{"ref":"FL-HH-CC-01","title":"Case Management, Coordination of Services, Case Conferences, and Reports to the Practitioner","category":"Service delivery","summary":"Names the case manager for each type of case (a registered nurse for nursing cases, a licensed therapist for therapy-only or therapy-and-aide cases, a licensed dietitian or nutritionist for dietetics-only cases, each a direct employee or contractor), sets the case manager's duties under the Florida definition of case management, and sets how the Agency coordinates all disciplines and contracted staff, holds and records case conferences, and reports to the physician, physician assistant, or advanced practice registered nurse when the patient's condition changes or care deviates from the plan of care. If the Agency is Medicare-certified, it adds the federal coordination of care standard.","inShort":["Every patient has one named case manager: a registered nurse for nursing cases, or the therapist or dietitian for cases without nursing.","Write your visit notes the same day and tell the case manager at once about falls, wounds, medicine problems, or other changes.","The practitioner is told when a patient's condition changes or care does not follow the plan. Write down every report.","Case conferences bring everyone caring for the patient together. Take part or send your report.","Work only from the current plan of care and your written assignment."],"primaryCitation":"Rule 59A-8.008, F.A.C.","citations":["Rule 59A-8.008(1), F.A.C.","Rule 59A-8.008(2), F.A.C.","Rule 59A-8.008(3), F.A.C.","Rule 59A-8.008(5), F.A.C.","Rule 59A-8.002(5), F.A.C.","Rule 59A-8.0095(3)(a), F.A.C.","Rule 59A-8.0095(2)(c), F.A.C.","Rule 59A-8.022(5)(i), F.A.C.","Rule 59A-8.022(5)(j), F.A.C.","Rule 59A-8.022(5)(k), F.A.C.","s. 400.487(5), F.S.","s. 400.487(6), F.S.","Rule 59A-8.0215(2), F.A.C."],"federalCitations":["42 CFR §484.60(d)","42 CFR §484.60(c)(1)","42 CFR §484.60(c)(3)","42 CFR §484.105(c)","42 CFR §484.105(e)"],"surveyorAsks":["Who is the case manager for this patient? Is that person an employee or a contractor?","Show me the record of the last case conference for this patient."],"forms":[{"ref":"FL-HH-CC-01-A","title":"Case Conference and Coordination Record"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (Rule 59A-8.008, F.A.C.)","5. Who Is the Case Manager","6. Case Manager Duties","7. Coordination Among Disciplines and Contracted Staff","8. Case Conferences","9. Reports to the Practitioner","10. Coordination With Other Providers and Facilities","11. Supervision Visits in the Record","12. Involving the Patient and Caregiver","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":"fl-hha","state":"Florida","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}}