Oklahoma Administrative Code
Title 310 - Oklahoma State Department of Health
Chapter 661 - Hospice
Subchapter 5 - Minimum Standards
Section 310:661-5-2.1 - Interdisciplinary group, care planning, and coordination of services

(a) General. The hospice must designate an interdisciplinary group or groups which, in consultation with the patient's attending physician, will prepare a written plan of care for each patient. The plan of care will specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions.

(b) Approach to service delivery.

(c) Plan of care. All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs. The hospice will ensure that each patient 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 plan of care.

(d) Content of the plan of care. The hospice must develop an individualized written plan of care for each patient. The plan of care will reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including at least the following:

(e) Review of the plan of care. The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) must review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every fifteen (15) calendar days. A revised plan of care must include information from the patient's updated comprehensive assessment and note the patient's progress toward outcomes and goals specified in the plan of care.

(f) Coordination of services. The hospice must develop and maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, to: