What should your patient's Plan of Care Include?

§418.56(b) Standard Plan of Care: All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. The plan of care must review, revise, and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. This includes any of the SMART care plan problems being addressed. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-C/section-418.56

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

1. 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 an appliances necessary to meet the needs of the patient.
   6. The interdisciplinary group's documentation of the patient's or representative's level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice's own policies ,in the clinical record

Plan of Care Resources: 

SOM-Appendix M-Guidance to Surveyors

CHAP Hospice Standards of Excellence

https://www.hospicetools.com/wp-content/uploads/2024/01/Hospice_Plan_of_Care_05_2023_Final-1.pdf

https://qsep.cms.gov/pubs/ClassInformation.aspx?cid=0CMS_HSP_QIF_1