42 CFR 418.52 · 418.54(a) · 418.56 · 418.22 · 418.24 · SOM Appendix M L522–L525
Spartan Coaching
Educational Use Only
Patient / Admission Info
Patient Name:
Date of Birth:
Primary Diagnosis:
Election Effective Date:
Benefit Period:
Visit Date / Time:
Visit Location (must match election effective address):
48-Hour Hard Stop: The RN initial assessment must be completed within 48 hours of the election effective date, at the location where hospice services are delivered. Visits completed late are a survey citation and payment risk. 42 CFR 418.54(a); SOM L522
Before the Visit - Pre-Visit Prep
Election statement is signed and effective date is established42 CFR 418.24(b)
Certification is complete with patient-specific narrative and physician signature42 CFR 418.22(b)
NOE submitted to MAC (target same day as election)MAC acceptance must occur by Day 5 42 CFR 418.24(e)
Clinical records reviewed prior to visit (H&P, diagnosis, medication list)Do not go in blind - review prognosis documentation
Patient rights packet prepared and ready to deliver at start of visitMust be delivered BEFORE any clinical task begins 42 CFR 418.52(a)
IDG team notified and domains assigned for 5-day comprehensive assessment42 CFR 418.54(b)
At Arrival - Patient Rights (Before Any Clinical Task)
Sequencing rule: Deliver rights and obtain signature BEFORE taking vitals, completing assessment forms, or providing any clinical service. Out of sequence = citable deficiency. 42 CFR 418.52(a); SOM L512
Required FirstPatient rights delivered verbally in a language the patient understandsIf language barrier: interpreter documented and involved 42 CFR 418.52(a)
Required FirstPatient rights delivered in writing (hospice-issued rights form)Document form number or version if applicable
Required FirstPatient or authorized representative provided opportunity to ask questions
Required FirstSigned patient rights acknowledgement obtainedFile original in clinical record 42 CFR 418.52(a)
Required FirstTime of rights delivery documented in clinical noteBefore any clinical task - document this explicitly SOM L512
Initial Assessment Content (42 CFR 418.54(a))
Immediate care needs identified and documentedSymptoms requiring urgent intervention, safety risks, comfort needs
Primary terminal diagnosis and related conditions assessed
Current functional status assessed (PPS or equivalent)
Pain and symptom burden assessed using standardized toolDocument tool used and score
Medication list reviewed for immediate safety concernsDuplicate therapy, inappropriate medications for comfort care
Caregiver identity, availability, and immediate capacity assessedNote whether patient is alone and safety implications
Home environment and safety assessed (falls, access, emergency egress)
Nutrition and hydration status assessed
Urgent clinical interventions needed are ordered and documented
Assessment completed at the location where hospice services will be deliveredNot at intake office; not by phone 42 CFR 418.54(a); SOM L522
After the Visit - Documentation and Handoffs
Initial assessment note completed and signed (same day preferred)42 CFR 418.104(b)
Signed election statement filed in clinical record42 CFR 418.24(b)
Signed patient rights acknowledgement filed in clinical record42 CFR 418.52(a)
NOE confirmation (MAC acceptance) confirmed and filedLate NOE = provider-liable days 42 CFR 418.24(e)
IDG notified of assessment findings; comprehensive assessment domains assignedAll 7 domains must be completed within 5 calendar days 42 CFR 418.54(b)
Attending physician notified of admission (if applicable)42 CFR 418.56(b)
Medical supplies and DME ordered per immediate care plan
Follow-up visit scheduled within plan of care42 CFR 418.56
Completion Sign-Off
Admitting RN:
Credentials:
Assessment completed:
Rights delivered at:
Notes / Flags for IDG:
Educational Use Only. Not legal advice. Verify against current primary sources and your organization's policies before use.