.11 Continuity of Care.

A. The hospice care program shall coordinate care to ensure continuity of care for the patient and family.

B. Any changes in service delivery are to be based on an assessment of the patient's and family's needs and desires for hospice services and a hospice care program's transfer and discharge criteria.

C. The hospice care program shall:

(1) Provide case management for the patient and family;

(2) Maintain an accurate, complete, and documented record of services and activities provided to the patient and family;

(3) Collaborate with other organizations and individuals providing care to the patient and family to ensure coordination of services;

(4) Provide on-call medical and nursing services in response to patient and family needs;

(5) Ensure the safety of staff and inform the patient and family of any personnel, service, or access limitations; and

(6) Have reporting mechanisms to keep all staff informed and updated about patient care changes to ensure continuity and coordination of care among interdisciplinary team members.