{"ref":"FL-HSP-IDG-01","title":"Hospice Care Team and Coordinated Care Program","category":"Hospice care","summary":"Establishes the Agency’s hospice care team (the Medicare interdisciplinary group) with at least a Florida-licensed physician, a nurse, a social worker and a pastoral or other counselor (s. 400.6105(3), F.S.; 42 CFR §418.56(a)); the full-time registered nurse who coordinates each plan of care (s. 400.6105(2), F.S.); the written plan for cooperative planning, decision-making and documentation required by Rule 59A-38.005(2)-(3), F.A.C.; team meetings; the medical director’s part in care conferences; and how the team shares information across disciplines, settings and outside providers (42 CFR §418.56(e)).","inShort":["Every patient has a hospice care team (physician, nurse, social worker and counselor) and a named coordinating RN.","The team reviews each patient at least every 15 days; meetings are held at least every 14 days.","Attend the meeting or send written input first, then read the decisions within 2 business days.","Do not wait for a meeting when something urgent changes: call the coordinating nurse and the physician now.","Share the plan of care and changes with facility staff and the attending physician."],"primaryCitation":"s. 400.6105(3), F.S.","citations":["s. 400.6105(2)-(3), (5), F.S.","s. 400.601(4), F.S.","Rule 59A-38.005(2)-(3), F.A.C.","Rule 59A-38.008(2)(a), (b)4., F.A.C.","s. 400.6085(1)(b), F.S.","s. 400.6095(5)(e), F.S."],"federalCitations":["42 CFR §418.56(a), (e)","42 CFR §418.54(d)","42 CFR §418.56(d)","42 CFR §418.64(a)"],"surveyorAsks":["Who is on the hospice care team for this patient? Which registered nurse coordinates the care?","How often does the team meet, and how is attendance recorded?"],"forms":[{"ref":"FL-HSP-IDG-01-A","title":"Hospice Care Team Meeting Record"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (s. 400.6105(2)-(3), F.S.; Rule 59A-38.005(2), F.A.C.; 42 CFR §418.56(a))","5. Team Composition","6. The Coordinating Nurse","7. The Agency’s Plan for Coordinated Care","8. Around-the-Clock Access and Continuity","9. Team Meetings","10. More Than One Team","11. Communication and Coordination","12. Responsibilities","13. Records and Compliance Monitoring","14. Staff Training","15. References","16. Related Policies and Forms","17. Approval","18. Revision History"],"version":"1.0","sample":false,"pack":"fl-hospice","state":"Florida","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}}