{"ref":"DC-HH-CP-01","title":"Plan of Care: Content, Patient Participation, and Practitioner Approval","category":"Service delivery","summary":"Requires a written, individualized plan of care for every patient, developed with the patient, containing every item in 22-B DCMR §3914.3 (and, if the Agency is Medicare-certified, 42 CFR §484.60(a)(2)), approved and signed by the physician or other practitioner DC Health allows within 30 days of the start of care, followed by all staff, reviewed and revised as the patient’s condition requires, and explained to the patient in written care instructions.","inShort":["Every patient has a written plan of care made with the patient. Give only the care in the plan, and only as ordered.","The physician (or another practitioner DC Health allows) must sign the plan within 30 days of the start of care.","Telephone orders are written down right away and sent for signature.","Give the patient written instructions: visit schedule, medicines, treatments, who to call, and what to do in an emergency.","If you cannot do part of the plan, write down why and tell the nurse the same day."],"primaryCitation":"22-B DCMR §3914","citations":["22-B DCMR §3914.1","22-B DCMR §3914.2","22-B DCMR §3914.3","22-B DCMR §3914.4","22-B DCMR §3914.5","22-B DCMR §3916.2","22-B DCMR §3916.3","22-B DCMR §3915.8","22-B DCMR §3911.2","22-B DCMR §3999.1","29 DCMR §5005.2","29 DCMR §5005.3","29 DCMR §5005.4","29 DCMR §5005.5","29 DCMR §5008.3"],"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 care. Who took part in developing it?","When did care start, and when did the physician sign the plan of care? Was it within 30 days?"],"forms":[{"ref":"DC-HH-CP-01-A","title":"Patient Care Instructions"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (22-B DCMR §3914)","5. Developing the Plan with the Patient","6. Content of the Plan of Care","7. Approval and Signature","8. Following the Plan of Care","9. Reviewing and Revising the Plan","10. Written Care Instructions for the Patient","11. Responsibilities","12. Records and Compliance Monitoring","13. Staff Training","14. References","15. Related Policies and Forms","16. Approval","17. Revision History"],"version":"1.0","sample":false,"pack":"dc-hha","state":"Washington, DC","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}}