Plan of Care, Review Every 15 Days and Patient and Caregiver Education
Sets out how the team establishes a written, individualized plan of care before care is provided, who takes part, what the plan must contain under Michigan rules and 42 CFR §418.56(c), how it is reviewed and revised at least every 15 days or sooner as needs change, how care follows the plan, how the team decides whether the patient or in-home caregiver can safely give drugs, and how the patient and caregivers are taught and show they can use drugs, supplies and equipment safely.
About this policy
- Policy number
- MI-HSP-IDG-02
- Version
- 1.0
- Main rule
- Mich. Admin. Code R 325.45353(3)-(5)
- Library
- Michigan hospice · 59 policies
- Category
- Hospice care
- Sections
- 19
In short
- No care starts until a written plan of care is in place. Write the initial plan at the admission visit.
- The plan lists problems, goals and interventions for the patient and family, all drugs and equipment, and how often each discipline visits.
- The team reviews and updates each plan at least every 15 days, and sooner when needs change.
- Give care only as the plan says. Report a missed visit or a change in needs to the nurse coordinator the same day.
- Teach caregivers in their language and have them show you they can use the drugs and equipment safely. Write down what you taught.
What's inside
19 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (Mich. Admin. Code R 325.45353(3)-(5))
- 5. The Initial Plan of Care
- 6. Who Takes Part
- 7. Content of the Plan of Care
- 8. Review and Revision
- 9. Following the Plan of Care
- 10. Deciding Who May Give Drugs at Home
- 11. Patient and Caregiver Education
- 12. Responsibilities
- 13. Records and Compliance Monitoring
- 14. Staff Training
- 15. References
- 16. Related Policies and Forms
- 17. Approval
- 18. Revision History
An inspector may ask
- Show me this patient's plan of care. Where are the problems, interventions and goals for the patient and family, and the list of all medications and equipment?
- When was the plan last reviewed? Was it within 15 days?
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