A. Professional Management.
(1) When a hospice care program delivers hospice care to a resident of a licensed health care facility, the hospice care program shall assume full responsibility for professional management of the patient's hospice care in accordance with the requirements of this chapter.
(2) When a hospice care program delivers hospice care to a resident of a licensed health care facility, the hospice and the facility shall have a written agreement which defines their respective roles and responsibilities in regard to the care of the patient.
(3) The hospice care program shall designate a qualified health care professional from the hospice care program who shall coordinate the activities of the interdisciplinary care team and the health care facility staff to assure continuous assessments of the patient's and family's needs, and to ensure implementation of an integrated plan of care.
(4) All core hospice services, specifically, physician, nursing, social work, and counseling services identified in the plan of care, shall be provided directly by hospice care program employees or volunteers and may not be delegated to the health care facility.
B. Plan of Care.
(1) The interdisciplinary plan of care shall be jointly developed by the patient, the patient's family, the hospice care program, and the licensed health care facility, and shall identify the services to be provided by each entity.
(2) Both providers shall review the interdisciplinary plan of care at intervals specified in the plan, and shall jointly update the plan as necessary to reflect the patient's current status.
(3) Both the hospice care program and the health care provider shall maintain the interdisciplinary plan of care in their respective medical records.