Policy Manual sample

MDT Home Health Care Agency, Inc. POLICY ON PLAN OF CARE ELIGIBILITY CRITERIA FOR ADMISSION A Registered Nurse, Physical Therapist, or Speech Therapist conducts an initial assessment to determine eligibility, immediate care and support needs of the patient. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician-ordered start of care date. A comprehensive assessment is completed in a timely manner, consistent with the patient’s immediate needs, but no later than five (5) calendar days after the start of care. The plan of care should be appropriate for the type of care that is needed. Care planning is directed toward driving positive patient outcomes. The Plan of Care shall be established for all of our clients, in consultation with the physician, physician assistant, or advanced registered nurse practitioner, acting within his or her respective scope of practice, and our staff who are involved in providing the care and services required to carry out the physician’s treatment orders. The plan must be included in the clinical record and available for review by all staff involved in providing care to the patient. Medicare patients must have documented eligibility for Medicare benefits and determination of homebound status. Have had a face-to-face encounter with a physician or allowed Non- Physician Practitioner (NPP). (Medicare recipient patients). Eligibility Criteria for Admission (Included in the Patient’s Admission package): Admission to this Agency can only be made under the directions of a physician, based upon the patient’s identified care needs, homebound status and the type of services required that we can provide directly or through coordination with other organizations. If we cannot meet our patients needs, either directly by our Agency or indirectly through service agreement with other providers, we will not admit them or will not continue to provide services to them. Have had a face-to-face encounter with a physician or allowed Non-Physician Practitioner (NPP). (Medicare recipient patients). The plan of care shall contain a list of individualized specific goals for each skilled discipline that provides patient care, with implementation plans addressing the level of staff who will provide care, the frequency/duration of home visits to provide direct care and case management, and the frequency of supervisory visits for staff providing direct care. All our staff must follow the physician’s treatment orders that are contained in the plan of care. If the order cannot be followed and must be altered in some way, the patient’s physician must be notified and must approve of the change. Any verbal changes are put in writing and signed and dated with the date of receipt by the nurse or therapist who talked with the physician’s, PA, advanced registered nurse practitioner (ARNP) office. The patient or guardian must be informed by our Agency personnel that: (A) He has the right to be informed of the plan of care (B) He has the right to participate in the development of the plan of care, and (C) He may have a copy of the plan if requested Also, in keeping with acceptable practices as outlined by the Office of Licensor and Regulation, this initial patient’s Plan of Care shall be reviewed at least once every sixty (60) days to determine the appropriateness of services continuation, modification or termination. In all cases of such a review, both the patient's physician, PA or ARNP (Advanced Registered Nurse Practitioner), acting within their scope of practice, and our agency's Director of Nursing, Clinical Manager shall affix their signatures to the Plan of Care form in order to authenticate the decision. The staff assigned to develop a Plan of Care/Treatment, or delivery the care to our patient must reach special education, experience or licensure/certification requirements necessary for the clinical personnel to provide any special procedures or treatments. Qualifications may vary Home Health Agency Policies A-20