement in 

their care. The agreement will identify 

how this service will be implemented 

by the certified hospice. Since the 

proposed language reflects the 

requirement already in hospice CoPs, 

we are not making any changes to the 

current language. Rather, we believe it 

should stay consistent with the current 

hospice regulation at § 418.112(c)(9). 

Interdisciplinary Team Member 

At § 483.75(r)(3)(i) through (v), we 

proposed that the LTC facility that 

arranges for the provision of hospice 

care under a written agreement 

designate a member of the facility’s 

interdisciplinary team to be responsible 

for working with hospice 

representatives to coordinate care 

provided by the LTC facility and 

hospice staff to the resident. This 

individual must be responsible for—(1) 

Collaborating with hospice 

representatives and coordinating LTC 

facility staff participation in the hospice 

care planning process for those 

residents receiving these services; (2) 

communicating with hospice 

representatives and other healthcare 

providers participating in the provision 

of care for the terminal illness, related 

conditions, and other conditions to 

ensure quality of care for the patient and 

family; (3) ensuring that the LTC facility 

communicates with the hospice medical 

director, the patient’s attending 

physician, and other physicians 

participating in the provision of care to 

the patient as needed to coordinate the 

hospice care of the hospice patient with 

the medical care provided by other 


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physicians; (4) obtaining pertinent 

information from the hospice including 

the most recent hospice plan of care 

specific to each patient; hospice election 

form; physician certification and 

recertification of the terminal illness 

specific to each patient; names and 

contact information for hospice 

personnel involved in hospice care of 

each patient; instructions on how to 

access the hospice’s 24-hour on-call 

system; hospice medication information 

specific to each patient; and hospice 

physician and attending physician (if 

any) orders specific to each patient); and 

(5) ensuring that the LTC facility staff 

provides orientation in the policies and 

procedures of the facility, including 

patient rights, appropriate forms, and 

record keeping requirements, to hospice 

staff furnishing care to LTC residents. 

Comment: The majority of the 

commenters supported the requirement 

designating a member of the LTC 

facility’s interdisciplinary team to be 

responsible for working with hospice 

representatives to facilitate the 

coordination of care. A few commenters 

however, were unsure if the designation 

of the facility’s interdisciplinary team 

member required a specific person by 

name or designation of a specified staff 

position and/or discipline. One 

commenter suggested the final rule 

specify the LTC representative be 

someone with a clinical background, 

possibly a registered nurse (RN), as well 

as credentialed in the nursing facility. 

Response: We agree with commenters 

that the LTC representative should be an 

employee of the facility with a clinical 

background. However, we do not want 

to limit LTC facilities’ clinical personnel 

options solely to a professional 

registered nurse. The responsibilities of 

the interdisciplinary team member 

could be fulfilled by other clinicians 

participating in the care of the resident. 

We believe that by limiting the 

interdisciplinary team member to only a 

registered nurse, staffing issues may 

arise in addition to the possibility of 

increasing burden on the facility. In 

light of the complex clinical needs of a 

resident who is in the terminal stages of 

life, we believe it would be beneficial 

for the interdisciplinary team member to 

have the ability to assess the resident or 

have access to someone that has the 

ability to assess the resident. We are not 

requiring the person assessing the 

resident to be on the LTC facility staff: 

for example, it could be the hospice RN 

that is required to be available 24 hours. 

Therefore, we have revised the 

regulation at § 483.75(t)(3) to clarify that 

the LTC representative must have a 

clinical background, function within 

their State scope of practice act, and 

have the ability to assess the resident or 

have access to someone that has the 

skills and capabilities to assess the 

resident. 

Comment: One commenter requested 

additional information regarding how a 

hospice program can best incorporate 

the LTC interdisciplinary member into 

the IDG. This commenter also wanted to 

know if this requirement would 

mandate that the interdisciplinary 

member directly participate in the 

hospice IDG meetings. 

Response: In accordance with 

§ 418.56(d), the hospice 

interdisciplinary group is required to 

update the hospice plan of care no less 

frequently than every 15 calendar days. 

The hospice interdisciplinary group 

must include specified core members; 

however, it is not limited to those core 

members. Rather, it is our expectation 

that all licensed professionals who 

participate in a patient’s care will give 

input to the interdisciplinary group 

(§ 418.62(b)). Furthermore, the hospice 

is required to have a system of 

communication that ensures the 

ongoing sharing of information with 

non-hospice providers that are caring 

for a patient (§ 418.56(e)(5)). Finally, the 

hospice is specifically required to 

designate an individual from each 

interdisciplinary group that is 

responsible for a patient that resides in 

an LTC facility to act as a communicator 

and coordinator with the LTC 

representatives. In addition, the LTC 

facility is specifically required to 

designate an individual to coordinate 

with the hospice representatives. The 

regulation doesn’t stipulate that the 

facility staff coordinator directly 

participate in the hospice care planning 

meeting, but it does not preclude them 

from attending. The LTC facility and 

hospice must work out the arrangements 

on how needed information for care 

planning and the delivery of care and 

services will be coordinated and 

provided based upon the needs of the 

resident. 

