Common use of INTEGRATED PLAN OF CARE Clause in Contracts

INTEGRATED PLAN OF CARE. (a) The hospice core team shall develop an integrated plan of care for the new patient within 72 hours after the admission. The integrated plan of care shall be developed jointly by the employee who performed the initial assessment and at least one other member of the core team. The core team shall use the initial plan of care as a basis for team deci- sion−making and shall update intervention strategies as a result of core team assessment and planning collaboration. The care coor- dinator is responsible for ensuring that ensuing interventions by hospice employees are consistent with the initial and integrated plans of care. (b) The integrated plan of care shall detail the scope and range of services to be provided, and shall: 1. Identify patient and family needs; 2. Specify service interventions to meet the identified needs; 3. Identify the employees responsible for providing the inter- ventions; 4. Include physician orders and medical procedures. If the physician’s orders were originally given orally, the registered nurse shall have immediately recorded and signed them and obtained the physician’s countersignature on the record within the next 10 days; and 5. Establish timeframes for evaluating the interventions needed to achieve the long−term and short−term goals and the effectiveness of those interventions as they relate to the identified patient and family problems or needs and the expected outcomes.