Section 22-B3914. PATIENT PLAN OF CARE

 

3914.1Each home care agency shall develop, with the participation of each patient or his or her representative, a written plan of care for that patient.

 

3914.2The plan of care shall be approved by the patient's physician.

 

3914.3The plan of care shall include the following:

 

(a)Physician orders for skilled services;

 

(b)Advanced practice registered nurse orders, when appropriate and permissible according to applicable law;

 

(c)The goals of the services to be provided, including the expected outcome, based upon the immediate and long-term needs of the patient;

 

(d)A description of the services to be provided, including: the frequency, amount, and expected duration; dietary requirements; medication administration, including dosage; equipment; and supplies;

 

(e)Identification of agency personnel who are responsible for the provision of each service, including, if applicable, contract providers by job title or discipline;

 

(f)Provisions relating to the reevaluation of services, discharge planning, referral of services and continuation or renewal of services;

 

(g)Physical assessment, including all pertinent diagnoses;

 

(h)Prognosis, including rehabilitation potential;

 

(i)Activities permitted or precluded because of functional limitations;

 

(j)Psychosocial needs of the patient;

 

(k)Safety measures required to protect the patient from injury;

 

(l)Identification of employees in charge of managing emergency situations;

 

(m)Emergency protocols; and

 

(n)Types and frequency of laboratory tests ordered, if applicable.

 

3914.4Each plan of care shall be approved and signed by a physician within thirty (30) days of the start of care; provided, however, that a plan of care for personal care aide services only may be approved and signed by an advanced practice registered nurse. If a plan of care is initiated or revised by a telephone order, the telephone order shall be immediately reduced to writing, and it shall be signed by the physician within thirty (30) days.

 

3914.5Each home care agency that provides more than one skilled service shall record, in the plan of care, evidence of coordination of care, and specific information related to the provision of each skilled service as set out in subsequent relevant sections of these regulations.

 

source

Final Rulemaking published at 51 DCR 2876 (March 19, 2004).