Comment: One commenter has 

expressed concern with the requirement 

of the LTC facility interdisciplinary 

team member obtaining hospice 

medication information specific to each 

patient. An LTC pharmacy may 

experience difficulty with billing 

hospice medications to the correct payer 

without the appropriate notification by 

either the hospice provider or the LTC 

facility. This includes information as to 

whether the medication is ‘‘related to’’ 

the terminal illness, and the patient’s 

insurance information. Because 

payment for medications not related to 

the terminal illness is the responsibility 

of the hospice patient or secondary 

payer, it is critical for the LTC pharmacy 

to have correct information. Generally, 

when an LTC facility resident elects 

hospice care, the LTC facility will 

typically have more information on the 

patient’s secondary insurance coverage. 

Because the hospice provider may not 

know the pharmacy contact information 

for each resident, it is only logical that 

notification by the LTC facility to the 

pharmacy seems most appropriate. 

Having specific regulatory language that 

would make the LTC facility aware of 

this requirement is needed to avoid the 

potential for inappropriate billing. The 

commenter recommends that the LTC 

facility be responsible for obtaining 

medication information from the 

hospice, and that the notification be 

communicated among the hospice 

provider, the LTC facility, and the 

pharmacy within 1 business day of any 

admission, discharge or any change in 

the patient’s medications or payer 

status. 

Response: We agree with the 

commenter that it is the responsibility 

of the LTC facility to obtain medication 

information from the hospice provider, 

and we believe that this concern has 

already been addressed in the 

regulations (see § 483.75(t)(3)(iv)(F)). 

Further, § 483.75(t)(3)(iv) clarifies what 

information the designated member of 

the LTC facility’s interdisciplinary team 

is responsible for obtaining from the 

hospice provider, including, medication 

information as set out at 

§ 483.75(t)(3)(iv)(F)). Also, we expect 

that the LTC facility’s designated 

member of the interdisciplinary team 

would appropriately communicate 

medication information and would 

identify the payer source for a resident 

before a change in their medical 

condition. 

After carefully considering how 

resident information is communicated 

between the hospice and the LTC 

providers, we are making a change in 

the regulations text at § 483.75(t)(3)(iii) 

regarding who is responsible for 

communicating with the hospice about, 

among other things, the resident’s 

medication orders. We are replacing the 

phrase, ‘‘other physicians’’ with ‘‘other 

practitioners’’ to encompass all other 

non-physician personnel such as an 

advanced practice registered nurse 

(APRN), licensed therapist, or 

pharmacist, in accordance with State 

law and scope of practice participating 

in the provision of care to the patient. 

We believe that this will address the 

commenter’s concerns. 

Comment: The majority of 

commenters agreed with the 

requirement that the LTC facility 

provide a written overview for 


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38602 Federal Register / Vol. 78, No. 124 / Thursday, June 27, 2013 / Rules and Regulations 

orientation on the policies and 

procedures of the facility to hospice 

staff furnishing care to LTC residents. 

One commenter suggested that the 

information be standardized and readily 

available in electronic format 

throughout all facilities in order for 

hospice staff to have access to quick and 

concise training. Another commenter 

suggested the overview address high 

priority regulatory and care related 

issues including facility layout with a 

tour of the facility, abuse and/or neglect 

prohibition and reporting policies and 

procedures, fire safety, infection control, 

falls prevention, and internal 

communications processes. Another 

commenter suggested that the facilitybased orientation overview should be 

reviewed and signed by hospice staff 

before provision of care and services to 

residents electing the hospice benefit. A 

commenter also suggested that a list of 

the services the facility would anticipate 

from the hospice would also help in 

focusing the orientation. 

Response: We appreciate the 

suggestion offered by the commenter 

regarding a standardized electronic 

format to facilitate training of hospice 

staff. This regulation does not preclude 

LTC facilities from using a standardized 

electronic format for their hospice 

orientation. Therefore, we believe that 

the proposed language at 

§ 483.75(t)(3)(v) provides enough 

flexibility to LTC facilities that provide 

orientation to hospice providers on their 

policies and procedures. Although, we 

have not required all of the specific 

elements of an orientation, we expect 

that both the LTC facility and the 

hospice provider will ensure 

appropriate orientation, including an 

outline of services that the hospice will 

provide, before the provision of care. 

Comment: One commenter stated that 

cross orientation would increase the 

quality of patient care, therefore, it was 

suggested that language from the 

hospice regulation at § 418.112 be added 

to the proposed rule to ensure that LTC 

staff furnishing care to hospice patients 

will also be oriented to the hospice 

procedures and policies. 

Response: The regulations for the 

written agreements between the LTC 

facility and a hospice provide for 

orientation from the perspective of each 

entity. The SNF/NF orientation is meant 

to address the overall facility 

environment including policies, rights, 

record keeping and forms requirements. 

