16 Del. Admin. Code § 3351-6.0

Current through Register Vol. 28, No. 3, September 1, 2024

Section 3351-6.0 - Patient Care Management

6.1 Admission

6.1.1 The admission policies shall be discussed with each patient entering the program or her/his representative, if applicable.

6.1.2 The home health agency shall only admit those individuals whose needs can be met by the agency.

6.1.3 There shall be a written agreement between the patient and the home health agency. The agreement shall:

6.1.3.1 Specify the services to be provided by the agency, including but not limited to: frequency of visits including hours per day or week, and days per week, transportation agreements as appropriate, emergency procedures and conditions for discharge and appeal.

6.1.3.2 Specify the procedure to be followed when the agency is not able to keep a scheduled patient visit.

6.1.3.3 Specify financial arrangements which shall minimally include:

6.1.3.3.1 A description of services purchased and the associated cost;

6.1.3.3.2 An acceptable method of payment(s) for these services;

6.1.3.3.3 An outline of the billing procedures; and

6.1.3.3.4 That all payments by the patient for services rendered shall be made directly to the agency or its billing representative and no payments shall be made to or in the name of individual employees/contractors of the agency.

6.1.3.4 Be signed by the patient, if (s)he is able, or a representative, if any, and the representative of the home health agency.

6.1.3.5 Be given to the patient and representative, if any, and a copy shall be kept at the agency in the patient record.

6.1.3.6 Be reviewed and updated as necessary to reflect any change in the services or the financial arrangements.

6.2 Assessment

6.2.1 All assessments of the patient must be performed by a registered nurse.

6.2.2 Prior to the provision of services, at a minimum, the initial assessment must include evidence of the following:

6.2.2.1 Physical condition, including ability to perform activities of daily living and sensory limitations;

6.2.2.2 Social situation, including living arrangements and the availability of family and community support;

6.2.2.3 Mental status, including any cognitive impairment and known psychiatric, emotional, and behavioral problems; and

6.2.2.4 Current medication regimen.

6.2.2.5 A visit to the patient's residence to determine whether the agency has the ability to provide the necessary services in a safe manner.

6.2.3 Reassessments must include, at a minimum, a description of the patient's:

6.2.3.1 Physical condition, including ability to perform activities of daily living and sensory limitations;

6.2.3.2 Social situation, including living arrangements and the availability of family and community support;

6.2.3.3 Mental status, including any cognitive impairment and known psychiatric, emotional, and behavioral problems; and

6.2.3.4 Current medication regimen.

6.2.4 Patient reassessments and monitoring occur at regular intervals based upon the patient's condition and needs, but no less often than every sixty (60) calendar days.

6.2.4.1 Every other patient reassessment must be completed in person.

6.2.4.2 Patient reassessments not completed in person must be completed by a telehealth mechanism.

6.2.5 A reassessment shall be conducted when the needs of the patient change which indicate a revision to the home health aide care plan is needed.

6.2.6 The initial assessment and reassessments shall become a permanent part of the patient's record.

6.3 Home Health Aide Care Plan

6.3.1 The home health agency must provide services in accordance with a written plan of care established by the registered nurse.

6.3.2 A plan of care is developed on admission based upon the initial assessment of the patient.

6.3.3 The patient plan of care shall include reference to at least the following:

6.3.3.1 Types of aide services, scope of services, frequency and duration of services to be provided, including any diet, procedures and transportation required;

6.3.3.2 Functional limitations of the patient;

6.3.3.3 Activities permitted; and

6.3.3.4 Safety measures required to protect the patient from injury.

6.3.4 The plan of care must be reviewed by the registered nurse at least every sixty (60) calendar days.

6.3.5 The home health agency shall consider benefits versus risks of care as well as patient choice and independence in the development and subsequent revisions of the plan of care.

6.3.6 A copy of the plan of care is kept at the patient's residence; the original is kept in the patient's record at the agency.

6.4 Scope of Services

6.4.1 Competent patients who do not reside in a medical facility or a facility regulated pursuant to 16 Del.C. Ch. 11 may delegate personal care services to home health aides provided:

6.4.1.1 The nature of the service/task is not excluded by law or other state or federal regulation;

6.4.1.2 The services/tasks are those competent patients could normally perform themselves but for functional limitation; and

6.4.1.3 The delegation decision is entirely voluntary.

6.4.2 Services provided to patients who are not able to delegate services/tasks due to impaired cognitive function shall be those delegated by the registered nurse as permitted by law.

6.4.3 Services are provided under the supervision and direction of the registered nurse.

6.4.3.1 On-site professional supervisory visits are required for all patients receiving home health aide services.

6.4.3.1.1 The registered nurse must make an on-site supervisory visit to the patient's residence (while the home health aide is providing care) no less frequently than every sixty (60) calendar days.

