Section 131.21. Plan of care.

 

(1)   General requirements. A written plan of care shall be established and maintained for each patient admitted to the hospice program and the patient's family. The hospice plan of care is a document that describes both the palliative and supportive care to be provided by the hospice to the patient and the patient's family, as well as the manner by which the hospice will provide that care. The care provided to the patient and the patient's family shall be in accordance with the plan of care.

(2)   Initial plan of care.

(a) The hospice shall develop an initial plan of care that does all of the following:

1. Defines the services to be provided to the patient and the patient's family.

2. Incorporates physician orders and medical procedures.

(b) The initial plan of care shall be developed upon conclusion of the assessment under s. DHS 131.20 (1) (a) .

(c) The initial plan of care shall be developed jointly by the employee who performed the initial assessment and at least one other member of the core team.

(d) The registered nurse shall immediately record and sign a physician's oral orders and shall obtain the physician's counter-signature within 20 days.

(3)   Plan of care.

(a) Integrated plan of care. The hospice core team shall develop an integrated plan of care for the new patient within 5 days after the admission. The core team shall use the initial plan of care as a basis for team decision-making and shall update intervention strategies as a result of core team assessment and planning collaboration.

(b) Content of the plan of care. The hospice shall develop an individualized written plan of care for each patient. The plan of care shall reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care shall include all services necessary for the palliation and management of the terminal illness and related conditions, including all of the following:

1. Interventions to manage pain and symptoms.

2. A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.

3. Measurable outcomes anticipated from implementing and coordinating the plan of care.

4. Drugs and treatment necessary to meet the needs of the patient.

5. Medical supplies and appliances necessary to meet the needs of the patient.

6. The interdisciplinary group's documentation of the patient's or representative's, if any, level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice's own policies, in the clinical record.

(c) Review of the plan of care. The hospice interdisciplinary group in collaboration with the individual's attending physician, if any, shall review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. A revised plan of care shall include information from the patient's updated comprehensive assessment and shall note the patient's progress toward outcomes and goals specified in the plan of care. The hospice interdisciplinary group shall primarily meet in person to review and revise the individualized plan of care.

(d) Bereavement plan of care. The hospice core team shall review and update the bereavement plan of care, at minimum:

1. Fifteen calendar days following a patient's death.

2. Within 60 calendar days following the patient's death.

3. As often as necessary based on identified family needs.

4. At the termination of bereavement services.

(e) Contents of the bereavement plan of care. The bereavement plan of care shall include all of the following:

1. The family and caregiver's specific needs or concerns.

2. Intervention strategies to meet the identified needs.

3. Employees responsible for delivering the care.

4. Established timeframes for evaluating and updating the interventions.

5. The effect of the intervention in meeting established goals.

(f) Record of notes. The core team shall develop a system for recording and maintaining a record of notes within the plan of care.

History: CR 10-034 : cr. Register September 2010 No. 657 , eff. 10-1-10.