The hospice regulations at § 418.112(f) 

require hospices to assure that LTC 

facility staff are educated about the 

hospice philosophy, hospice policies 

and procedures, principles of death and 

dying, individual responses to death, 

hospice patient rights, and paperwork 

requirements. The orientation 

requirements, while separate regulations 

for both the LTC facility and Medicare 

Certified Hospice, should be a 

collaborative effort between the hospice 

and the LTC facility, to assure that the 

hospice employees provide services and 

care effectively in the LTC facility and 

that the hospice ensures that the LTC 

facility staff understands the basic 

philosophy and principles of hospice 

care. We believe that the requirement at 

§ 483.75(t)(4)(v) is sufficient; therefore, 

we are finalizing this requirement as 

proposed. 

Plan of Care 

At § 483.75(r)(4), we proposed that 

each LTC facility providing hospice care 

under a written agreement ensure that 

each resident’s written plan of care 

includes both the hospice plan of care 

and a description of the services 

furnished by the LTC facility to attain or 

maintain the resident’s highest 

practicable physical, mental, and 

psychosocial well-being, as required at 

§ 483.20(k). 

Comment: Some commenters 

suggested that the regulation be changed 

to mirror the State Operations Manual 

(SOM) which states, ‘‘Highest 

practicable physical, mental, and 

psychosocial well-being is defined as 

the highest possible level of functioning 

and well-being, limited by the 

individual’s recognized pathology and 

normal aging process.’’ 

Response: We do not agree that this 

regulation should include the language 

that mirrors the definition in the SOM. 

The interpretive guidelines in the SOM 

are subject to more frequent informal 

changes based on the regulatory text of 

a final rule. Therefore, we will not 

change the language in the regulation. 

Comment: One commenter suggested 

deleting the requirement for LTC 

facilities to have the most recent 

hospice care plan in its possession. LTC 

facilities would not know when the 

hospice revised its care plan and would 

rely on hospice staff to provide the 

updated care plan. The LTC facility 

should not be held responsible for not 

having it in place. It should be the 

obligation and compliance requirement 

for hospice. Therefore, if hospice staff 

failed to provide the most current plan 

of care, the LTC facility would not be 

held responsible. 

Response: At § 418.112(e)(3)(i) of the 

hospice regulations, hospices are 

required to provide the LTC facility 

with the most recent hospice plan of 

care for each patient. To ensure that all 

care providers are performing their 

duties in accordance with the most 

recent plan, it is appropriate to require 

the LTC facility to include the most 

recent plan of care in its files. If an LTC 

facility has reason to believe that the 

plan of care in its possession is out of 

date, it is incumbent upon the LTC 

facility to seek out the most recent 

information. The intent of this 

regulation is to ensure coordination of 

care between the hospice and LTC 

facility. We would expect, through this 

coordination that the LTC facility would 

always have the most current hospice 

plan of care. 

Comment: While the majority of the 

commenters supported the written 

agreement, some commenters had 

concerns about the lack of clear 

regulatory direction regarding the 

responsibilities of the LTC facility and 

the hospice provider and requested 

clarification regarding the requirement 

for two plans of care. There was concern 

that medical errors that could result 

from a requirement for two plans of care 

for patients electing to use the hospice 

benefit along with the subsequent 

increase in possible transitions and 

transfer. Commenters believed that 

dividing medical care duties and 

services between two facilities will open 

the door for medical malpractice and 

further the chances for neglect of health 

care and safety and continue to 

exacerbate the lack of coordination 

between hospice and LTC providers. 

Response: Having a written agreement 

that clearly delineates roles, 

responsibilities, expectations, and 

communication strategies should 

enhance, rather than impede, the 

coordination of care. This rule, when 

paired with the hospice regulatory 

requirements for written agreements, 

required services, and designated 

hospice representatives, will provide 

the overall structure for LTC-hospice 

relationships and written agreements. 

The hospice and LTC facility must 

collaborate to develop a coordinated 

plan of care for each patient that guides 

both providers. When a hospice patient 

is a resident of a facility, that patient’s 

hospice plan of care must be established 

and maintained in consultation with 

representatives of the facility and the 

patient and/or family (to the extent 

possible). The hospice portion of the 

plan of care governs the actions of the 

hospice and describes the services that 

are needed to care for the patient. In 

addition, the coordinated plan of care 

must identify which provider (hospice 

or facility) is responsible for performing 

a specific service. The coordinated plan 

of care may be divided into two 

portions, one of which is maintained by 

the facility and the other by the hospice. 

The facility is required to update its 


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plan of care in accordance with any 

Federal, State or local laws and 

regulations governing the particular 

facility, just as hospices need to update 

their plans of care according to 

§ 418.56(d) of the CoPs. The hospice 

plan of care must specifically identify or 

delineate the provider responsible for 

each function, service, and intervention 

included in the plan of care. The 

providers must have a procedure that 

clearly outlines the chain of 

communication between the hospice 

and facility in the event a crisis or 

emergency develops, a change of 

condition occurs, and/or changes to the 

hospice portion of the plan of care are 

indicated. 

