W. Va. Code R. § 64-54-6 - Coordination of care

6.1. At the time an individual is accepted for care, or no later than the second calendar day, a hospice shall obtain documentation from the attending physician and the physician member of the hospice interdisciplinary team or medical director stating the client is terminally ill.

6.1.a. The physician shall certify the patient to be terminally ill indicating a life expectancy of six (6) months or less or another length of time as determined by the Centers for Medicare and Medicaid Services and designated in federal hospice regulations.

6.1.b. A verbal certification shall be obtained and signed by both physicians if the written certification is not obtained by both physicians within two (2) calendar days following the initiation of hospice care.

6.1.c. The certification may be completed up to two (2) weeks before hospice care is elected.

6.2. The physician member of the hospice interdisciplinary team or medical director shall document re-certification of the terminal illness at the end of the first ninety (90) days of care and again at the end of the second ninety (90) days of care if the patient remains under the care of the hospice.

6.3. A patient remaining under the care of a hospice for a period of time in excess of six (6) months shall be re-evaluated every sixty (60) days by the physician member of the interdisciplinary team or medical director with respect to the prognosis for life expectancy. A patient shall be considered for transfer to other types of health care providers in the event of an improvement in his or her medical condition.

6.3.a. The documentation shall be included in the clinical record and shall be signed by the hospice physician within fourteen (14) days of the re-evaluation assessment.

6.4. A registered nurse shall make an initial assessment evaluation visit to the patient's residence in a time frame consistent with Medicare hospice guidelines after a hospice receives a physician's order for care, unless ordered otherwise by the physician, to determine the patient's immediate care and support needs.

6.5. The medical social worker shall make an initial home visit to assess the patients' needs in a time frame consistent with Medicare hospice guidelines after the initial visit by the registered nurse.

6.6. The initial spiritual assessment and documentation of volunteer services shall be conducted after the initial visit in a time frame consistent with Medicare hospice guidelines.

6.7. All other assessments shall be conducted in a time frame consistent with Medicare hospice guidelines.

6.8. The interdisciplinary team, in consultation with the patient's attending physician, shall complete a comprehensive assessment in a time frame consistent with Medicare hospice guidelines.

6.8.a. The comprehensive assessment shall include an assessment of the patient's physical, psychosocial, emotional and spiritual needs and a family bereavement assessment.

6.9. The interdisciplinary team shall develop an interdisciplinary plan of care within seven (7) days of the patient's acceptance into the hospice program.

6.9.a. The plan of care shall contain at a minimum the following:

6.9.a.1. A diagnosis and prognosis;

6.9.a.2. Orders for each service that includes the scope and frequency of visits needed to meet the patient's needs;

6.9.a.3. Orders for medications and treatments;

6.9.a.4. Orders for medical tests; and

6.9.a.5. Any other information needed to meet the needs of the patient for palliation and management of the patient's terminal illness.

6.9.b. The interdisciplinary team shall update the plan of care as frequently as the patients condition requires:

6.9.b.1. But no less than every fourteen (14) days; and

6.9.b.2. At the time of each re-certification.

6.9.c. All personnel representing the scope of services being provided to the patient shall participate in the plan of care.

6.9.d. The patient and his or her family shall be included in the establishment and review of the plan of care.

6.10. When the patient requires an inpatient stay for services related to the hospice diagnosis, the hospice shall provide, at a minimum, the written interdisciplinary team plan of care to the facility within twenty- four (24) hours of the patient's transfer.

6.10.a. An inpatient stay for acute symptom management shall:

6.10.a.1. Be provided in a facility acceptable to the Centers for Medicare and Medicaid Services for this purpose, and;

6.10.a.2. Include the hospice ensuring a Registered Nurse is directly available for care of the patient at all times.

6.10.b. Respite care for caregiver relief shall:

6.10.b.1. Be provided in a facility acceptable to the Centers for Medicare and Medicaid Services for this purpose.

6.10.c. Upon transfer to an inpatient facility the hospice nurse shall make a visit to the facility to provide instructions and ensure the patient's continuity of care.

6.10.c.1. If the visit to the facility can not be completed on admission, then the hospice shall contact the facility with a verbal report to the nursing staff and follow up with a visit within forty-eight (48) hours of the transfer.

6.10.d. The plan of care shall be updated to reflect the change in the patient's status.

6.10.e. The hospice shall continue to make visits as noted in the plan of care to the patient during the inpatient stay to ensure the continuity of care.

Notes

W. Va. Code R. § 64-54-6