{"ref":"CA-HH-CP-01","title":"Plan of Treatment, Plan of Care, and Plan for Personal Care Services","category":"Service delivery","summary":"Sets out how the Agency writes, signs, follows, reviews, and changes each patient’s plan: the plan of treatment (plan of care for Medicare and Medi-Cal agencies) for every patient whose care requires medical orders, approved and signed by the attending practitioner within 30 working days and reviewed at least every 62 days, with the 14 required elements (22 CCR §74697(a)-(b)); the written plan for personal care services for patients without a physician’s plan (§74697(f)); telling patients in advance of changes (§74743(c)); and, if the Agency is Medicare-certified, the federal plan of care content, review at least every 60 days, communication of revisions, and written information to the patient (42 CFR §484.60).","inShort":["Give care only as the written plan and the doctor’s orders say.","The doctor or practitioner must sign the plan within 30 working days and review it at least every 62 days (every 60 days for Medicare).","No change to the plan without the practitioner’s approval. Tell the patient before any change is made.","Patients who get personal care only have a written personal care plan, reviewed at each supervisory visit.","If a visit is missed or the patient’s needs change, tell the nurse supervisor the same day."],"primaryCitation":"22 CCR §74697","citations":["22 CCR §74697","Cal. Health & Safety Code §1727.5(a)","22 CCR §74735(a)(2)","22 CCR §74735(a)(3)","22 CCR §74743(c)","22 CCR §74701(d)","22 CCR §74701(e)","22 CCR §74709(a)","22 CCR §74709(a)(3)","22 CCR §74711(b)(3)","22 CCR §74713(c)(2)"],"federalCitations":["42 CFR §484.60","42 CFR §484.60(a)","42 CFR §484.60(b)","42 CFR §484.60(c)","42 CFR §484.60(e)","42 CFR §409.43"],"surveyorAsks":["Show me this patient’s plan of treatment. When was it signed, and when was it last reviewed by the physician?","Does the plan include every element the regulation requires, including safety measures and the discharge and referral plan?"],"forms":[{"ref":"CA-HH-CP-01-A","title":"Plan for Personal Care Services"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (22 CCR §74697)","5. Developing the Plan of Treatment","6. Content of the Plan of Treatment","7. Approval and Signature","8. Following the Plan","9. Changes to the Plan","10. Periodic Review","11. Written Information to the Patient","12. Plan for Personal Care Services","13. Responsibilities","14. Records and Compliance Monitoring","15. Staff Training","16. References","17. Related Policies and Forms","18. Approval","19. Revision History"],"version":"1.0","sample":false,"pack":"ca-hha","state":"California","service":"Home health","guides":[{"path":"/guides/home-health-agency-policies/","h1":"What policies and procedures are required for home health agencies?"},{"path":"/guides/home-health-conditions-of-participation/","h1":"Home health Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}