{"ref":"TX-HSP-IDG-02","title":"Plan of Care, Plan of Care Review and Caregiver Education","category":"Hospice care","summary":"Sets out how the interdisciplinary group writes an individualized plan of care for every patient with the attending practitioner, patient and caregiver, what the plan must contain, how it is reviewed and revised at least every 15 calendar days, how patients and caregivers are taught to carry out their part of the plan, and how plan changes link to the election statement addendum.","inShort":["All care follows the written plan of care. Do not change care without the plan being changed.","The plan lists pain and symptom care, what each discipline does and how often, the goals, medicines and supplies.","The team reviews each plan at least every 15 calendar days, and sooner if the patient changes.","Ask the patient and family how they want to take part, and write down what they understand and agree to.","Teach caregivers what they need to do, check they can do it, and write it down.","Report a missed visit to the RN coordinator the same day."],"primaryCitation":"42 CFR §418.56(b)-(d)","citations":["26 TAC §558.821","26 TAC §558.822","26 TAC §558.281(10)-(12)","26 TAC §558.861(f)","26 TAC §558.810(b)","26 TAC §558.301(a)(9)(C)"],"federalCitations":["42 CFR §418.56(b)-(d)","42 CFR §418.200","42 CFR §418.24(d)(2)","42 CFR §418.52(c)(2)","42 CFR §418.104(a)(1)"],"surveyorAsks":["Show me this patient’s plan of care. Where are the pain and symptom interventions, the scope and frequency of each service, and the measurable outcomes?","Show me the plan of care reviews for the last 30 days. Was each one within 15 calendar days of the last?"],"forms":[],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §418.56(b)-(d); 26 TAC §558.821-§558.822)","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":"tx-hospice","state":"Texas","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 Hospice","legalName":"Sample Hospice, LLC","logo":null}}