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Title: Section 763.6 - Patient assessment and plan of care

Effective Date


763.6 Patient assessment and plan of care.

(a) A comprehensive interdisciplinary patient assessment shall be completed, involving, as appropriate, a representative of each service needed, the patient, the patient's family or legally designated representative and patient's authorized practitioner. Such assessment shall address, at a minimum, the medical, social, mental health and environmental needs of the patient.

(b) A plan of care shall be developed within 10 days of admission to the agency and approved by the patient based on the comprehensive interdisciplinary patient assessment. The plan shall designate a professional person employed by the agency to be responsible for coordinating care which includes but is not limited to:

(1) coordination of all services provided directly or by contract to the patient by the agency, informal supports and other community resources to carry out the agency's plan of care;

(2) cooperation with other health, social and community organizations providing or coordinating care;

(3) consultation with the patient's authorized practitioner, the local social services representative and discharge planner, if applicable. If an authorized practitioner has referred a patient under a plan of care that cannot be completed until after an evaluation visit, the authorized practitioner shall be consulted to approve additions or modifications to the original plan; and

(4) responsibility for maintaining current clinical records, conducting case reviews and completing required patient-specific records and reports, as appropriate.

(c) The plan of care shall cover all pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, prognosis, need for palliative care, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items.

(d) Orders for therapy services shall include the specific procedures and modalities to be used and the amount, frequency and duration of such services.

(e) The plan of care shall be reviewed as frequently as required by changing patient conditions but at least every 60 days.

(1) Each review shall be documented in the clinical record; and

(2) Agency professional personnel shall promptly alert the patient's authorized practitioner to any significant changes in the patient's condition that indicate a need to alter the plan of care.


VOLUME E (Title 10)