{"ref":"NC-HSP-IDG-02","title":"Care Plan: Development, Monthly Update and Review Every 15 Days","category":"Hospice care","summary":"Requires a written care plan for each patient and family, established by the IDT under the attending physician's orders and based on the medical, psychosocial and spiritual assessment, with the North Carolina content (diagnosis and prognosis, problems and goals, types and frequency of services, responsible disciplines) and the federal content; reviewed at every IDT meeting and at least every 15 calendar days, and fully updated at least monthly.","inShort":["Every patient and family has one written plan of care set by the team under the attending physician's orders.","The plan states the diagnosis and prognosis, problems and goals, how often each service happens and who gives it.","The team reviews each plan at least every 15 calendar days and does a full update every month.","Involve the patient and caregiver and record how well they understand and agree.","If a plan change affects what the hospice does not cover, update the addendum within 3 days.","Send the current plan to the inpatient unit or facility when the patient goes there."],"primaryCitation":"10A NCAC 13K .0701(a)","citations":["10A NCAC 13K .0102(2)","10A NCAC 13K .0301(a)(7)","10A NCAC 13K .0701(a), (b)","10A NCAC 13K .0501(1)(a)(ii), (5)(c)","10A NCAC 13K .0505(a)(9)","10A NCAC 13K .0901(b)(11)"],"federalCitations":["42 CFR §418.56(b)-(d)","42 CFR §418.54(d)","42 CFR §418.24(d)(2)","42 CFR §418.104(a)(1)"],"surveyorAsks":["Show me this patient's care plan. Where are the diagnosis and prognosis, the goals, the frequency of each service and the disciplines responsible?","Show me the plan reviews for the last 30 days. Were they no more than 15 calendar days apart?"],"forms":[],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (10A NCAC 13K .0701(a))","5. Developing the Plan","6. Content of the Plan","7. Reviews and the Monthly Update","8. Changes Between Reviews","9. Patient and Family Involvement and Teaching","10. Sharing the Plan","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":"nc-hospice","state":"North Carolina","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}}