III. Provisions of This Final Rule 

We are adopting the provisions of this 

final rule as proposed, with the 

following changes: 

• We originally proposed the 

standard regarding LTC facility/Hospice 

cooperation at § 483.75(r); however, 

during the process of finalizing this 

rule, CMS published a separate interim 

final rule, Requirements for Long-Term 

Care (LTC) Facilities; Notice of Facility 

Closure (76 FR 9503). The interim final 

rule added standards § 483.75(r) and (s). 

Since the standards at § 483.75(r) and (s) 

are now in use, we are finalizing this 

standard at § 483.75(t). 

• In consideration of public 

comments, we are making three 

substantive changes in this final rule. 

We have made a revision at 483.75(t)(3) 

to clarify that the LTC representative 

must have a clinical background, 

function within their State scope of 

practice act, and have the ability to 

assess the resident or have access to 

someone that has the skills and 

capabilities to assess the resident. We 

have also made a revision to the 

requirement at § 483.75(t)(3)(iii) 

removing the phrase ‘‘other physicians’’ 

and replacing it with ‘‘other 

practitioners.’’ Lastly, we have made a 

revision to the requirement at 

§ 483.75(t)(2)(ii)(E)(3) by removing the 

phrase ‘‘that is not related to the 

terminal condition.’’ 

Technical Correction 

• We are finalizing the proposed 

technical correction which would fix an 

incorrect citation at § 483.10(n). In 

§ 483.10(n), we are revising the 

reference ‘‘§ 483.20(d)(2)(ii)’’ to read 

‘‘§ 483.20(k)(2)(ii).’’ 

• We are also finalizing the proposed 

technical correction which would fix an 

incorrect citation at proposed 

§ 483.75(r)(4). In § 483.75(t)(4), we are 

revising the reference ‘‘483.20(k)’’ to 

read ‘‘483.25.’’ 

IV. Collection of Information 

Requirements 

Under the Paperwork Reduction Act 

of 1995, we are required to provide 30- 

day notice in the Federal Register and 

solicit public comment before a 

collection of information requirement is 

submitted to the Office of Management 

and Budget (OMB) for review and 

approval. In order to fairly evaluate 

whether an information collection 

should be approved by OMB, section 

3506(c)(2)(A) of the Paperwork 

Reduction Act of 1995 requires that we 

solicit comment on the following issues: 

• The need for the information 

collection and its usefulness in carrying 

out the proper functions of our agency. 

• The accuracy of our estimate of the 

information collection burden. 

• The quality, utility, and clarity of 

the information to be collected. 

• Recommendations to minimize the 

information collection burden on the 

affected public, including automated 

collection techniques. 

We solicited public comment on each 

of these issues for the following sections 

of this document that contain 

information collection requirements 

(ICRs): 

Proposed § 483.75(r)(2)(ii) stated that 

if hospice care were to be provided in 

an LTC facility through an agreement 

with a Medicare-certified hospice, the 

LTC facility would have to have a 

written agreement with the Medicarecertified hospice before care was 

furnished to any resident. 

An LTC facility will be required to 

have only one written agreement with 

each hospice that provides services in 

the facility. This final rule will not 

require an LTC facility to have an 

individual agreement with a hospice for 

each resident receiving hospice services. 

Therefore, the burden associated with 

this requirement is the time and effort 

necessary for an LTC facility to develop 

and finalize one written agreement. 

Initially, the development of an 

agreement will require staff time; 

however, it will also require additional 

staff time to coordinate the care between 

the hospice and the LTC facility. 

We estimate the number of hours to 

develop and finalize a written 

agreement to be approximately 5 hours 

the first year. The estimated burden 

associated with the first year is 80,695 

hours or $5,512,275 for the 16,139 LTC 

facilities that would be affected by this 

rule. The current requirements at 

§ 483.75(h) ‘‘Use of Outside Resources,’’ 

requires a written agreement when 

contracting for outside services. 

Therefore, we expect that a facility will 

modify an existing agreement to make it 

specific to hospice services. Review and 

revision of an already existing 

agreement will be expected to take less 

time thereafter. We estimate that it will 

take 2 hours to review and revise the 

agreement annually. The estimated 

annual burden associated with each 

successive year after the first is 32,278 

hours or $2,204,910. We have based our 

projections of the hourly cost on the rate 

for a staff lawyer at $68.31 an hour, 

which includes fringe benefits 

(estimated to be 25 percent of the 

salary). (Source: Bureau of Labor 

Statistics, Occupational Employment 

Statistics Survey.) 

Proposed § 483.75(r)(2)(ii)(E)(1) 

through (4) stated that the LTC would 

have to notify the hospice immediately 

about— 

• A significant change in the 

resident’s physical, mental, social, or 

emotional status; 

• Clinical complications that suggest 

a need to alter the plan of care; 

• A need to transfer the resident from 

the facility for any condition that is not 

related to the terminal condition; or 

• The resident’s death. 

