(a) A hospice must designate an interdisciplinary team (IDT) to prepare a written plan of care for a client in consultation with the client's attending practitioner, if any, the client or the client's legal representative, and the primary caregiver, if any of them so desire.
(b) The IDT must develop an individualized written plan of care for each client. The plan of care must reflect client and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments.
(c) The hospice must provide care and services to a client and the client's family in accordance with an individualized written plan of care established by the hospice IDT.
(d) The client's plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. The plan of care must include:
  (1) interventions to manage pain and symptoms;
  (2) a detailed statement of the scope and frequency of services necessary to meet the specific client and family needs;
  (3) measurable outcomes anticipated from implementing and coordinating the plan of care;
  (4) drugs and treatments necessary to meet the needs of the client;
  (5) medical supplies and equipment necessary to meet the needs of the client; and
  (6) the IDT's documentation, in the client record, of the client's or the client's legal representative's level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice's policies.
(e) The hospice must ensure that the client and the client's primary caregiver receives education and training provided by hospice staff as appropriate to the client's and the client's primary caregiver's responsibilities for providing the care and services specified in the client's plan of care.

Source Note: The provisions of this §558.821 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427