Hospice Care in a California Residential Care Home

Can your parent stay in their care home on hospice?

If your parent’s doctor has brought up hospice, one of the first questions is whether your parent can stay where they live now. In California, that depends on the home. A residential care facility for the elderly (RCFE) can accept or keep a resident who is receiving hospice care only if it holds a hospice care waiver from the California Department of Social Services (CDSS). A home without the waiver can’t.

Medicare covers hospice when the hospice doctor and the person’s regular doctor certify a terminal illness with a life expectancy of six months or less, and the person chooses comfort care instead of treatment aimed at a cure. California’s care home rules use the same six-month measure. Medicare.gov says you can usually get hospice care where you live, including an assisted living facility.

What the hospice care waiver is

An RCFE gives non-medical care and supervision. Its usual rules limit keeping residents who need more care and supervision than other residents, or who are bedridden other than for a temporary illness. The waiver is an exception to those limits. It covers only residents whose hospice care follows a written care plan that meets the state’s requirements.

The waiver doesn’t turn the home into a medical facility. State law says it is not meant to expand the scope of care and supervision an RCFE provides. The medical side of hospice comes from the hospice agency.

There is no single statewide limit on how many hospice residents a home may have. Each home states, in its own waiver request, the maximum number of terminally ill residents it wants at any one time. So the number varies from home to home.

CDSS must deny a waiver request if the home is not in substantial compliance with the state’s RCFE laws and regulations. It approves one only if the home shows it can meet the care needs of terminally ill residents and agrees to add care staff if a hospice care plan calls for it.

Your parent chooses the hospice, not the home

Under the regulations, a hospice agency must be Medicare-certified for hospice and hold either a Hospice license or a Home Health Agency license from the California Department of Public Health.

Your parent, or the person who makes health care decisions for them if they can’t, signs up with the hospice directly. The care home does not contract with a hospice on a resident’s behalf, and the hospice may not subcontract with the home or any of its staff.

Who does what

Before hospice starts in the home, the hospice writes a care plan covering the care, services and medical help for the terminal illness that add to what the home already provides. The home and your parent (or their decision maker) both agree to it, and both the home and the hospice must carry it out in full.

The plan names a 24-hour emergency number, what the hospice will provide and how often, your parent’s main contact at the hospice, and a primary and an alternate caregiver at the home. It also sets out the home’s duties, record keeping and communication with the hospice, the physician and the family.

Hospice agency	Care home
Writes the care plan and keeps overall responsibility for it	Agrees to the plan and carries out its assigned part
Names the licensed professional who controls and supervises the storage and giving of controlled drugs	Can help your parent with medications they take themselves, without hospice staff present
Provides the care, services and medical help for the terminal illness set out in the plan	Is never asked by the plan to perform procedures that only a physician or skilled professional may legally do
Trains staff on your parent’s specific needs before care begins	Trains staff on typical hospice needs such as turning, incontinence care to prevent skin breakdown, hydration and infection control, and keeps training records for three years

The paperwork involved

Your parent, or their health care decision maker, signs a written request to stay in the home, or to move in, while receiving hospice.

The home must then notify CDSS in writing within five working days after hospice starts, or after admitting someone who is already on hospice. The notice gives the resident’s name, the date they moved in, and the hospice’s name and address.

If your parent shares a room, the roommate signs a statement acknowledging the plan and agreeing to let hospice staff, family, friends and clergy into the shared space. If the roommate later withdraws that agreement, the home must make other arrangements that fully meet your parent’s needs.

Moving into a home while already on hospice

A parent who is already receiving hospice can move into a home that holds a waiver. The regulations allow it, and so does state law, when the person would keep receiving hospice without disruption after moving in. A resident who is bedridden can live there too, as long as the home meets the state’s separate rules for the care of bedridden residents.

Health conditions a home normally can’t care for

RCFEs are normally barred from caring for certain health conditions, such as gastrostomy tubes or stage 3 and 4 pressure injuries. The list is covered in RCFE vs. nursing home. For a resident on hospice under a waiver, the home does not need a separate state exception for those conditions, as long as the hospice care plan addresses their treatment.

When staying may no longer work

The waiver doesn’t guarantee a resident can stay. CDSS can still require a move if a terminally ill resident’s personal care, supervision or health care needs are not being met in the home. And if the hospice, the home or the resident decides that staying has become a threat to the health and safety of that resident or others, the home may start transfer procedures.

The home must also report to CDSS when a resident’s hospice care is interrupted or stopped, including when the resident refuses hospice or is discharged from it. It must also report any departure from the care plan that threatens someone’s health or safety. These reports go by phone within one working day and in writing within five working days.

What Medicare covers, and what it may not

Medicare’s hospice benefit covers hospice care. The home’s own charges are a separate matter. In Medicare.gov’s words: “You may have to pay for room and board if you live in a facility (like a nursing home) and choose to get hospice care.” Ask the home in writing what it will charge once hospice begins. Paying for assisted living in California covers the programs that may help with the home’s own costs.

Questions to ask a care home

The state’s consumer guide tells families to ask about specialized services such as hospice, because not every licensed home can provide them. Ask the home directly whether it holds a waiver. If the answer is unclear, ask the local Community Care Licensing regional office.

• Do you hold a hospice care waiver from CDSS? May I see the approval letter?
• What maximum number of hospice residents does your waiver allow, and how many do you have now?
• Would you admit a new resident who is already on hospice?
• Can my parent keep the hospice agency they already use, or choose a different one?
• Who would be my parent’s primary and alternate caregiver here?
• What hospice training have your staff completed?
• How do you handle a roommate’s agreement when a resident starts hospice?
• Does your monthly rate change once hospice begins?
• In what situations would you ask a resident on hospice to move?

Before you decide, check the home’s license and inspection history. How to check a California care home’s license and inspection reports shows how. You can find licensed homes in our California directory.

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