{"ref":"FL-HSP-IDG-02","title":"Plan of Care, Plan of Care Review and Patient and Family Teaching","category":"Hospice care","summary":"Sets the content of each patient’s written plan of care under s. 400.6095(5), F.S. (primary caregiver or alternative plan; diagnosis, prognosis and preferences; needs and the services to meet them; teaching plans; the coordinating nurse; and how care continues in an emergency) and 42 CFR §418.56(c); its preparation with the patient and the attending physician and its medical validation by the medical director; review at least every 15 calendar days; family access; and patient and family teaching toward comfort and self-sufficiency at home.","inShort":["Every patient has a written plan of care before care starts, made with the patient, family and attending physician.","The plan names the primary caregiver (or an alternative plan), the coordinating nurse and what happens in an emergency.","Follow the plan at every visit. If it no longer fits, tell the coordinating nurse the same day.","The team reviews and updates the plan at least every 15 days.","Teach the family in plain words and check they understood by having them show or tell you back."],"primaryCitation":"s. 400.6095(5)-(6), F.S.","citations":["s. 400.6095(5)-(6), F.S.","s. 400.601(9), F.S.","s. 400.609(2), F.S.","Rule 59A-38.005(1)(c), (2)(c)-(e), F.A.C.","Rule 59A-38.008(2)(b)3., F.A.C.","Rule 59A-38.018(14), F.A.C.","s. 400.6105(4), F.S."],"federalCitations":["42 CFR §418.56(b)-(d)","42 CFR §418.200","42 CFR §418.54(c)(7)"],"surveyorAsks":["Show me this patient’s plan of care. Where are the primary caregiver, the coordinating nurse and the emergency provisions?","How were the patient, family and attending physician involved in the plan?"],"forms":[],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (s. 400.6095(5)-(6), F.S.; 42 CFR §418.56)","5. Content of the Plan of Care","6. Establishing the Plan","7. Review and Revision","8. Teaching the Patient and Family","9. Access to the Plan","10. Responsibilities","11. Records and Compliance Monitoring","12. Staff Training","13. References","14. Related Policies and Forms","15. Approval","16. 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}}