16 Del. Admin. Code § 3330-12.0

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

Section 3330-12.0 - Patient Plan of Care

12.1 The interdisciplinary team must develop and implement a written, comprehensive, individualized plan of care for each patient based on the comprehensive assessment which:

12.1.1 Specifies the services necessary to address the patient's needs; and

12.1.2 Includes measureable and expected outcomes and estimated timetables to achieve these outcomes.

12.1.2.1 Outcomes must be consistent with current evidence-based professionally-accepted clinical standards of practice.

12.2 The plan of care must address:

12.2.1 Dose of dialysis;

12.2.2 Dialysis adequacy;

12.2.3 Nutritional status;

12.2.4 Mineral metabolism;

12.2.5 Anemia;

12.2.6 Vascular access;

12.2.7 Psychosocial status;

12.2.8 Modality;

12.2.9 Transplantation status;

12.2.10 Rehabilitation status; and

12.2.11 Patient education and training.

12.3 The plan of care shall include evidence of coordination with other providers (i.e. hospitals, long term care facilities, home and community support services, transportation services, etc.) as needed to assure the provision of safe care.

12.4 Implementation of the plan of care

12.4.1 The plan of care must be signed and dated by all members of the interdisciplinary team.

12.4.1.1 If the patient chooses not to sign the plan of care, this choice must be documented along with the rationale the signature was not provided.

12.4.2 The initial plan of care must be implemented within the latter of 30 calendar days after admission to the dialysis center or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session.

12.4.3 Implementation of monthly or annual updates of the plan of care must be performed within 15 days of the completion of the comprehensive assessment as required by subsection 12.4.

12.4.4 If the expected outcome is not achieved, the interdisciplinary team must:

12.4.4.1 Revise the plan of care to reflect the patient's current condition;

12.4.4.2 Document the reason(s) why the patient was unable to achieve the goal; and

12.4.4.3 Implement the revisions to the plan of care.

12.5 The dialysis center must ensure that all dialysis patients are seen and evaluated by a physician or non-physician provider providing ESRD care at least monthly and at least quarterly while the patient is receiving in-center hemodialysis, as evidenced by documentation in the medical record.

16 Del. Admin. Code § 3330-12.0

22 DE Reg. 853( 4/1/2019) (final)