N.J. Admin. Code § 10:60-2.3

Current through Register Vol. 56, No. 23, December 2, 2024

Section 10:60-2.3 - Plan of care

(a) An interdisciplinary plan of care shall be developed by agency personnel in cooperation with the attending physician/practitioner, and be approved by the attending physician/practitioner. It shall include, but not be limited to, medical, nursing, therapies, nutrition, home health aide services, and social care information. The plan shall be re-evaluated by the nursing staff at least every 60 days and revised as necessary, appropriate to the beneficiary's condition. The following shall be part of the plan of care:

1. The beneficiary's major and minor impairments and diagnoses;

2. A summary of case history, including medical, nursing, and social data;

3. The period covered by the plan;

4. The number and nature of service visits to be provided by the home health agency;

5. Additional health related services supplied by other providers;

6. A copy of physician's/practitioner's initial orders and any subsequent verbal or written orders for changes to the plan of care;

7. Medications, treatments and personnel involved;

8. Equipment and supplies required;

9. Goals, long and short-term;

10. Preventive, restorative, maintenance techniques to be provided, including the amount, frequency and duration;

11. The beneficiary's, family's, and interested person's involvement (for example, teaching); and

12. Discharge planning in all areas of care (coordinated with short and long-term goals);

i. As a significant part of the plan of care, a beneficiary's potential for improvement shall be periodically reviewed and appropriately revised. These revisions shall reflect changes in the medical, nursing, social and emotional needs of the beneficiary, with attention to the economic factors when considering alternative methods of meeting these needs.

ii. Discharge planning shall take the beneficiary's preferences into account when changing the intensity of care in his or her residence, arranging services with other community agencies, and transferring to or from home health providers. Discharge planning also provides for the transfer of appropriate information about the beneficiary by the referring home health agency to the new providers to ensure continuity of health care.

(b) The plan of care shall include an assessment of the beneficiary's acceptance of his or her illness and beneficiary's receptivity to home health care services.

(c) The plan of care shall include a determination of the beneficiary's psycho-social needs in relation to the utilization of other community resources.

(d) The plan of care shall include a description of social services, when provided by the social worker, and be reviewed, with any referrals required to meet the needs of the beneficiary.

N.J. Admin. Code § 10:60-2.3

Amended by 50 N.J.R. 1992(b), effective 9/17/2018

Amended by 54 N.J.R. 1721(a), effective 9/6/2022