The burden associated with these 

requirements is the time and effort it 

will take the LTC facility to provide 

notification to the hospice. We estimate 

it will take approximately 5 minutes per 

notification. We anticipate that this will 

affect 16,139 LTC facilities. If each LTC 

facility makes one notification each 

month, the burden associated with this 

requirement is 16,139 annual burden 

hours and the cost will be $504,344 

annually, based on an hourly rate of 

$31.25 for a blended salary of a 

registered nurse and licensed practical 

nurse that includes fringe benefits, since 

either practitioner could notify the 

hospice of stated changes. (Source: 

Bureau of Labor Statistics, Occupational 

Employment Statistics Survey). 

Proposed § 483.75(r)(2)(ii)(J) stated 

that under the agreement, the LTC 

facility would be required to report all 

alleged violations involving 

mistreatment, neglect, or verbal, mental, 

sexual, and physical abuse, including 

injuries of unknown source, and 

misappropriation of patient property by 

hospice personnel to the hospice 

administrator immediately when the 

LTC facility becomes aware of the 

alleged violation. The burden associated 

with this requirement is the time and 

effort it will take the LTC facility to 

report this information to the hospice 

administrator. We estimate it will take 

approximately 10 minutes per incident. 

We anticipate that this will affect 16,139 

LTC facilities. If each LTC facility made 

one report per month, the burden 

associated with this requirement will be 


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32,278 annual burden hours and the 

cost would be $1,032,895 annually 

based on an hourly rate of $32 for a 

registered nurse that includes fringe 

benefits. (Source: Bureau of Labor 

Statistics, Occupational Employment 

Statistics Survey.) 

ESTIMATED ANNUAL REPORTING AND RECORDKEEPING BURDEN

Regulation section(s) OMB control No. Respondents Responses 

Burden per 

response 

(hours) 

Total 

annual 

burden 

(hours) 

Hourly 

labor cost 

of 

reporting 

($) 

Total labor 

cost of 

reporting 

($) 

Total 

capital/ 

maintenance 

costs 

($) 

Total cost 

($) 

§ 483.75(r)(2)(ii) ............... 0938—New ..................... 16,139 16,139 5 * 80,695 68.31 5,512,275 0 5,512,275 

16,139 16,139 2 ** 32,278 68.31 2,204,910 0 2,204,910 

§ 483.75(r)(2)(ii)(E)(1–4) .. 0938—New ..................... 16,139 193,668 .08333 16,139 31.25 504,344 0 504,344 

§ 483.75(r)(2)(ii)(J) ........... 0938—New ..................... 16,139 193,668 .16666 32,278 32.00 1,032,895 0 1,032,895 

Total .......................... ......................................... 16,139 209,807 .................. 161,390 .................. .................. .................. 9,254,424 

* One time burden estimate for initial development of written agreement. 

** Annual burden estimate associated with updating existing written agreements. 

The comments we received on this 

proposal and our responses are set forth 

below. 

Comment: A few commenters 

expressed concern about this rule 

creating additional administrative 

burden. One commenter was concerned 

that if the contracting process became 

too burdensome it could reduce 

beneficiary access to the critical services 

being requested. 

Response: The burden associated with 

this requirement is the time and effort 

necessary to develop, draft, sign, and 

maintain the written agreement. The 

hospice regulations at § 418.112 require 

hospices that provide services to LTC 

residents to have written agreements 

with LTC facilities. Furthermore, the 

regulations at § 418.112 require those 

written agreements to include specific 

provisions that are equivalent to the 

specific provisions that were proposed 

for LTC facilities. This requirement has 

been in place for hospices since 

December, 2008. Therefore, LTC 

facilities that currently have 

relationships with hospice providers 

should already have these written 

agreements in place. In addition, we 

believe the use of this type of written 

agreement is a usual and customary 

business practice, and therefore will not 

create additional burden on the facility. 

Comment: Other commenters stated 

that the rule would save money by 

preventing double billing of services 

provided to the patients. 

Response: We appreciate the support 

from commenters who recognized that 

this rule may save money by preventing 

double billing of services to the patients. 

If you have comments on the 

reporting, recordkeeping or third-party 

disclosure requirements contained in 

this final rule, please submit your 

comments to the Office of Information 

and Regulatory Affairs, Office of 

Management and Budget, 

Attention: CMS Desk Officer, [CMS– 

3140–F] 

Fax: (202) 395–6974; or 

Email: 

OIRA_submission@omb.eop.gov. 

V. Regulatory Impact Analysis 

A. Statement of Need 

This final rule will revise the 

requirements that an institution will 

have to meet in order to qualify to 

participate as a SNF in the Medicare 

program, or as an NF in the Medicaid 

program. These requirements will 

ensure that LTC facilities that choose to 

arrange for the provision of hospice care 

through an agreement with one or more 

Medicare-certified hospice providers 

will have in place a written agreement 

with the hospice that specified the roles 

and responsibilities of each entity. 

Additionally, this rule will ensure 

that the duties and responsibilities of a 

hospice are clearly articulated if the 

hospice provides care in an LTC facility. 

Therefore, in order to ensure that 

quality hospice care is provided to LTC 

residents, we believe it is essential to 

add these requirements to the LTC 

regulations. 

