{"ref":"DC-HSP-IDG-02","title":"Plan of Care, Plan of Care Review and Caregiver Education","category":"Hospice care","summary":"Sets how the interdisciplinary group, with the attending physician, the patient or representative and the primary caregiver, establishes each patient’s written plan of care before care is provided, what it must contain, how it is reviewed and revised at least every 15 calendar days, how care follows it, and how the Agency teaches patients and caregivers the care they give.","inShort":["Every service follows a written plan of care set up before care starts.","The plan shows each service and how often, the drugs, supplies and equipment, and measurable goals.","Go over the plan with the patient and family and record how well they understand and agree.","The team reviews and updates the plan at least every 15 calendar days, and sooner when things change.","Teach caregivers each task, ask them to show it back, and record what you taught."],"primaryCitation":"42 CFR §418.56(b)-(d)","citations":["29 DCMR §939.19(c)","29 DCMR §939.34(b)","29 DCMR §939.99","29 DCMR §940.15","29 DCMR §940.20"],"federalCitations":["42 CFR §418.56(b)-(d)","42 CFR §418.200","42 CFR §418.24(d)(2)","42 CFR §418.52(c)(2)","42 CFR §418.104(a)","42 CFR §418.112(d)"],"surveyorAsks":["Show me this patient’s initial plan of care. Was it established before the first service?","Where does the plan show the scope and frequency of each service and measurable outcomes?"],"forms":[],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §418.56(b))","5. The Initial Plan of Care","6. What the Plan of Care Contains","7. Involving the Patient, Representative and Caregiver","8. Reviewing and Revising the Plan of Care","9. Following the Plan of Care","10. Educating and Training Patients and Caregivers","11. Responsibilities","12. Records and Compliance Monitoring","13. Staff Training","14. References","15. Related Policies and Forms","16. Approval","17. Revision History"],"version":"1.0","sample":false,"pack":"dc-hospice","state":"Washington, DC","service":"Hospice","guides":[{"path":"/guides/hospice-policies/","h1":"What policies are required for hospice?"},{"path":"/guides/hospice-conditions-of-participation/","h1":"Hospice Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}