Section 141.202 - Plan of Care/Assessments(A) The hospice shall develop a comprehensive written plan of care by an interdisciplinary hospice care team and if applicable, the patient's attending physician or primary care provider, prior to provision of services. The initial plan of care shall be developed within three days of admission by at least three members of the interdisciplinary team as defined by 105 CMR 141.203, including a registered nurse and the medical director. The initial plan of care shall be reviewed and ratified by the full interdisciplinary team at their next scheduled meeting.(B) The patient/family shall be permitted and encouraged to actively participate in the care planning process and the provision of care. Such participation shall be documented in the patient/ family record.(C) The plan of care shall include, but not be limited to:(1) pertinent diagnosis and prognosis;(2) identification of the physical, psychological, social, economic and spiritual status of the patient/family;(3) need for inpatient care (respite or general), nutritional needs, medication needs, need for management of discomfort and symptom control, and need for management of grief;(4) plan to address identified needs including scope of services required;(5) identification of anticipated frequency of services needed;(6) designation of the primary care giver or alternate plan to provide 24-hour care and support in the patient's home;(7) identification of the person responsible for coordinating care;(8) plans instructing the patient/family or designated caregiver in patient care;(9) plans for support and care at the time of death; and(10) plans for providing bereavement care to family.(D) The comprehensive plan of care shall reflect the changing care needs of the patient/family, and be reviewed and revised as necessary, but at least twice a month by the interdisciplinary care team. These reviews shall be documented in the patient/family record.Amended by Mass Register Issue 1358, eff. 2/9/2018.Amended by Mass Register Issue 1453, eff. 9/8/2021.Amended by Mass Register Issue 1457, eff. 9/8/2021.Amended by Mass Register Issue 1505, eff. 9/29/2023.