HOPE Assessment Tool Blog Series: Skin Conditions, Medications, and Training Updates

It is now August 2025, and we are a few short months away from implementation of the HOPE assessment tool. CHAP is counting down our last few blogs in this series before October 1, 2025. But, before we get to this blog’s content, there is an update from the Centers for Medicare & Medicaid Services CMS about HOPE training for hospice providers. CMS posted on July 15, 2025, they are offering a series of five self-paced recorded presentations and corresponding PDFs which highlight items that are new for HOPE, as well as the existing and updated items carried over from the Hospice Item Set (HIS).

To access the videos, click on the following links:

Part 1: Training Overview and Introduction to the HOPE Tool

Part 2: HOPE Section A. Administrative Information Didactic Training

Part 3: HOPE Sections F. Preferences, and I. Active Diagnoses Didactic Training

Part 4: HOPE Section J. Health Conditions Didactic Training

Part 5: HOPE Sections M. Skin Conditions, N. Medications, and Z. Record Admin. Didactic Training

Questions about accessing resources or feedback regarding training – please email the PAC Training Mailbox.

Content-related questions should be submitted to HospiceQualityQuestions@cms.hhs.gov.

HOPE Coding Workshop

Registration open for live HOPE training: Hospice Outcomes and Patient Evaluation (HOPE) National Implementation Virtual Training Program Course 2: Coding Workshop

The Centers for Medicare & Medicaid Services (CMS) is offering a live coding workshop on August 5, 2025 which will provide coding practice for items that are new for HOPE, as well as the existing and updated items carried over from the Hospice Item Set (HIS).

Completion of Course 1: Didactic Recorded Training Series is recommended as a prerequisite for the coding workshop. This course can be found here.

Skin Conditions and Medications

This installment will tackle assessment information and guidance in Section M: Skin Conditions and Section N: Medications which are the last clinical sections in the HOPE tool. CMS’s newly posted Part 5 of their recorded education includes a review of Part 5: HOPE Sections M. Skin Conditions, N. Medications.

Hopefully, you have been able to view your electronic medical record vendor’s HOPE assessment tool and are in the testing stage. It is critical that your vendor provides enough time for providers to carefully review the content, flow, and format of the HOPE tool so changes can be made as needed before the 10/1/2025 implementation date. By this time, your vendor should also be training your staff about the tool.

Section M: Skin Conditions

This is a new data item for collection and submission, but not for the comprehensive assessment of a patient. CMS feels it is important to recognize and evaluate each patient for current or potential skin injury and to recognize these factors to identify individuals at increased risk for further complications or additional skin injury.

Wounds frequently occur in patients with a terminal illness, with pressure injuries or ulcers being the most prevalent type. If not appropriately managed, wounds can affect patients physically and psychosocially, which affects their quality of life. Proper wound care addresses both physical healing and overall well-being.

This section of the HOPE tool collects data about the presence, type and current treatment of various skin conditions common in the hospice patient population. There is a skip pattern embedded in the item which allows the assessing clinician to skip the it if the patient does not have any of the following types of wounds:

Diabetic foot ulcer(s)
Open lesion(s) other than ulcers, rash, or skin tear (cancer lesions)
Pressure ulcer(s)/Injuries
Rash(s)
Skin tear(s)
Surgical wound(s)
Ulcers other than diabetic or pressure ulcers (i.e., venous stasis ulcer, Kennedy ulcer)
Moisture associated skin damage (MASD) (i.e., incontinence-associated dermatitis [IAD], perspiration, drainage)

Optimally, assessment of skin integrity or wounds should occur at least weekly depending on the organization’s policy, the patient’s overall status, tolerance and imminence of death. Nurses should follow the patient’s cues related to completing a skin/wound assessment. For example, if the patient is experiencing pain or other symptom exacerbation on the day of a planned skin assessment, the nurse may delay the assessment to the next visit to promote comfort and quality of life. Nurses should also instruct family/caregivers about looking for any skin integrity issues during their care of the patient.

