12VAC5-391-320: Plan of care

A. At the time of a patient's admission to the hospice program, the IDG shall develop and maintain a plan of care, including but not limited to:

1. Identification of the primary caregiver, or an alternative in the absence of a primary caregiver, to ensure the patient's needs will be met;

2. The patient's diagnosis and prognosis;

3. Assessment of the patient's family medical, physical, psychosocial, spiritual and bereavement needs, identification of the services required to meet those needs and plans for providing the services through the IDG, contractual providers, and community resources;

4. A comprehensive assessment of pain, as warranted by the patient's condition and the scope of services provided by the hospice program;

5. Services to be provided, including (i) specific procedures, (ii) treatment modalities, and (iii) frequency and duration of the services ordered;

6. Special dietary or nutritional needs, when applicable;

7. Medical equipment, supplies, medications, and specialized therapies when applicable;

8. Identification of the members of the staff designated to carry out the plan of care; and

9. Physician orders, including any orders to change the plan when appropriate.

B. Services shall be provided according to the patient's plan of care. The plan of care shall be updated at intervals determined by the IDG and specified in the plan.

C. The plan of care shall be reviewed, approved and signed by the patient's attending physician or the hospice program's medical director after consultation with the patient's attending physician.

D. The attending physician shall be notified immediately of any changes in the patient's condition that indicates a need to alter the plan of care.