Rule 111-8-31-.09 - Standards for Patient CarePatients shall be accepted for treatment on the basis of a reasonable expectation that the patient's medical, nursing, and social needs can be met adequately by the agency in the patient's place of residence. Patients shall not be denied services because of their age, sex, race, religion, or national origin. Care shall follow a written plan of treatment established and periodically reviewed by a physician, and shall continue under the supervision of a physician.
(a) Plan of Treatment. An individual plan of treatment shall be developed for each patient in consultation with agency staff, and shall cover all pertinent diagnosis, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, safety measures to protect against injury, instructions for timely discharge or referral, and other appropriate items. If a physician refers a patient under a plan of treatment which cannot be completed until after an evaluation visit, the physician shall be consulted to approve additions or modifications to the original plan. Orders for therapy services shall specify the procedures and modalities to be used, and the amount, frequency, and duration.(b) Periodic Review of Plan of Treatment. The total plan of treatment shall be reviewed by the attending physician and home health agency personnel as often as the severity of the patient's condition requires, but at least once every sixty (60) days. Date of the review and approval of the plan shall be documented by the physician's signature. Agency professional staff shall promptly alert the physician to any changes that suggest a need to alter the plan of treatment.(c) Conformance with Physician's Orders. Drugs and treatment shall be administered by agency staff only as ordered by the physician. The nurse or therapist shall immediately record and sign oral orders and forward the written order within five (5) business days to the physician for countersignature. Documentation of the physician's countersignature must appear in the patient's medical record within thirty (30) days of the verbal order. Professional agency staff shall check all medicines a patient may be taking to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies, and contraindicated medication, and shall promptly report any problems to the physician.(d) Clinical Records. 1. A clinical record shall be established and maintained on each patient in accordance with accepted professional standards and shall contain:(i) pertinent past and current findings;(iii) appropriate identifying information;(v) drug, dietary, treatment and activity orders;(vi) signed and dated clinical and progress notes (clinical notes are written the day service is rendered by the providing member of the health team and incorporated no less often than weekly);(vii) copies of case conferences;(viii) copies of summary reports sent to the physician; and(ix) a discharge summary.2. If a patient transfers to another home health agency or a health facility, a copy of the record or abstract shall be furnished to accompany the patient.3. Sufficient space and equipment for record processing, storage and retrieval shall be provided.4. Policies and procedures shall be written and implemented to assure organization and continuous maintenance of the clinical records system.(e) Retention of Records. Clinical records shall be retained for a period of six years after the last patient encounter for adults, and for six years after a minor reaches the age of majority. These records may be retained as originals, microfilms, or other usable forms and shall afford a basis for complete audit of professional information. If the home health agency dissolves or changes ownership, a plan for record retention shall be developed and placed into effect. The Department shall be advised of the disposition and/or location of said records.(f) Protection of Records. Clinical record information shall be safeguarded against loss or unauthorized use. Written procedures shall govern the use and removal of records and conditions for release of information. A patient's written consent is required for release of information not authorized by law.Ga. Comp. R. & Regs. R. 111-8-31-.09
O.C.G.A. § 31-7-150et seq.
Original Rule entitled "Standards for Patient Care" adopted. F. Feb. 20, 2013; eff. Mar. 12, 2013.