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Title: Section 793.4 - Patient Plan of Care, Interdisciplinary Group and Coordination of Care

Effective Date


793.4 Patient Plan of Care, Interdisciplinary Group and Coordination of Care. The governing authority must: 

(a) designate an interdisciplinary group or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. The members of the interdisciplinary group are responsible for providing the care and services offered by the hospice, and the group must collectively supervise the care and services.  

(1) The interdisciplinary group must include, but is not limited to:  

(i) a doctor of medicine or osteopathy (who is an employee or under contract with the hospice); 

(ii) a registered nurse; 

(iii) a social worker; and 

(iv) a pastoral or other counselor. 

(2) The governing authority must designate a registered nurse who is a member of the interdisciplinary group to coordinate care and ensure continuous assessment of each patient’s and family’s needs and implementation of the interdisciplinary plan of care;  

(b) if the hospice has more than one interdisciplinary group, specifically designate an interdisciplinary group to establish policies governing the day-to-day provision of hospice care and services;  

(c) ensure that all hospice care and services furnished to patients and their families follow an individualized written plan of care established by the interdisciplinary group in collaboration with the patient's attending physician, if any, and, if they so desire, the patient or representative and the primary caregiver. The plan of care shall indicate for each patient/family how palliative and supportive care is to be achieved including: 

(1) goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments; 

(2) all services necessary for the palliation and management of the terminal illness and related conditions and the individual(s) who will provide those services, including: 

(i) interventions to manage pain and symptoms; 

(ii) a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs; 

(iii) measurable outcomes anticipated from implementing and coordinating the plan of care; 

(iv) drugs, biologicals, treatments, medical supplies, appliances and durable medical equipment that must be provided by the hospice while the patient is under hospice care; 

(v) identification of the registered nurse responsible for coordinating care; and 

(vi) documentation in the clinical record of the patient’s or representative’s level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice’s own policies; 

(d) ensure that the hospice interdisciplinary group confers with an individual educated and trained in drug management to ensure that drugs and biologicals meet each patient’s needs;  

(e) ensure that each patient and the primary caregiver(s) receives education and training regarding their responsibilities for the care and services identified in the plan of care followed by an assessment of their ability to provide care including their ability to self-administer drugs and biologicals; 

(f) ensure discussion and written instructions are provided to the patient/family regarding the management and disposal of controlled drugs in the home when controlled drugs are initially ordered and documentation of such in the clinical record;  

(g) ensure that the hospice interdisciplinary group reviews, revises and documents the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. A revised plan of care must include information from the patient’s updated comprehensive assessment, must note the patient’s progress toward the outcomes and goals specified in the plan of care, and must be documented in the clinical record; and 

(h) develop and maintain a system of communication and integration, in accordance with the hospice’s own policies and procedures, to: 

(1) ensure that the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided by all hospice and non-hospice healthcare providers; 

(2) ensure that care and services provided are based on all assessments of the patient and family needs; 

(3) provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement; and 

(4) provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. 


VOLUME E (Title 10)