La. Admin. Code tit. 48 § I-8221

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-8221 - Plan of Care (POC)

A. Prior to providing care, a written plan of care is developed for each patient/family by the attending physician, the medical director, physician designee or the APRN and the IDT. The care provided to an individual shall be in accordance with the POC.

1. The initial plan of care (IOPC) will be established on the same day as the assessment if the day of assessment is to be a covered day of hospice.

2. The IDT member who assesses the patient's needs shall meet or call at least one other IDT member before writing the IPOC. At least one of the persons involved in developing the IPOC shall be a registered nurse or physician. Within two days of the assessment, the other members of the IDT shall review the IPOC and provide their input. This input may be by telephone. The IPOC shall be signed by the attending licensed medical practitioner and an appropriate member of the IDT.

3. At a minimum the POC shall include the following:

a. an assessment of the individual's needs and identification of services, including the management of discomfort and symptom relief;

b. in detail, the scope and frequency of services needed to meet the patient's and family's needs;

c. identification of problems with realistic and achievable goals and objectives;

d. medical supplies and appliances including drugs and biologicals needed for the palliation and management of the terminal illness and related conditions;

e. patient/family understanding, agreement and involvement with the POC; and

f. recognition of the patient/family's physiological, social, religious and cultural variables and values.

4. The POC is incorporated into the individual clinical record.

5. The hospice shall designate a registered nurse to coordinate the implementation of the POC for each patient.

B. Review and Update of the Plan of Care. The plan of care is reviewed and updated at intervals specified in the POC, when the patient's health status changes, and a minimum of every 14 days for home care and every 7 days for general inpatient/continuous care, collaboratively with the IDT and the attending licensed medical practitioner.

NOTE: In the event that the day of the regularly scheduled IDT meeting falls on a holiday, 15 days is acceptable.

1. The hospice agency shall have policy and procedures for the following:

a. the attending licensed medical practitioners participation in the development, revision, and approval of the POC is documented. This is evidenced by change in patient orders and documented communication between hospice staff and the attending licensed medical practitioner;

b. orders shall be signed and dated in a timely manner, not to exceed 14 days, unless the hospice has documentation that verifies attempts to get orders signed (in this situation up to 30 days will be allowed).

2. The agency shall have documentation that the patient's health status and POC is reviewed and the POC updated, even when the patients health status does not change.

C. Coordination and Continuity of Care. The hospice shall adhere to the following additional principles and responsibilities:

1. an assessment of the patient/family needs and desire for hospice services and a hospice program's specific admission, transfer, and discharge criteria determine any changes in services;

2. nursing services, physician services, and drugs and biologicals are routinely available to hospice patients on a 24-hour basis, seven days a week;

3. all other covered services are available on a 24-hour basis to the extent necessary to meet the needs of individuals for care that is reasonable and necessary for the palliation and management of terminal illness and related conditions;

4. case-management is provided and an accurate and complete documented record of services and activities describing care of patient/family is maintained;

5. collaboration with other providers to ensure coordination of services;

6. maintenance of professional management responsibility and coordination of the patient/family care regardless of the setting;

7. maintenance of contracts/ agreements for the provision of services not directly provided by the hospice, including but not limited to:

a. radiation therapy;

b. infusion therapy;

c. inpatient care;

d. consulting physician;

8. provision or access to emergency medical care;

9. when home care is no longer possible, assistance to the patient in transferring to an appropriate setting where hospice care can be delivered;

10. when the patient is admitted to a setting where hospice care cannot be delivered, hospice adheres to standards, policies and procedures on transfer and discharge and facilitates the patient's transfer to another care provider;

11. maintenance of appropriately qualified IDT health care professionals and volunteers to meet patients need;

12. maintenance and documentation of a volunteer staff to provide administrative or direct patient care. The hospice shall document a continuing level of volunteer activity;

13. coordination of the IDT, as well as of volunteers, by a qualified health care professional, to assure continuous assessment, continuity of care and implementation of the POC;

14. supervision and professional consultation by qualified personnel, available to staff and volunteers during all hours of service;

15. hospice care provided in accordance with accepted professional standards and accepted code of ethics;

16. each member of the IDT accepts a fiduciary relationship with the patient/family, maintaining professional boundaries and an understanding that it is the responsibility of the IDT to maintain appropriate agency/patient/family relationships;

17. has a written agency policy to follow at the time of death of the patient; and

18. has written agency policies and procedures for emergency response based on an all hazards risk assessment, inclusive of training for employees, patients and their caregivers.

La. Admin. Code tit. 48, § I-8221

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 15:482 (June 1989), amended LR 24:2268 (December 1998), Amended by the Department of Health, Bureau of Health Services Financing, LR 44599 (3/1/2018).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2181-2191.