10a NCAC 13K .0701       CARE PLAN

(a)  The hospice shall develop and implement policies and procedures which ensure that a written care plan is developed and maintained for each patient and family.  The plan shall be established by the interdisciplinary care team in accordance with the orders of the attending physician and be based on the complete assessment of the patient's and family's medical, psychosocial and spiritual needs.  The patient and family care coordinator shall have the primary responsibility for assuring the implementation of the patient's care plan.  The plan shall include the following:

(1)           patient's diagnosis and prognosis;

(2)           identification of problems or needs and the establishment of appropriate goals;

(3)           types and frequency of services required to meet the goals; and

(4)           identification of personnel and disciplines responsible for each service.

(b)  The care plan shall be reviewed by appropriate interdisciplinary care team members and updated at least once monthly.  The interdisciplinary care team and other appropriate personnel shall meet at least once every two weeks for the purpose of care plan review and staff support.  Minutes shall be kept of these meetings that include the date, names of those in attendance and the names of the patients discussed.  Additionally, entries shall be recorded in the medical records of those patients whose care plans are reviewed.


History Note:        Authority G.S. 131E‑202;

Eff. November 1, 1984;

Amended Eff. February 1, 1996; November 1, 1989.