Rule 111-8-22-.12 - Patient Care Plans(1) The facility shall coordinate services for each patient through an interdisciplinary treatment team approach. An interdisciplinary treatment team shall be identified at the time of admission for each patient and shall consist of at least: (a) The patient and any family member(s) or other(s) designated as a representative of the patient who wishes to participate and is invited by the patient to participate;(b) Either the patient's attending physician or the medical director of the end stage renal disease facility;(c) A qualified registered nurse, who is responsible for nursing services at the facility;(d) A licensed social worker;(e) A licensed dietitian; and(f) A transplant surgeon or surgeon-designee.(2) There shall be documentation of the participation of the patient (or their representative) in the development and review of the patient's plan of care, with consideration given to the patient's preferences. If participation is declined, the declination shall be documented, and there shall be evidence that the content of the plan(s) or decisions were reviewed with the patient or their representative.(3) The treatment team shall develop a written, individualized plan of care for each patient, designating a selected treatment modality and a selected setting for treatment. (a) The care plan shall be developed within 30 days of admission to the facility.(b) All suitable treatment modalities shall be considered by the treatment team, regardless of their availability at the current facility, and there shall be consideration of the patient's preferences as well as clinical and psychosocial needs.(c) The care plan for patients deemed unsuitable for transplant shall indicate the specific rationale for the unsuitability.(d) For patients for whom transplant referral has been selected, educational and rehabilitation needs shall be addressed as a part of the care plan.(e) The care plan shall be reviewed and updated at least annually, or sooner if there has been a change in the selected treatment modality or setting.Ga. Comp. R. & Regs. R. 111-8-22-.12
O.C.G.A. § 31-44-3.
Original Rule entitled "Patient Care Plans" adopted. F. Feb. 20, 2013; eff. Mar. 12, 2013.Amended: F. May 9, 2017; eff. May 29, 2017.