Title: Section 793.3 - Initial and Comprehensive Assessment

793.3 Initial and Comprehensive Assessment. (a) The hospice registered nurse, as a member of the interdisciplinary group identified in section 793.4 of this Part, must complete an initial assessment within 48 hours after the election of hospice care in accordance with section 793.2 of this Part unless the physician, patient, or representative requests that the initial assessment be completed in less than 48 hours. Initial assessment means an evaluation of the patient’s physical, psychosocial and emotional status related to the terminal illness and related conditions to determine the patient’s immediate care and support needs.　

(b) The hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), shall conduct and document in writing a patient-specific comprehensive assessment no later than 5 calendar days after the election of hospice care. Comprehensive assessment means a thorough evaluation of the patient's physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions including the caregiver's and family's willingness and capability to care for the patient.　

(c) The comprehensive assessment must take into consideration the following factors:　

(1) the nature and condition causing admission (including the presence or lack of objective data and subjective complaints);　

(2) complications and risk factors that affect care planning;　

(3) functional status, including the patient’s ability to understand and participate in his or her own care;　

(4) imminence of death;　

(5) severity of symptoms;　

(6) a review of all of the patient’s prescription and over-the counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following:　

(i) effectiveness of drug therapy;　

(ii) drug side effects;　

(iii) actual or potential drug interactions;　

(iv) duplicate drug therapy; and 　

(v) drug therapy currently associated with laboratory monitoring;　

(7) an initial bereavement assessment of the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment must be incorporated into the plan of care and considered in the bereavement plan of care; and　

(8) the need for referrals and further evaluation by appropriate health professionals.　

(d) The comprehensive assessment must include data elements that allow for measurement of outcomes. The data elements must:　

(1) take into consideration aspects of care related to hospice and palliation;　

(2) be measured and documented in the same way for all patients;　

(3) be an integral part of the comprehensive assessment and documented in a systematic and retrievable way for each patient;　

(4) be used in individual patient care planning and in the coordination of services; and 　

(5) be used in the aggregate for the hospice’s quality assessment and performance improvement program.　

(e) The hospice interdisciplinary group must update the comprehensive assessment in collaboration with the individual’s attending physician, if any, as frequently as the condition of the patient requires, but no less frequently than every 15 days. The update must consider changes that have taken place since the initial assessment and include information on the patient’s progress toward desired outcomes, as well as a reassessment of the patient’s response to care.