Section 7 AAC 12.513 - Plan of care(a) A home health agency shall, in consultation with the patient and the patient's attending physician, advanced practice registered nurse, or physician assistant, develop a plan of care for each patient accepted by the agency. The plan of care must (1) be reviewed, as often as the patient's condition requires but at least every 62 days, by (A) the attending physician, advanced practice registered nurse, or physician assistant; and(B) the professional staff of the agency;(2) be signed by the attending physician, advanced practice registered nurse, or physician assistant and included in the patient's clinical record not later than 21 days after the start of care or the recertification date of the agency;(3) identify long and short term goals of patient care that provide measurable indices of performance;(4) address all pertinent diagnoses, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, safety measures to protect against injury, planning for discharge, instructions for timely discharge or referral, and any other factors relevant to the care of that patient.(b) The agency shall promptly alert the attending physician, advanced practice registered nurse, or physician assistaint of conditions that may require a change to the plan of care. The attending physician, advanced practice registered nurse, or physician assistant must approve any changes to the plan of care.(c) The agency shall discuss the following information with the patient and document the discussion in the patient's clinical record: (2) the services that the agency will provide;(3) alternate services available when the agency is unable to meet identified needs of the patient.Eff. 9/6/96, Register 139; am 5/14/2021, Register 238, July 2021 Authority:AS 18.05.040
AS 47.32.010
AS 47.32.030