42 CFR 484.60 — Condition of Participation: Care Planning, Coordination of Services, and Quality of Care

What this rule requires your agency to do

• 1Patients may be accepted only on the reasonable expectation the HHA can meet the patient's medical, nursing, rehabilitative, and social needs at home, and each patient must receive an individualized written plan of care specifying the services necessary to meet the needs identified in the comprehensive assessment, the responsible discipline(s), anticipated measurable outcomes, and patient/caregiver education and training; services must be furnished in accordance with accepted standards of practice (introductory paragraph).(42 CFR 484.60 — Condition of Participation: Care Planning, Coordination of Services, and Quality of Care)
• 2The HHA must provide the patient and caregiver written instructions outlining the visit schedule, the medication schedule/instructions (name, dosage, frequency, and which are HHA-administered), treatments to be administered, other pertinent care instructions, and the name and contact information of the HHA clinical manager (subd. e).(42 CFR 484.60 — Condition of Participation: Care Planning, Coordination of Services, and Quality of Care)
• 3The individualized plan of care must be established, periodically reviewed, and signed by a physician or allowed practitioner and must include all pertinent diagnoses; mental/psychosocial/cognitive status; services, supplies and equipment; frequency and duration of visits; prognosis; rehabilitation potential; functional limitations; activities permitted; nutritional requirements; all medications and treatments; safety measures; the patient's ED/hospital-readmission risk and interventions; patient/caregiver education and training; measurable outcomes and goals; and any advance-directive information (subd. a).(42 CFR 484.60 — Condition of Participation: Care Planning, Coordination of Services, and Quality of Care)
• 4Revisions to the plan of care must be communicated: health-status changes to the patient, representative, caregiver, and all ordering practitioners; discharge-related revisions also to the patient's primary care practitioner or other professional responsible for post-discharge care (subd. c(3)).(42 CFR 484.60 — Condition of Participation: Care Planning, Coordination of Services, and Quality of Care)
• 5All patient care orders, including verbal orders, must be recorded in the plan of care; drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner; verbal orders may be accepted only by authorized personnel, must be documented (signed, dated, and timed) in the clinical record, and must be authenticated and dated by the ordering practitioner (subds. a(3), b).(42 CFR 484.60 — Condition of Participation: Care Planning, Coordination of Services, and Quality of Care)
• 6The plan of care must be reviewed and revised by the responsible physician/allowed practitioner and the HHA as frequently as the patient's condition requires but no less frequently than once every 60 days from the start-of-care date, and the HHA must promptly alert the practitioner to changes suggesting outcomes are not being achieved (subd. c).(42 CFR 484.60 — Condition of Participation: Care Planning, Coordination of Services, and Quality of Care)
• 7The HHA must coordinate care — assuring communication with all involved practitioners, integrating orders and services (including services under arrangement), coordinating delivery with patient/caregiver involvement, and ensuring ongoing patient and caregiver education including training necessary for timely discharge (subd. d).(42 CFR 484.60 — Condition of Participation: Care Planning, Coordination of Services, and Quality of Care)