B. Overall Impact 

We have examined the impact of this 

rule as required by Executive Order 

12866 on Regulatory Planning and 

Review (September 30, 1993), Executive 

Order 13563 on Improving Regulation 

and Regulatory Review (February 2, 

2011), the Regulatory Flexibility Act 

(RFA) (September 19, 1980, Pub. L. 96– 

354), section 1102(b) of the Social 

Security Act, section 202 of the 

Unfunded Mandates Reform Act of 1995 

(March 22, 1995; Pub. L. 104–4), 

Executive Order 13132 on Federalism 

(August 4, 1999) and the Congressional 

Review Act (5 U.S.C. 804(2). 

Executive Orders 12866 and 13563 

direct agencies to assess all costs and 

benefits of available regulatory 

alternatives and, if regulation is 

necessary, to select regulatory 

approaches that maximize net benefits 

(including potential economic, 

environmental, public health and safety 

effects, distributive impacts, and 

equity). A regulatory impact analysis 

(RIA) must be prepared for major rules 

with economically significant effects 

($100 million or more in any 1 year). 

This rule does not qualify as a major 

rule as the estimated economic impact 

is $7,049,515 the first year and 

$3,742,150, thereafter. 

The RFA requires agencies to analyze 

options for regulatory relief of small 

entities, if a rule has a significant impact 

on a substantial number of small 

entities. For purposes of the RFA, we 

estimate that the great majority of 

hospitals and most other health care 

providers and suppliers are small 

entities, either by being nonprofit 

organizations or by meeting the SBA 

definition of a small business (having 

revenues of less than $7.0 million to 

$34.5 million in any 1 year). For 

purposes of the RFA, the majority of 

hospitals, LTC facilities and hospices 

are considered to be small entities. 

Individuals and States are not included 

in the definition of a small entity. A rule 

has a significant economic impact on 

the small entities if it significantly 

affects their total costs or revenues. 

Under statute, we are required to assess 

the compliance burden the regulation 

will impose on small entities. Generally, 

we analyze the burden in terms of the 

impact it will have on entities’ costs if 

these are identifiable or revenues. As a 

matter of sound analytic methodology, 

to the extent that data are available, we 

attempt to stratify entities by major 

operating characteristics such as size 

and geographic location. If the average 

annual impact on small entities is 3 to 

5 percent or more, it is to be considered 


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significant. We estimate that these 

requirements will cost $437 

($7,049,515/16,139 facilities) per facility 

initially and $232 ($3,742,150/16,139 

facilities) thereafter. This clearly is 

much below 1 percent; therefore, we do 

not anticipate it to have a significant 

impact. We do not have any data related 

to the number of LTC facilities 

contracting hospice care through an 

outside hospice provider; however, we 

are aware through annual surveys that 

not all LTC facilities arrange for the 

provision of hospice care. 

In addition, section 1102(b) of the 

Social Security Act requires us to 

prepare a regulatory impact analysis if 

a rule may have a significant impact on 

the operations of a substantial number 

of small rural hospitals. This analysis 

must conform to the provisions of 

section 604 of the RFA. For the 

purposes of section 1102(b) of the Act, 

we define a small rural hospital as a 

hospital that is located outside of a 

metropolitan statistical area and has 

fewer than 100 beds. This rule will 

impact only LTC facilities. Therefore, 

the Secretary has determined that this 

proposed rule will not have any impact 

on the operations of small rural 

hospitals. 

Section 202 of the Unfunded 

Mandates Reform Act of 1995 (UMRA) 

also requires that agencies assess 

anticipated costs and benefits before 

issuing any rule whose mandates 

require spending in any 1 year of $100 

million in 1995 dollars, updated 

annually for inflation. In 2011, that 

threshold is approximately $136 

million. This rule will not have a 

significant impact on the governments 

mentioned or on private sector costs. 

The estimated economic effect of this 

rule is $7,049,515 the first year and 

$3,742,150 thereafter. These estimates 

are derived from our analysis of burden 

associated with these requirements in 

section III, ‘‘Collection of Information 

Requirements.’’ 

Executive Order 13132 establishes 

certain requirements that an agency 

must meet when it promulgates a 

proposed rule (and subsequent final 

rule) that imposes substantial direct 

requirement costs on State and local 

governments, preempts State law, or 

otherwise has Federalism implications. 

This rule will not have any effect on 

State or local governments. 

C. Anticipated Effects 

1. Effects on LTC Facilities 

The purpose of this rule is to ensure 

the coordination of care for LTC facility 

residents who elect hospice services. 

The coordination of care is anticipated 

to result in better outcomes related to 

quality of care and quality of life for 

residents. With appropriate 

coordination of care, we anticipate 

improved outcomes through more 

efficient coordination of care between 

the LTC facility staff and hospice staff, 

a decrease in duplication of services 

provided, and improved resident care. 

2. Effects on Other Providers 

We expect improved consistency in 

the provision of services to residents 

receiving hospice care in an LTC 

facility. We anticipate that primarily 

LTC facilities and Medicare-certified 

hospice providers will be affected, as 

this rule will be expected to improve 

coordination of care between LTC 

facilities and Medicare-certified hospice 

providers. In instances where a patient 

is transferred to the hospital for care 

unrelated to their terminal illness, the 

hospital should be notified that the 

patient has elected hospice care. 

