Plan of Care

(A) Establishment of Plan. The hospice interdisciplinary team in collaboration with the attending physician if any, the member or representative, and primary caregiver must establish and follow an individualized written plan of care in accordance with the member’s needs. The hospice must ensure that each member and the primary care giver(s) receive education and training from the hospice provider as appropriate to their responsibilities for the care and services identified in the plan of care. (B) Scope of Plan. The plan of care must reflect member and family goals and interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments as described in 130 CMR 437.422. The plan must include all services necessary for the palliation and management of the terminal illness and related conditions, including the coordination of all in- home supports. The plan of care must be coordinated with any personal care services the member may be authorized to receive from the MassHealth Personal Care Attendant Program and the MassHealth Adult Foster Care /Group Adult Foster Care Program, and/or personal care services provided through a MassHealth HCBS waiver as well as with any in-home support services that the member is receiving or is eligible to receive from a home and community-based services network. Services that provide in-home personal care may be used only to the extent that the hospice provider would routinely use the services of a hospice member’s family in implementing the plan of care. For members under age 21, the hospice plan of care must identify any curative treatment the member is receiving. (C) Review of Plan. The plan of care must be reviewed, revised, and documented at intervals specified in the plan of care, but no less frequently than every 15 days, by the attending physician, and the hospice interdisciplinary team (in collaboration with the member’s attending physician, if any). These reviews must be documented in the member's clinical record.