Hospice service plan of care

1. After an initial assessment of patient and family needs, a written plan of care must be established by the hospice care team for each patient and family admitted to the hospice program. a. At least a registered nurse or physician shall conduct an initial assessment of each patient and shall meet with one hospice care team member to develop the initial plan of care prior to admission. b. Within seven days following admission of each patient and family, the hospice care team members shall meet to develop a comprehensive hospice service plan of care. c. The hospice service plan of care must be developed with the participation of the patient and family and may include only those services which are acceptable to the patient and family. The family must be involved whenever possible in the implementation and continuous assessment of the hospice service plan of care. 2. The hospice service plan of care must include at least the following: a. Patient diagnosis. b. Complete assessment of patient and family needs. c. Appraisal of, and need for, symptom control. d. Identification of problems and goals and the types of services required to meet the patient and family goals. e. Frequency of the services, medication, treatments needed to meet patient and family needs and the discipline involved in the delivery of care. 3. There must be written policies and procedures relating to the development, review, and revision of the hospice service plan in the home care and inpatient services. The plan of care must be reviewed, updated, and documented as needed, but at least biweekly, by the hospice care team.