(A) Each hospice care program shall have an interdisciplinary team or teams that provides or supervises the provision of hospice care and services. The governing body of the hospice care program shall designate a registered nurse that is a member of an interdisciplinary team to coordinate the overall functioning of that interdisciplinary team to ensure all of the following.
(1) There is ongoing assessment of the hospice patient's and family's needs;
(2) That all components of the plan of care are addressed by the interdisciplinary team; and
(3) The plan of care is implemented in accordance with its terms.
(B) The interdisciplinary team or teams shall perform the following functions:
(1) Establish policies and procedures governing the provision of care.
Interpretive guideline: If the hospice care program has more than one interdisciplinary team, it shall designate which team is to be responsible for establishing the policies and procedures or it shall specify particular areas for which each team is to establish policies and procedures;
(2) Establish an interdisciplinary plan of care for each patient and family;
(3) Review the interdisciplinary plan of care on a periodic basis no less frequently than every fifteen days.
(4) Encourage and foster active involvement of the patient and family in the development and implementation of the interdisciplinary plan of care; and
(5) Evaluate the hospice care and services provided and monitor the continuity of care across all settings for the hospice care program's patients and their families.
(C) A hospice care program shall ensure that each patient's attending physician, if any, periodically reviews the patient's plan of care.
Intepretive guideline: The requirement for periodic review by the attending physician may be satisfied by review whenever there is a significant change in the patient's condition or every ninety days, whichever is sooner.