Policy Manual sample

MDT Home Health Care Agency, Inc. POLICY ON PATIENT VISITS/PLAN OF CARE/VERBAL ORDERS/ASSESSMENT AND CONSULTATION WITH A PHYSICIAN POLICY: Define the Agency Policy on Patient’s visit, Plan of Care, Verbal Orders, assessment and physician consultation Following the acceptance of a case, the Director of Nursing, Clinical Manager or a Registered Nurse shall visit the patient within 48 hours and make an initial assessment of the case to include a well defined Patient Care Plan (including all discipline ordered), for Patient’s required OASIS assessment, the completed Assessment must be delivered to Agency in 72 hours. In consultation with a treating or attending physician, the Admitting RN shall draw up a Plan of Treatment/Care, which must be approved and signed by a treating or attending physician (Mandatory for Medicare Providers), physician assistant, or advanced registered nurse practitioner, acting within his or her respective scope of practice within 30 days if possible, but always before billing. This policy and procedure shall be followed in all cases. As a Medicaid/Medicare Certified Agency, we shall comply with a review/update the Plan of Care every 60 days, in coordination with the Patient’s treating or attending Physician (Mandatory for Medicare Providers), PA or ARNP, (Advanced Registered Nurse Practitioner), acting within their scope of practice. Verbal order means a physician order that is spoken to appropriate personnel and later put in writing for the purposes of documenting as well as establishing or revising the patient’s plan of care. When services are provided on the basis of a physician’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and our HHA’s policies, we must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician in accordance with applicable state laws and regulations, as well as our HHA’s internal policies. All Modify/Verbal order (including Initial-Admission, Reinstatement, Recertification, Modify, or Medication orders), Medical Necessity Letter if applicable, must be signed by the treating or attending Physician (Mandatory for Medicare Providers), PA, or ARNP when the Agency receive the Referral from Doctor’s Office or Referral Source, within 30 days, and always before billing for services. Verbal orders are put in writing and signed and dated with the date of receipt by the Registered Nurse or qualified therapist responsible for furnishing or supervising the ordered services and countersigned by the physician as soon as possible (at least within 30 days). It is the RN’s or therapist’s responsibility to make any necessary revisions to the plan of care based on that order. Changes in patient status, including measurements outside of stated parameters, or any changes that suggest a need to alter the plan of care, are reported promptly to the physician. This includes notifying the treating or attending physician of discharge when the patient's needs have been met. A D/C summary will be faxed/emailed or mailed to the attending Physician. The treatment orders shall be reviewed, as frequently as the patient's illness requires, by the physician, physician assistant, or advanced registered nurse practitioner in consultation with Home Health Agency Policies A-199