Agreement for Professional Services s1

HOSPICE AGENCY

AGREEMENT FOR PROFESSIONAL SERVICES

Page 4 of 19

NURSING FACILITY

THIS AGREEMENT FOR PROFESSIONAL SERVICES, hereinafter referred to as Agreement, is made and entered into this day of , 2011 by and between HOSPICE AGENCY, hereinafter referred to as Hospice, and , hereinafter referred to as Nursing Facility.

WHEREAS Hospice is a patient and family-centered program engaged in the provision of interdisciplinary services for the palliation and management of terminal illness.

WHEREAS Nursing Facility is skilled and experienced in the operation of a nursing facility and in the provision of long term care services to its residents, including certain assistance with activities of daily living. Nursing Facility is certified to participate in the Medicaid program and has established policies and protocols for the care of terminally ill patients consistent with those of Hospice.

WHEREAS The parties contemplate that from time to time individuals residing in Nursing Facility will need Hospice Services (as defined below) and individuals previously accepted into Hospice will need care in Nursing Facility. Hospice and Nursing Facility desire by entering into this Agreement to make it possible for individuals with terminal illness to receive needed Hospice Services in conjunction with Nursing Facility Services. (as defined below).

Hospice Services means those services provided to a Hospice patient for the palliation and management of such Hospice patient’s terminal illness, either directly or under arrangement by Hospice, as specified in the Plan of Care. Short-term inpatient care for symptom management and pain control as well as for respite purposes is included in these services.

Hospice services include nursing care and services by or under the supervision of a registered nurse; medical social services provided by a qualified social worker under the direction of a physician; physician services to the extent that these services are not provided by the Attending Physician and the Hospice Medical Director; counseling services (including bereavement, dietary and spiritual counseling); Physical Therapy, Occupational Therapy and Speech- Language Pathology services; home health aide / homemaker services; medical supplies; drugs and biologicals; use of medical appliances; 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 inpatient care when needed for pain control, symptom management and respite purposes.

The hospice must assume responsibility for professional management of the resident’s hospice services provided, in accordance with the hospice plan of care and the hospice conditions of participation, and make any arrangements necessary for hospice-related inpatient care in a participating Medicare/Medicaid facility according to § 418.100 and §418.108.

Medicaid Eligible Residential Hospice Patient means a Residential Hospice Patient who either (a) is eligible for Medicaid benefits in a state which has a hospice benefit and who has elected to receive the state’s Medicaid hospice benefit or (b) is eligible for both Medicaid and Medicare Part A benefits and who has elected the Medicare hospice benefit.

I. SERVICES TO BE PROVIDED BY HOSPICE

A.  Admission to Hospice Program

1.  If a resident of Nursing Facility requests the provision of Hospice Services, Hospice shall perform an assessment of such resident and shall notify the Nursing Facility, either orally or in writing, whether such resident is authorized for admission as a Residential Hospice Patient. Hospice shall maintain adequate records of each authorization of Hospice admission.

2.  On or prior to the execution of this Agreement, Hospice will provide Nursing Facility with its current criteria for admission. Hospice will promptly provide Nursing Facility with any modification to these criteria.

B.  Design and Maintenance of Plan of Care

1.  Nursing Facility Residents. In accordance with applicable Federal and state laws and regulations, Hospice shall coordinate with Nursing Facility to develop a Plan of Care for each new Residential Hospice Patient. Hospice shall furnish Nursing Facility with a copy of the Plan of Care and specifies the inpatient services to be furnished if they are admitted for inpatient care.

2.  Non-residential Hospice Patients. Promptly upon admission of Hospice Patient, who has not been residing in a Nursing Facility, to the Nursing Facility and consent of the Hospice Patient (or his/her legal representative), Hospice will furnish Nursing Facility with a copy of the then-current Hospice Plan of Care. In coordination with the Nursing Facility, Hospice shall promptly modify the Plan of Care, as necessary, to accommodate Hospice Patient’s change in residence.

3.  Modifications. At intervals established by the Interdisciplinary Group, the Interdisciplinary Group will review and modify, if necessary, the Plan of Care. The Hospice will consult and coordinate with Nursing Facility, as reasonably necessary, with respect to any modification to the Plan of Care, and will provide the Nursing Facility with any modification to the Plan of Care.

4.  Monitoring. Hospice will promptly inform Nursing Facility of any identified change in the condition of a Residential Hospice Patient which requires supplementation, modification or alteration of the Plan of Care.

5.  Physician Orders. All physician orders communicated to Nursing Facility on behalf of Hospice in connection with Plan of Care shall be in writing and signed by the applicable Attending Physician or Hospice Physician; provided, however, that in the case of urgent or emergency circumstances, such orders may be communicated by the Attending Physician or the Hospice Physician orally and confirmed in writing thereafter. Hospice shall maintain adequate records of all physician orders communicated in connection with the Plan of Care.

C.  Notification of Hospice Services. Hospice shall fully inform Residential Hospice Patients of the Hospice Services to be provided by Hospice and the Nursing Facility Room and Board Services and Purchased Hospice Services, if any, to be provided by Nursing Facility.

