15 MAC Pt. 16, R. 1.19.2

Plan of Care (POC) - Within 48 hours of the admission, a written plan of care must be developed for each patient/family by a minimum of two IDT members and approved by the full IDT and the Medical Director at the next meeting. The care provided to an individual must be in accordance with the POC. 1. The IDT member who assesses the patient’s needs must meet or call at least one other IDT member before writing the IPOC. At least one of the persons involved in developing the IPOC must be a registered nurse or physician. 2. At a minimum the POC will include the following: a. An assessment of the individual’s needs and identification of services, including the management of discomfort and symptom relief; b. In detail, the scope and frequency of services needed to meet the patient’s and family’s needs. The frequency of services established in the POC will be sufficient to effectively manage the terminal diagnosis of the patient, provide appropriate amounts of counseling to the family, and meet or exceed nationally accepted hospice standards of practice; c. Identification of problems with realistic and achievable goals and objectives; d. Medical supplies and appliances including drugs and biologicals needed for the palliation and management of the terminal illness and related conditions; e. Patient/family understanding, agreement and involvement with the POC; and f. Recognition of the patient/family’s physiological, social, religious and cultural variables and values. 3. The POC must be maintained on file as part of the individual’s clinical record. Documentation of updates shall be maintained. 4. The hospice will designate a registered nurse to coordinate the implementation of the POC for each patient.