Hospice organizations can choose their own evidence-based wound assessment tool, which should be designated in in the organization’s policies and procedures. All nurses should also be trained to use the designated assessment tool no matter their experience level or tenure as a hospice nurse. Training and competency evaluation documentation should be housed in the nurse’s personnel file.

CMS requires collection and submission of skin condition data at admission and on the HOPE Update Visits (HUVs). They also provide coding tips with wound descriptors in the HOPE manual for additional guidance to the assessing clinician.

While physical assessment of skin integrity is a nursing skill, other members of the interdisciplinary team (IDT) can ask the patient and/or family/caregiver during their visits if there are any new wounds or concerns with current wounds. Changes and concerns would then be reported by the team member to the hospice nurse. Documenting this communication in the clinical record shows IDT care coordination and may necessitate an update to the patient’s plan of care.

Skin and Ulcer/Injury Treatments

This item lists a variety of skin and ulcer/injury treatments that may be interventions in the patient’s plan of care. See the item content below.

A screenshot of a medical treatment

AI-generated content may be incorrect.

This data is also collected and submitted at admission and on the HOPE Update Visits (HUVs). The clinician should document all interventions/treatments in place during the assessment including those initiated or continued. Per CMS guidance in the HOPE manual, treatment begins when the hospice receives the order and documents that the patient or caregiver was told to start the medication or treatment. If the patient lives in a facility, the nurse should consult direct-care staff and the treatment nurse to verify findings from the medical record review. The HOPE manual includes examples for skin assessment, treatment and coding of the items in this section.

Relatedness and Wounds

Wound etiology must be determined to ensure hospice providers are covering not only palliative wound management, but also the cost for that management. In most cases, a wound at the end of life is related to the terminal or related diagnoses and is therefore the responsibility of the hospice provider. Even if a wound is determined to be unrelated to the terminal or related diagnoses, it still may impact or contribute to the terminal prognosis.

Hospice providers are responsible for providing all items and services needed for the palliative care and managing the terminal illness and related conditions per federal regulatory requirements. All care/items/services that are determined as non-covered should be discussed with the patient and family/caregiver at admission and throughout the hospice stay. And the hospice provider should offer an election statement addendum if there are conditions, items, services, and drugs determined to be unrelated to the individual’s terminal illness and related conditions and will not be covered by the hospice. Remember, it is the hospice physician who determines relatedness, not the CEO or CFO.

Regulatory Allowance

The federal hospice Conditions of Participation at §418.64(b)(3) states highly specialized nursing services, such as complex wound care, that are provided infrequently may be provided under contract because provision of such services by direct hospice employees would be impracticable and prohibitively expensive. For example, a hospice may need to contract with a wound, ostomy, and continence (WOC) nurse because of the very infrequent patients with complicated wounds the hospice cares for and that to employee a wound, ostomy, and continence (WOC) nurse would be impracticable and expensive.

Section N: Medications

This section of HOPE tool collects data on opioids use and bowel regimens. This item providers currently collect data on using the Hospice Item Set (HIS). The item has a skip pattern and is completed on admission and on the HOPE Update Visits (HUVs) for patients if a scheduled opioid was initiated or continued. It should be noted that providing proactive education regarding opioid medications included in a comfort kit does not constitute initiation of those medications. Per the HOPE manual guidance, treatment begins once the hospice receives the order for the opioid and documents that the patient or caregiver was instructed to start the medication or therapy. CMS directs completion of this item should be based on what is determined during the assessment visit and/or included in the clinical record. The assessing clinician should not use sources external to the clinical record.

The bowel regimen item collects data whether a treatment was initiated or continued in tandem with the opioid. This information is also collected and submitted on admission and on the HOPE Update Visits (HUVs). The HOPE manual provides extensive guidance related to determining if a bowel regimen is initiated or continued, how to code the item related to an ordered comfort kit and documentation for non-pharmacologic bowel regimens or multiple regimens.

Watch for the CMS HQRP webpage, QRP Announcements & Spotlight area for more information about the August 2025 Coding Education.

Stay tuned for the next installment in the HOPE Assessment Tool blog series and keep your actions and momentum moving forward for the October 1, 2025 implementation.