D. Alternatives Considered 

We considered the effects of not 

addressing specific requirements for the 

provision of hospice care in LTC 

facilities. However, we believe that to 

improve quality and ensure consistency 

in the provision of hospice services in 

LTC facilities, it is important to 

delineate clear responsibilities for 

Medicare-certified hospice providers 

and LTC facilities. We expect that these 

requirements will result in 

improvement in the quality of care 

provided to LTC residents receiving 

hospice services. 

E. Conclusion 

This rule sets out an LTC facility’s 

responsibilities for developing a written 

agreement with a hospice if a resident 

elects to receive hospice care. This rule 

also clarifies the responsibility of the 

facility that chooses not to arrange for 

the provision of hospice services at the 

facility through an agreement with a 

Medicare-certified hospice. These 

facilities must assist the resident in 

transferring to a facility that will arrange 

for the provision of hospice services 

when a resident requests a transfer. 

In accordance with the provisions of 

Executive Order 12866, this regulation 

was reviewed by the Office of 

Management and Budget. 

List of Subjects in 42 CFR Part 483 

Grant programs—health, Health 

facilities, Health professions, Health 

records, Medicaid, Medicare, Nursing 

homes, Nutrition, Reporting and 

recordkeeping requirements, Safety. 

For the reasons set forth in the 

preamble, the Centers for Medicare & 

Medicaid Services amends 42 CFR part 

483 as set forth below: 

PART 483—REQUIREMENTS FOR 

STATES AND LONG TERM CARE 

FACILITIES 

■ 1. The authority citation for part 483 

continues to read as follows: 

Authority: Secs. 1102, 11281, and 1871 of 

the Social Security Act (42 U.S.C. 1302 and 

1395hh). 

Subpart B—Requirements for Long 

Term Care Facilities 

§ 483.10 [Amended] 

■ 2. In § 483.10(n), the reference 

‘‘§ 483.20(d)(2)(ii)’’ is revised to read 

‘‘§ 483.20(k)(2)(ii)’’. 

■ 3. Section 483.75 is amended by 

adding paragraph (t) to read as follows: 

§ 483.75 Administration. 

* * * * * 

(t) Hospice services. (1) A long-term 

care (LTC) facility may do either of the 

following: 

(i) Arrange for the provision of 

hospice services through an agreement 

with one or more Medicare-certified 

hospices. 

(ii) Not arrange for the provision of 

hospice services at the facility through 

an agreement with a Medicare-certified 

hospice and assist the resident in 

transferring to a facility that will arrange 

for the provision of hospice services 

when a resident requests a transfer. 

(2) If hospice care is furnished in an 

LTC facility through an agreement as 

specified in paragraph (t)(1)(i) of this 

section with a hospice, the LTC facility 

must meet the following requirements: 

(i) Ensure that the hospice services 

meet professional standards and 

principles that apply to individuals 

providing services in the facility, and to 

the timeliness of the services. 

(ii) Have a written agreement with the 

hospice that is signed by an authorized 

representative of the hospice and an 

authorized representative of the LTC 

facility before hospice care is furnished 

to any resident. The written agreement 

must set out at least the following: 

(A) The services the hospice will 

provide. 

(B) The hospice’s responsibilities for 

determining the appropriate hospice 

plan of care as specified in § 418.112 (d) 

of this chapter. 

(C) The services the LTC facility will 

continue to provide, based on each 

resident’s plan of care. 

(D) A communication process, 

including how the communication will 

be documented between the LTC facility 

and the hospice provider, to ensure that 


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the needs of the resident are addressed 

and met 24 hours per day. 

(E) A provision that the LTC facility 

immediately notifies the hospice about 

the following: 

(1) A significant change in the 

resident’s physical, mental, social, or 

emotional status. 

(2) Clinical complications that suggest 

a need to alter the plan of care. 

(3) A need to transfer the resident 

from the facility for any condition. 

(4) The resident’s death. 

(F) A provision stating that the 

hospice assumes responsibility for 

determining the appropriate course of 

hospice care, including the 

determination to change the level of 

services provided. 

(G) An agreement that it is the LTC 

facility’s responsibility to furnish 24- 

hour room and board care, meet the 

resident’s personal care and nursing 

needs in coordination with the hospice 

representative, and ensure that the level 

of care provided is appropriately based 

on the individual resident’s needs. 

(H) A delineation of the hospice’s 

responsibilities, including but not 

limited to, providing medical direction 

and management of the patient; nursing; 

counseling (including spiritual, dietary, 

and bereavement); social work; 

providing medical supplies, durable 

medical equipment, and drugs 

necessary for the palliation of pain and 

symptoms associated with the terminal 

illness and related conditions; and all 

other hospice services that are necessary 

for the care of the resident’s terminal 

illness and related conditions. 

