10.07.21.10

.10 The Interdisciplinary Plan of Care.

A. The interdisciplinary team shall develop a written plan of care for each patient and family. The plan of care shall reflect current standards of practice. The hospice care program shall document the attending physician's participation in the development, revision, and overall approval of the plan of care.

B. The interdisciplinary plan of care shall reflect continuing communication between the attending physician and other members of the interdisciplinary care team. The interdisciplinary plan of care shall be reviewed, and revised if necessary, at least:

(1) Every 14 days after admission for home-based hospice services; and

(2) Every 7 days after admission for inpatient hospice services.

C. The interdisciplinary plan of care shall recognize the patient's and family's psychological, social, religious, and cultural values.

D. The interdisciplinary plan of care shall reflect efforts that the hospice care program staff and volunteers have made to:

(1) Maximize patient independence;

(2) Deliver services at the convenience of the patient, family, and caregiver;

(3) Arrange respite services for caregivers;

(4) Bridge gaps in the patient's care giving network; and

(5) Adapt the home environment to meet the patient's physical needs.

E. The interdisciplinary plan of care shall be based on the initial assessments conducted by interdisciplinary care team members.

F. The hospice care program shall encourage the patient and family to participate in developing and implementing the interdisciplinary plan of care.

G. Contents. The interdisciplinary plan of care shall include, at a minimum:

(1) Identification of patient and family problems and needs;

(2) Identification of realistic and achievable goals, objectives, and outcomes;

(3) The frequency and mix of services, including bereavement needs;

(4) The level of care to be provided;

(5) Prescribed medication and treatments; and

(6) Required medical equipment.

H. Bereavement Plan.

(1) The hospice care program shall initiate a written plan of bereavement intervention at the time of admission to the hospice which shall be incorporated into the patient's plan of care.

(2) The bereavement plan shall be based on an assessment of the needs of the family and shall recognize the family's social, religious, and cultural values.

(3) At a minimum, the bereavement plan shall include the:

(a) Scope and frequency of bereavement services; and

(b) Family's acceptance of bereavement services.