130 CMR 437.423 - Plan of Care
(A)
Establishment of Plan. The hospice interdisciplinary
team in collaboration with the attending physician if any, the member or
representative, and primary caregiver must establish and follow an
individualized written plan of care in accordance with the member's needs. The
hospice must ensure that each member and the primary care giver(s) receive
education and training from the hospice provider as appropriate to their
responsibilities for the care and services identified in the plan of
care.
(B)
Scope of
Plan. The plan of care must reflect member and family goals and
interventions based on problems identified in the initial, comprehensive, and
updated comprehensive assessments as described in
130
CMR 437.422. The plan must include all
services necessary for the palliation and management of the terminal illness
and related conditions, including the coordination of all in-home supports. The
plan of care must be coordinated with any personal care services the member may
be authorized to receive from the MassHealth Personal Care Attendant Program
and the MassHealth Adult Foster Care /Group Adult Foster Care Program, and/or
personal care services provided through a MassHealth HCBS waiver as well as
with any in-home support services that the member is receiving or is eligible
to receive from a home and community-based services network. Services that
provide in-home personal care may be used only to the extent that the hospice
provider would routinely use the services of a hospice member's family in
implementing the plan of care. For members under age 21, the hospice plan of
care must identify any curative treatment the member is receiving.
(C)
Review of Plan.
The plan of care must be reviewed, revised, and documented at intervals
specified in the plan of care, but no less frequently than every 15 days, by
the attending physician, and the hospice interdisciplinary team (in
collaboration with the member's attending physician, if any). These reviews
must be documented in the member's clinical record
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.