DHS 131.25(2)(b)2.2. Promptly notify the registered nurse of any change in patient status that suggests a need to update the plan of care. DHS 131.25(2)(b)4.4. Provide education and counseling to the patient and, as necessary, to the patient’s family, consistent with the plan of care. DHS 131.25(2)(b)5.5. Participate in developing and revising written patient care policies and procedures. DHS 131.25(2)(c)(c) The hospice may contract for physician services as specified in par. (a). A hospice may use contracted staff, if necessary, to supplement hospice employees in order to meet the needs of patients under extraordinary or other non-routine circumstances. A hospice may also enter into a written arrangement with another Medicare certified hospice program for the provision of core services to supplement hospice staff to meet the needs of patients. Circumstances under which a hospice may enter into a written arrangement for the provision of core services include unanticipated periods of high patient loads, staffing shortages due to illness or other short-term temporary situations that interrupt patient care and temporary travel of a patient outside of the hospice’s service area. DHS 131.25(3)(3) Physician services. The hospice medical director, physician employees, and contracted physicians of the hospice, in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness and conditions related to the terminal illness. DHS 131.25(3)(a)(a) All physician employees and those under contract must function under the supervision of the hospice medical director. DHS 131.25(3)(b)(b) All physician employees and those under contract shall meet this requirement by either providing the services directly or through coordinating patient care with the attending physician. If the attending physician is unavailable, the medical director, contracted physician, and or hospice physician employee is responsible for meeting the medical needs of the patient. DHS 131.25(4)(a)(a) Nursing services shall be provided by or under the supervision of a registered nurse and shall consist of all of the following: DHS 131.25(4)(a)1.1. Regularly assessing the patient’s nursing needs, implementing the plan of care provisions to meet those needs and reevaluating the patient’s nursing needs. DHS 131.25(4)(a)2.2. Supervising and teaching other nursing personnel, including licensed practical nurses, nurse aides. DHS 131.25(4)(a)3.3. Evaluating the effectiveness of delegated acts performed under the registered nurse’s supervision. DHS 131.25(4)(b)(b) Highly specialized nursing services that are provided so infrequently that the provision of such services by direct hospice employees would be impracticable and prohibitively expensive, may be provided under contract. DHS 131.25(4)(c)(c) Licensed practical nursing services. If licensed practical nursing services are provided, the licensed practical nurse shall function under the supervision of a registered nurse with duties specified in writing and updated by a registered nurse. DHS 131.25(5)(a)(a) Social services shall be provided by a qualified social worker and shall consist of all of the following: DHS 131.25(5)(a)1.1. Regularly assessing the patient’s social service needs, implementing the plan of care to meet those needs and reevaluating the patient’s needs and providing ongoing psychosocial assessment of the family’s coping capacity relative to the patient’s terminal condition. DHS 131.25(5)(a)2.2. Linking patient and family with needed community resources to meet ongoing social, emotional and economic needs. DHS 131.25(6)(6) Counseling services. Counseling services shall be available to the patient and family to assist the patient and family in minimizing the stress and problems that arise from the terminal illness, related conditions, and the dying process. DHS 131.25(6)(a)(a) Bereavement services. Bereavement services shall be provided to families of hospice patients. Each hospice shall have its own bereavement program. Bereavement services shall be: DHS 131.25(6)(a)1.1. Coordinated by an individual who possesses the capacity by training and experience to provide for the bereavement needs of families, including the ability to organize a program of directed care services provided to family members. DHS 131.25 (6). DHS 131.25(6)(a)2.2. Compatible with the core team’s direction within the plan of care for the patient. DHS 131.25(6)(a)3.3. Available for one year following the patient’s death as part of an organized program and provide all of the following: DHS 131.25(6)(a)3.a.a. Orientation and training to individuals providing bereavement services to ensure that there is continuity of care. DHS 131.25(6)(a)3.b.b. Service intervention either directly or through trained bereavement counselors. DHS 131.25(6)(a)3.c.c. Assignment, supervision and evaluation of individuals performing bereavement services. DHS 131.25(6)(a)3.d.d. Referrals of family members to non-hospice community programs where appropriate.