(I) A provision that when the LTC 

facility personnel are responsible for the 

administration of prescribed therapies, 

including those therapies determined 

appropriate by the hospice and 

delineated in the hospice plan of care, 

the LTC facility personnel may 

administer the therapies where 

permitted by State law and as specified 

by the LTC facility. 

(J) A provision stating that the LTC 

facility must report all alleged violations 

involving mistreatment, neglect, or 

verbal, mental, sexual, and physical 

abuse, including injuries of unknown 

source, and misappropriation of patient 

property by hospice personnel, to the 

hospice administrator immediately 

when the LTC facility becomes aware of 

the alleged violation. 

(K) A delineation of the 

responsibilities of the hospice and the 

LTC facility to provide bereavement 

services to LTC facility staff. 

(3) Each LTC facility arranging for the 

provision of hospice care under a 

written agreement must designate a 

member of the facility’s 

interdisciplinary team who is 

responsible for working with hospice 

representatives to coordinate care to the 

resident provided by the LTC facility 

staff and hospice staff. The 

interdisciplinary team member must 

have a clinical background, function 

within their State scope of practice act, 

and have the ability to assess the 

resident or have access to someone that 

has the skills and capabilities to assess 

the resident. The designated 

interdisciplinary team member is 

responsible for the following: 

(i) Collaborating with hospice 

representatives and coordinating LTC 

facility staff participation in the hospice 

care planning process for those 

residents receiving these services. 

(ii) Communicating with hospice 

representatives and other healthcare 

providers participating in the provision 

of care for the terminal illness, related 

conditions, and other conditions, to 

ensure quality of care for the patient and 

family. 

(iii) Ensuring that the LTC facility 

communicates with the hospice medical 

director, the patient’s attending 

physician, and other practitioners 

participating in the provision of care to 

the patient as needed to coordinate the 

hospice care with the medical care 

provided by other physicians. 

(iv) Obtaining the following 

information from the hospice: 

(A) The most recent hospice plan of 

care specific to each patient. 

(B) Hospice election form. 

(C) Physician certification and 

recertification of the terminal illness 

specific to each patient. 

(D) Names and contact information for 

hospice personnel involved in hospice 

care of each patient. 

(E) Instructions on how to access the 

hospice’s 24-hour on-call system. 

(F) Hospice medication information 

specific to each patient. 

(G) Hospice physician and attending 

physician (if any) orders specific to each 

patient. 

(v) Ensuring that the LTC facility staff 

provides orientation in the policies and 

procedures of the facility, including 

patient rights, appropriate forms, and 

record keeping requirements, to hospice 

staff furnishing care to LTC residents. 

(4) Each LTC facility providing 

hospice care under a written agreement 

must ensure that each resident’s written 

plan of care includes both the most 

recent hospice plan of care and a 

description of the services furnished by 

the LTC facility to attain or maintain the 

resident’s highest practicable physical, 

mental, and psychosocial well-being, as 

required at § 483.25. 

(Catalog of Federal Domestic Assistance 

Program No. 93.778, Medical Assistance 

Program) 

(Catalog of Federal Domestic Assistance 

Program No. 93.773, Medicare—Hospital 

Insurance; and Program No. 93.774, 

Medicare—Supplementary Medical 

Insurance Program) 

Dated: December 7, 2012. 

Marilyn Tavenner, 

Acting Administrator, Centers for Medicare 

& Medicaid Services. 

Approved: June 14, 2013. 

Kathleen Sebelius, 

Secretary, Department of Health and Human 

Services. 

[FR Doc. 2013–15313 Filed 6–26–13; 8:45 am] 

BILLING CODE 4120–01–P 

FEDERAL COMMUNICATIONS 

COMMISSION 

47 CFR Part 54 

[WC Docket No. 02–60; FCC 12–150] 

Rural Health Care Support Mechanism 

AGENCY: Federal Communications 

Commission. 

ACTION: Final rule; announcement of 

effective date. 

SUMMARY: In this document, the 

Commission announces that the Office 

of Management and Budget (OMB) has 

approved the non-substantive revisions 

to the information collection associated 

with the Commission’s Service Provider 

Identification Number and Contact 

Form. This announcement is consistent 

with the Universal Service—Rural 

Health Care Program, Report and Order 

(Order), which stated that the 

Commission would publish a document 

in the Federal Register announcing the 

effective date of those rules. 

DATES: The amendments affecting 47 

CFR 54.640(b) and 54.679 published at 

78 FR 13936, March 1, 2013, are 

effective June 27, 2013. 

FOR FURTHER INFORMATION CONTACT: 

Mark Walker, Wireline Competition 

Bureau at (202) 418–2668 or TTY (202) 

418–0484. 

SUPPLEMENTARY INFORMATION: This 

document announces that, on May 29, 

2013, OMB approved the nonsubstantive revisions to the information 

collection requirements contained in the 

Commission’s Service Provider 

Identification Number and Contact 

Form, 77 FR 42728, July 20, 2012. The 

OMB Control Number is 3060–0824. 

The Commission publishes this notice 

as an announcement of the effective 

date of the rules. If you have any 

comments on the burden estimates 


TKELLEY on DSK3SPTVN1PROD with RULES