{"ref":"PA-HSP-IDG-02","title":"Plan of Care, Plan of Care Review and Caregiver Education","category":"Hospice care","summary":"Sets out how the interdisciplinary group, with the attending physician, patient, representative and primary caregiver, establishes an individualized written plan of care before care is provided, what it must contain, how it is reviewed and revised at least every 15 calendar days, how the patient's involvement and agreement are documented, and how patients and caregivers are taught to carry out their part of the care.","inShort":["There must be a written plan of care before any hospice care is given, and all care follows it.","The plan states pain and symptom interventions, what each discipline does and how often, measurable outcomes, drugs, treatments, supplies and equipment.","The IDG reviews and updates the plan at least every 15 calendar days, and sooner if the patient changes.","Record how well the patient or representative understands, takes part in and agrees with the plan.","Teach caregivers their tasks, check they can do them, and write it down."],"primaryCitation":"42 CFR §418.56(b)-(d)","citations":["55 Pa. Code §1130.61"],"federalCitations":["42 CFR §418.56(b)-(d)","42 CFR §418.200","42 CFR §418.52(c)(2)","42 CFR §418.104(a)(1)","42 CFR §418.106(d)(1)","42 CFR §418.24(d)(2)"],"surveyorAsks":["Show me this patient's plan of care. Was it established before care was provided?","Where does the plan state the scope and frequency of each service, and the measurable outcomes?"],"forms":[],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §418.56(b)-(d))","5. The Initial Plan of Care","6. Contents of the Plan of Care","7. Review and Revision","8. Involving the Patient, Representative and Caregiver","9. Education and Training of the Patient and Caregiver","10. Following the Plan of Care","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":"pa-hospice","state":"Pennsylvania","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}}