6.4.3.1.1.1 Every other supervisory visit must be completed in person.

6.4.3.1.1.2 Supervisory visits not completed in person must be completed by a telehealth mechanism.

6.4.3.1.2 A report of the supervisory visit should be kept with the patient's record.

6.5 Records and Reports

6.5.1 There shall be a separate record maintained at the home health agency for each patient, in accordance with accepted standards, which shall contain:

6.5.1.1 Admission record including patient's:

6.5.1.1.1 Name;

6.5.1.1.2 Birth date;

6.5.1.1.3 Home address;

6.5.1.1.4 Telephone number; and

6.5.1.1.5 Date of admission.

6.5.1.2 Assessment (initial and reassessments) including but not limited to:

* Age;

* Height;

* Weight;

* Sex;

* Hearing;

* Vision;

* Speech;

* Functional limitations;

* Nursing diagnosis; and

* History.

6.5.1.3 Home health aide care plan.

6.5.1.4 A copy of the written agreement between the patient and the home health agency including any updates made to the original reflecting changes in services or arrangements.

6.5.1.5 Written acknowledgment that the patient or the patient's representative has been fully informed of the patient's rights.

6.5.1.6 Aide notes which must contain the following information:

6.5.1.6.1 Date(s) on which service(s) are provided;

6.5.1.6.2 Hour(s) of service(s) provided;

6.5.1.6.3 Type(s) of service(s) provided; and

6.5.1.6.4 Observations/problems/comments.

6.5.1.7 A discharge statement.

6.5.1.8 Names, addresses and telephone numbers of family members, friends or other designated people to be contacted in the event of illness or an emergency.

6.5.2 All notes written in the patient's record must be signed and dated or authenticated on the day that the service is rendered.

6.5.3 All notes and reports in the patient's record shall be electronic or legibly written in ink, dated and signed by the recording person with her/his full name and title.

6.5.4 Original notes must be incorporated into the patient's record located at the agency no less often than every 30 days.

6.5.5 All patient records shall be available at all times for review by authorized representatives of the Department and to legally authorized persons; otherwise patient records shall be held confidential. The written consent of the patient or her/his representative, if the patient is incapable of making decisions, shall be obtained before any personal information is released from her/his records as authorized by these regulations or Delaware law.

6.5.6 Computerized patient records must be printed by the agency as requested by authorized representatives of the Department.

6.5.7 The agency must develop acceptable policies for authentication of any computerized records.

6.5.8 The home health agency records shall be retained in a retrievable form until destroyed.

6.5.8.1 Records of adults (18 years of age and older) shall be retained for a minimum of six (6) years after the last date of service before being destroyed.

6.5.8.2 Records of minors (less than 18 years of age) shall be retained for a minimum of six (6) years after the patient reaches eighteen (18) years of age.

6.5.8.3 All records must be disposed of by shredding, burning, or other similar protective measure in order to preserve the patients' rights of confidentiality.

6.5.8.4 Documentation of record destruction must be maintained by the home health agency.

6.5.8.5 At least thirty (30) calendar days before the agency discontinues operations, it must inform the Department where patient records will be maintained.

6.5.9 Records shall be protected from loss, damage, and unauthorized use.

6.5.10 Report of Major Adverse Incidents

6.5.10.1 The home health agency must report all major adverse incidents, occurring in the presence of a home health home health aide, involving a patient to the Department within forty-eight (48) hours in addition to other reporting requirements required by law.

6.5.10.2 A major adverse incident includes but is not limited to:

6.5.10.2.1 Suspected abuse, neglect, mistreatment, financial exploitation, solicitation or harassment;

6.5.10.2.2 An accident that causes serious injury to a patient; and

6.5.10.2.3 The unexpected death of a patient.

6.5.10.3 Major adverse incidents must be investigated by the agency.

6.5.10.4 A complete report will be forwarded to the Department within thirty (30) calendar days of occurrence or of the date that the agency first became aware of the incident.

6.6 Discharge

6.6.1 The patient or her/his representative if any, shall be informed of and participate in discharge planning.

6.6.2 The home health agency shall develop a written plan of discharge which includes a summary of services provided and outlines the services needed by the patient upon discharge.

6.6.3 When discharging a patient who does not wish to be discharged, a minimum of two (2) weeks notice will be provided to permit the patient to obtain an alternate service provider. Exceptions to the two (2) week notice provision would include:

6.6.3.1 The discharge of patients when care goals have been met.

6.6.3.2 The discharge of patients when care needs undergo a change which necessitates transfer to a higher level of care.

6.6.3.3 The discharge of patients when there is documented non-compliance with the plan of care or the admission agreement (including, but not limited to, non-payment of justified charges).

6.6.3.4 The discharge of patients when activities or circumstances in the home jeopardize the welfare and safety of the home health aide.

16 Del. Admin. Code § 3351-6.0

12 DE Reg. 1209 (03/01/09)
19 DE Reg. 847(3/1/2016)
25 DE Reg. 521(11/1/2021)
26 DE Reg. 915( 5/1/2023) (Emer.)
27 DE Reg. 45( 7/1/2023) (Final)