D.  Provision of Hospice Services. Hospice shall be available to provide Hospice Services, as required by applicable Federal and state laws and regulations, twenty-four (24) hours a day, seven (7) days a week room and board, meeting the personal care and nursing needs that would have been provided by the primary caregiver at home at the same level of care provided before hospice care was elected. The hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.

1. Hospice’s responsibility is to provide services at the same level and to the same extent as those services would be provided if the SNF/NF or ICF/MR resident were in his or her own home.

2. A delineation of the hospice’s responsibilities, which include, but are not limited to the following: Providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary and bereavement); social work; 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; and all other hospice services that are necessary for the care of the resident’s terminal illness and related conditions.

3. The hospice may use the SNF/NF or ICF/MR nursing personnel where permitted by State law and as specified by the SNF/NF or ICF/ MR to assist in the administration of prescribed therapies included in the plan of care only to the extent that the hospice would routinely use the services of a hospice patient’s family in implementing the plan of care.

4.  The hospice 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 anyone unrelated to the hospice to the SNF/NF or ICF/MR administrator within 24 hours of the hospice becoming aware of the alleged violation.

5.  It is the responsibilities of the hospice and the SNF/NF or ICF? MR to provide bereavement services to SNF/NF or ICF/ MR staff.

E. Coordination of services. The hospice must:

1. Designate a member of each interdisciplinary group that is responsible for a patient who is a resident of a SNF/NF or ICF/MR. The designated interdisciplinary group member is responsible for:

a. Providing overall coordination of the hospice care of the SNF/NF or ICF/ MR resident with SNF/NF or ICF/MR representatives; and

b. Communicating with SNF/NF or ICF/MR representatives and other health care providers participating in the provision of care for the terminal illness and related conditions and other conditions to ensure quality of care for the patient and family.

2. Ensure that the hospice IDG communicates with the SNF/NF or ICF/ MR 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 physicians.

3. Provide the SNF/NF or ICF/MR with the following information:

a. The most recent hospice plan of care specific to each patient;

b. Hospice election form and any advance directives specific to each patient;

c. Physician certification and recertification of the terminal illness

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; and

g. Hospice physician and attending physician (if any) orders specific to each patient.

F. Supervision of Hospice Plan of Care and nursing facility staff: Hospice will be responsible for the professional management of the Plan of Care, including any Purchased Hospice Services. The hospice retains responsibility for ensuring that the training of personnel who will be providing the patient’s care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented; and a method for verifying that this requirement is met.

II.  SERVICES TO BE PROVIDED BY NURSING FACILITY

A.  Admission to Nursing Facility

1.  Request for Admission. In the event that a pre-existing Hospice Patient requests admission to the Nursing Facility, Nursing Facility shall admit such Hospice Patient, subject to Nursing Facility’s admission policies and procedures and the availability of beds. Nursing Facility shall notify Hospice, either orally or in writing, whether such Hospice Patient is authorized for admission as a Residential Hospice Patient. Nursing Facility shall maintain adequate records of all such authorizations of admission.

2.  Admission Policies. On or prior to the execution of this Agreement, Nursing Facility will provide Hospice with its current admission policies and procedures. Nursing Facility will promptly provide Hospice with any modification to these policies and procedures.

B.  Notification of Nursing Facility Residents. Nursing Facility shall inform each terminally ill resident of the Nursing Facility of that resident’s option to elect to receive Hospice Services, subject to such resident’s meeting the Hospice criteria for admission.

C.  Notification of Services. Nursing Facility shall fully inform Residential Hospice Patients of the Other Nursing Facility Services and Uncovered Items and Services to be provided by Nursing Facility.

D.  Coordination with Hospice Regarding Plan of Care

Design of Plan. In accordance with applicable Federal and state laws and regulations, the Nursing Facility shall coordinate with Hospice in developing a Plan of Care for each new Residential Hospice Patient and the plan of care will include both the most recent hospice plan of care and a description of the services furnish by the LTC facility to attain or maintain the resident’s highest practicable physical, mental and psychosocial well-being, as required at 483.25r The plan of care will reflect participation of the patient and family with the facility and hospice to the extent possible. The Hospice plan of care must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. The Facility must 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. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to access the resident or have access to someone that has the skills and capabilities to access the resident. The designated interdisciplinary team member is 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 patient with the medical care provided by other physicians;

4.  Obtaining pertinent information from the hospice (that is, the most recent hospice plan of care specific to each patient; hospice election form and any advance directives specific to each patient; 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)

The Nursing Facility will assist with periodic review and modification of the Plan of Care. Any changes in the hospice plan of care must be discussed with the patient or representative, and SNF/NF or ICF/MR representatives, and must be approved by the hospice before implementation.

5.  Nursing Facility shall immediately inform Hospice of any change in the condition of a Residential Hospice Patient. The SNF/NF or ICF/MR agrees to immediately notifies the hospice if—

a. A significant change in a patient’s physical, mental, social, or emotional status occurs;

b. Clinical complications appear that suggest a need to alter the plan of care;

c. A need to transfer a patient from the SNF/NF or ICF/MR for any condition, and the hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care necessary related to the terminal illness and related conditions; or