Current through Register Vol. 35, No. 9, May 7, 2024
Section 7.28.2.33 - PLAN OF CARE Care of a patient/client by the agency must follow a written plan of care which is reviewed at least annually.
A.Medically directed care: An agency must follow a written plan of care established and periodically reviewed by a physician, physician assistant, nurse practitioner or clinical nurse specialist within the extent of their licensed scope of practice as defined by state law. Care continues under the supervision of a physician, physician assistant, nurse practitioner and clinical nurse specialist acting within the extent of their licensed scope of practice as defined by state law. (1) The plan of care shall be developed in consultation with a patient/client , appropriate agency staff and cover all pertinent diagnoses, including but not limited to: (b) types of services and equipment required;(c) frequency and duration of visits;(d) functional limitations;(e) activities permitted;(f) nutritional requirements;(g) medications and treatments;(h) safety measures to protect against injury;(i) plans or goals for care;(j) any other appropriate items.(2) If a physician, physician assistant, nurse practitioner and clinical nurse specialist acting within the extent of their licensed scope of practice, refers a patient/client under a plan of care which cannot be completed until after an evaluation visit, the patient/client, and physician, physician assistant, nurse practitioner or clinical nurse specialist must be consulted to approve additions or modifications to the original plan.(3) The plan of care must be reviewed by the patient/client, the attending physician, physician assistant, nurse practitioner or clinical nurse specialist acting within the extent of their licensed scope of practice, and home health agency personnel at least annually or as often as the condition of the patient/client requires.(4) Agency professional staff must promptly alert the physician, physician assistant, nurse practitioner or clinical nurse specialist to any changes that suggest a need to alter the plan of care.(5) Conformance with physician, physician assistant, nurse practitioner and clinical nurse specialist's orders:(a) Drugs and treatments shall be administered by agency staff only as ordered by the physician, or physician assistants, nurse practitioners and clinical nurse specialists within the extent of their licensed scope of practice as defined by state law.(b) Licensed professionals must immediately record and sign oral orders and obtain the physician, or physician assistant, nurse practitioner or clinical nurse specialist's countersignature.(c) For a patient/client receiving nursing services, all medications a patient/client may be taking must be checked to identify possible ineffective drug therapy, adverse reactions, significant side effects, drug allergies and contraindicated medications. Medication problems must be promptly reported to the physician, or physician assistant, nurse practitioner or clinical nurse specialist.B.Non-medically directed care: An agency must follow a written plan of care, which includes goals and objectives appropriate to the patient/client being served, and which is established and reviewed at least annually by agency staff.9/12/74, 8/1/77, 5/7/91, 4/1/97; Recompiled 10/31/01, Adopted by New Mexico Register, Volume XXXI, Issue 12, June 23, 2020, eff. 6/5/2020, Adopted by New Mexico Register, Volume XXXI, Issue 21, November 10, 2020, eff. 11/10/2020