{"ref":"MI-HSP-IDG-01","title":"Interdisciplinary Care Team","category":"Hospice care","summary":"Sets out the membership of the Agency's interdisciplinary care team (at a minimum a doctor of medicine or osteopathy, a registered nurse, a social worker and a pastoral or other counselor under Michigan rules), how teams and the registered nurse coordinator are designated, how often the team meets so that every plan of care is reviewed at least every 15 days, what the meeting record shows, and how the team supervises care between meetings.","inShort":["Every team has at least a physician, a registered nurse, a social worker and a chaplain or other counselor.","Each patient has a named registered nurse coordinator. Check the record to see who it is.","The team meets every week so that every plan of care is reviewed at least every 15 days.","No plan reviews happen unless the physician, nurse, social worker and chaplain are all present, in person or by video or phone.","If a patient's needs change between meetings, the nurse coordinator and physician change the plan at once and tell the team."],"primaryCitation":"42 CFR §418.56(a)","citations":["Mich. Admin. Code R 325.45105(e)","Mich. Admin. Code R 325.45353(3)-(4)","Mich. Admin. Code R 325.45359","Mich. Admin. Code R 325.45349(1)","Mich. Admin. Code R 325.45361(4)","MCL 333.21415(2)"],"federalCitations":["42 CFR §418.56(a)","42 CFR §418.56(d)","42 CFR §418.64","42 CFR §418.114"],"surveyorAsks":["Who is on this patient's interdisciplinary care team? Show me that each required discipline took part in the last review.","Which registered nurse coordinates this patient's care, and where is that recorded?"],"forms":[{"ref":"MI-HSP-IDG-01-A","title":"Interdisciplinary Care Team Meeting Record"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §418.56(a))","5. Membership","6. Designating Teams and the Coordinator","7. Team Meetings","8. The Meeting Record","9. Supervising Care Between Meetings","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":"mi-hospice","state":"Michigan","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}}