La. Admin. Code tit. 48 § I-8069

Current through Register Vol. 50, No. 9, September 20, 2024

Section I-8069 - Plan of Care (POC)

A. A written plan of care is developed for each patient/family by the physician, the medical director or physician designee and the IDT. The care provided to an individual must be in accordance with the POC.

B. At least one of the persons involved in developing the POC must be the registered nurse who conducted the initial assessment. Within three days of the assessment, the IDT must establish the POC. The POC shall be signed by the physician and an appropriate member of the IDT.

C. At a minimum the POC will include:

1. an assessment of the individual's needs and identification of services;

2. detailed description of the scope and frequency of services needed to meet the patient's and family's needs;

3. identification of problems with realistic and achievable goals and objectives;

4. medical supplies and appliances, including drugs and biologicals needed for the palliation and management of the life-limiting illness and related conditions;

5. patient/family understanding, agreement and involvement with the POC; and

6. recognition of the patient/family's psychological, social, religious and cultural variables, values, strengths, and risk factors.

D. The POC shall be incorporated into the clinical record within one week of its completion.

E. The CRCC shall designate a registered nurse to coordinate the implementation of the POC for each patient.

F. The plan of care shall be reviewed and updated when the patient's condition changes, and at a minimum every 90 days for home care and every 14 days for inpatient care, collaboratively with the IDT and the physician.

G. the agency shall have documented policies and procedures for the following:

1. the physician's participation in the development, revision, and approval of the POC. This is evidenced by a change in patient orders and documented communication between CRCC staff and the physician;

2. physician orders must be signed and dated in a timely manner, not to exceed 30 days.

H. The agency shall have documentation that the patient's condition and POC is reviewed and the POC updated, even when the patient's condition does not change.

I. The CRCC shall adhere to the following additional principles and responsibilities:

1. an assessment of the patient/family needs and desire for services and the CRCC programs' specific admission, transfer, and discharge criteria to determine any changes in services;

2. core services routinely available to CRCC patients on a 24-hour basis, seven days a week;

3. all other covered services available to the extent necessary to meet the needs of individuals for care that is reasonable and necessary for the palliation and management of a life-limiting illness and related conditions;

4. case-management provided and an accurate and complete documented record of services and activities describing care of patient/family is maintained;

5. collaboration with other providers to ensure coordination of services;

6. maintenance of professional management responsibility and coordination of the patient/family care regardless of the setting;

7. maintenance of contracts/agreements for the provision of services not directly provided by the CRCC;

8. provision or access to emergency medical care;

9. when the patient is admitted to a setting where CRCC care cannot be delivered, CRCC adheres to standards, policies and procedures on transfer and discharge and facilitates the patient's transfer to another care provider;

10. maintenance of appropriately qualified IDT health care professionals and volunteers to meet the patient's need;

11. maintenance and documentation of a volunteer staff that provide administrative and/or direct patient care. The CRCC must document a continuing level of volunteer activity; and

12. coordination of the IDT, as well as of volunteers, by a qualified health care professional, to assure continuous assessment, continuity of care and implementation of the POC.

La. Admin. Code tit. 48, § I-8069

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 31:455 (February 2005).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2175.14(B).