{"ref":"MO-HSP-IDG-02","title":"Plan of Care, Two-Week Review and Caregiver Education","category":"Hospice care","summary":"Sets out how the IDG, with the attending physician, establishes a written plan of care for every patient within seven days of admission (with an initial plan before care starts), what the plan contains under Missouri and federal rules, how the patient and caregiver take part, Missouri's requirement that the IDG review and update the plan at least every two weeks (stricter than the federal 15 days), how changes are made and communicated in advance, and how patients and primary caregivers are educated and trained for their part of the care.","inShort":["Write an initial plan of care at the admission visit, before any care is given.","The IDG, with the attending physician, sets the full plan of care within seven days of admission.","The plan must show each problem, every service with who gives it and how often, the level of care, goals and all physician orders.","The IDG reviews and updates every plan at least every two weeks. Any IDG member may update it at the time of a change.","Tell the patient about any change before it is made, and teach and watch the caregiver do each task they are asked to do."],"primaryCitation":"19 CSR 30-35.010(2)(D)","citations":["19 CSR 30-35.010(2)(D)","19 CSR 30-35.010(1)(F)3.D-G","19 CSR 30-35.010(2)(F)3.A","19 CSR 30-35.010(2)(K)5.C","19 CSR 30-35.010(2)(H)7","19 CSR 30-35.010(2)(I)2","19 CSR 30-35.010(2)(L)2.A","13 CSR 70-50.010(3)(D)","13 CSR 70-50.010(5)","RSMo §197.264.1"],"federalCitations":["42 CFR §418.56(b)-(e)","42 CFR §418.200","42 CFR §418.24(d)(2)","42 CFR §418.106(d)(1)"],"surveyorAsks":["Show me this patient's plan of care. Was it established by the IDG with the attending physician's involvement within seven days of admission?","Does the plan state the level of care, the scope and frequency of each service and who provides it, and all physician orders?"],"forms":[{"ref":"MO-HSP-IDG-02-A","title":"Plan of Care Review Log"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (19 CSR 30-35.010(2)(D))","5. The Initial Plan of Care","6. The IDG Plan of Care Within Seven Days","7. Content of the Plan of Care","8. Following the Plan","9. Review and Update","10. Telling the Patient About Changes","11. Education and Training of the Patient and Primary Caregiver","12. Coordination of Services","13. Responsibilities","14. Records and Compliance Monitoring","15. Staff Training","16. References","17. Related Policies and Forms","18. Approval","19. Revision History"],"version":"1.0","sample":false,"pack":"mo-hospice","state":"Missouri","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}}