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the client’s clinical record. The agency shall update the plan of care at intervals specified in the plan of care, or more frequently if determined necessary by the

(1) medical director;

(2) attending physician;

(3) advanced practice registered nurse responsible for the client’s care; or

(4) interdisciplinary team. (c) Each plan of care must address client and family problems and needs, goals and objectives, the frequency and type of services, the level of care to be provided, agreed-upon outcomes, prescribed or required medical equipment, and evidence of client and family understanding, agreement, and involvement with the plan of care. The interdisciplinary team shall consider the need for at least the following services when developing the plan of care:

(1) social work services;

(2) nursing care;

(3) counseling;

(4) pastoral care;

(5) volunteer visits to provide comfort, companionship, and respite;

(6) bereavement services to be provided for at least one year after the death of the person who is terminally ill;

(7) medical services. (d) The hospice agency shall designate a registered nurse to coordinate each client’s overall plan of care. (e) The hospice agency shall promptly alert the attending physician or advanced practice registered nurse of conditions that may require a change to a plan of care. The agency must obtain a verbal order from the attending physician or advanced practice registered nurse, or from the medical director, before making any change to a client’s medical treatment. The agency shall ensure that signed written orders are in the client’s file within 21 days after the verbal order was taken. (Eff. 5/24/2007, Register 182; am 5/14/2021, Register 238) Statutory Authority: Authority: AS 47.32.010 AS 47.32.030