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ACHC Trivia Challenge: The Top Ten, Part Two!

November 13, 2020, by Kelly Olmeda

ACHC Standard: The hospice develops an individualized written plan of care for each patient in collaboration with the attending physician, the patient or representative, and the primary caregiver in accordance with the patient’s needs, if any of them so desire. The plan of care must reflect patient/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.

Tips for Compliance:

Ensure the plan of care includes all services necessary for the palliation and management of the terminal illness to include medications, treatments, disciplines providing care, equipment, and supplies. (All of the above)

Ensure an individualized plan of care is established for each patient and family based on the identified needs in the initial and ongoing assessments. 


ACHC Standard: There is evidence that the plan of care is reviewed and changes are made to the plan of care based on reassessment data.

Tips for Compliance:

When should changes be made to the plan of care? When the patient’s or family’s needs change

Ensure the medical record contains documentation to support progress toward goals identified in the Plan of Care.

List two changes to the Plan of Care you might expect to see when a patient appears to be transitioning or actively dying.

These are the wonderful answers we received:
– Increased visit frequency for all disciplines
– Medication changes (new meds, less meds, meds for comfort, change in dosage, different routes)
– Decrease in PPS score
– Ending or beginning goals/interventions, adding actively dying
– Education provided to families on the use of comfort meds and other interventions

Thanks for playing along!