Hospice Audit Documentation

V 2.0

Introduction

Resident Selection

Residents Included

All residents with an MD order to be put on Hospice care.

Business Rules

Tasks:

1. Hospice Order Diagnosis - MD order for hospice care includes diagnosis for hospice services. (Q1501)

   1. Location in PCC:

      1. Orders

   2. Business Rule:

      1. IF a resident has an MD order for hospice care,
         THEN there must be a diagnosis included in the order

   3. Due Date:

      1. Within 24 Hours of the order

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the hospice order is no longer active

2. Hospice UDA - Hospice UDA completed (Q1503)

   1. Location in PCC:

      1. Assessments

   2. Business Rule:

      1. IF a resident has an MD order for hospice care,
         THEN there must be a hospice UDA completed every 3 months

   3. Due Date:

      1. Within 24 Hours of the order 
         OR within 3 months of the last Hospice UDA

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the hospice order is no longer active

3. Hospice Care Plan Focus - Hospice/Palliative Care Plan Focus in place. (Q1504)

   1. Location in PCC:

      1. Care Plan

         1. Focus

   2. Business Rule:

      1. IF a resident has an MD order for hospice care,
         THEN there must be a care plan focus in place

   3. Due Date:

      1. Within 24 Hours of the order
         OR within 3 weeks of admission for new residents

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the hospice order is no longer active

4. Hospice Care Plan Interventions - Hospice care plan includes interventions that the facility collaborates/coordinates with the Hospice Team. (Q1505)

   1. Location in PCC:

      1. Care Plan

         1. Interventions

   2. Business Rule:

      1. IF a resident has an MD order for hospice care,
         AND the resident has a care plan focus for hospice care,
         THEN there must be an intervention in that care plan that the facility should collaborate with the hospice team.

   3. Due Date:

      1. Within 24 Hours of the order
         OR within 3 weeks of admission for new residents

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the hospice order is no longer active