Section 141.203 - Interdisciplinary Team(A) The hospice shall establish an interdisciplinary care team(s) that includes, but is not limited to:(3) coordinator of volunteers(5) spiritual or other counselor(6) bereavement coordinator A team member may serve more than one role on the team.(B) The interdisciplinary team's responsibilities shall include, but not be limited to: (1) establishing a plan of care for each patient/family.(2) conducting regularly scheduled meetings to review the plan of care as needed but at least twice monthly for each patient/family receiving hospice services(3) encouraging active involvement of the patient/family in development and implementation of plan of care(4) providing or supervising the provision of hospice care and services(5) implementing written policies governing the day-to-day provision and evaluation of hospice care and services(6) monitoring continuity of care across all settings(C) The hospice shall designate one member of the interdisciplinary team as coordinator of a patient's care who shall be responsible for coordinating the implementation of the plan of care for that particular patient and assuring that all services required for the particular patient's care are in place.Amended by Mass Register Issue 1358, eff. 2/9/2018.Amended by Mass Register Issue 1453, eff. 9/8/2021.Amended by Mass Register Issue 1457, eff. 9/8/2021.Amended by Mass Register Issue 1505, eff. 9/29/2023.