23 Miss. Code. R. 205-1.5 - Hospice Plan of Care (POC)

A. The hospice provider must ensure each beneficiary has an individualized written plan of care (POC) established by the hospice interdisciplinary team/interdisciplinary group (IDT/IDG) in collaboration with the attending physician, if any, beneficiary, family and/or primary care giver that specifies the hospice care and services necessary to meet the beneficiary's and family's specific needs identified in the initial, comprehensive, and updated comprehensive assessments.

B. The hospice provider must ensure that each beneficiary and the primary care giver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the POC.

C. The IDT/IDG must be designated by the hospice and be composed of representatives from all the core services and include, at a minimum:

1. A doctor of medicine or osteopathy,

2. A registered nurse (RN) designated to provide coordination of care and to ensure continuous assessment of each beneficiary's and family's needs and implementation of the interdisciplinary POC,

3. A social worker, and

4. A pastoral or other counselor.

D. The POC must be developed for each beneficiary/family by a minimum of two (2) IDT/IDG members and must be approved or revised by the full IDT/IDG and the hospice medical director at the next IDT/IDG meeting. The IDT/IDG is responsible for:

1. Participation in the establishment of the POC within forty-eight (48) hours of admission to hospice,

2. Periodic review and revision of the most current beneficiary/family assessment, evaluation of care needs and updating the POC as frequently as the beneficiary's condition requires but no less than every:

a) Fourteen (14) calendar days for home care, and

b) Seven (7) calendar days for general inpatient care,

3. Direction, coordination and supervision of the hospice care and services provided in accordance with the POC and comprehensive assessments, and

4. Signing initial, periodic, and revisions of the POC.

D. The POC must include all services necessary for the palliation and management of the terminal illness and related conditions, including 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 beneficiary and family needs,

3. Measurable outcomes anticipated from implementing and coordinating the POC,

4. Drugs and treatment necessary to meet the needs of the beneficiary,

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

6. The IDT's/IDG's documentation of the beneficiary's or guardian's/legal representative's level of understanding, involvement, and agreement with the POC in accordance with the hospice's own policies, in the medical record.

E. The POC of a resident of a long-term care facility receiving hospice care should be coordinated between the long-term care facility and the hospice provider to ensure continuity of care.

F. The POC of a waiver participant receiving hospice care should be coordinated between the hospice provider and the waiver provider to ensure continuity of care. Waiver participants who elect to receive hospice care may not receive waiver services which are duplicative of any services rendered through hospice.

Notes

23 Miss. Code. R. 205-1.5

42 C.F.R. Part 418; Miss. Code Ann. § 43-13-121.

Amended 4/1/2018