Assess/Plan- Assess and develop individualized needs and plan of care: Initial and ongoing comprehensive assessments are complete and appropriate for patients age, special care needs, patient’s knowledge level, and psychosocial, emotional, physical, functional, environmental, and spiritual needs. The Registered Nurse / Care Manager in Hospice is responsible for managing and coordinating the plan of care for hospice patients in their place of residence and to coordinate care with the Interdisciplinary Team, patients, families, referring agency/facility, and/or caregivers.