{"ref":"LA-HH-CC-01","title":"Coordination of Services, Case Conferences, and Communication with Authorized Healthcare Providers","category":"Service delivery","summary":"Sets out how the Agency coordinates the care given by every discipline, employed or under contract, with the patient, caregivers and authorized healthcare providers from admission through discharge: who coordinates, how changes in the patient's condition are reported to the authorized healthcare provider and the supervising RN, case conferences and their records, written instructions given to the patient and caregiver, and ongoing education and training.","inShort":["Every patient has a case manager who coordinates all disciplines.","Report any change in condition to the supervising RN; urgent changes before you leave the home.","Aides call the RN about abnormal vital signs.","Record every call with the provider: who, what you reported and the answer.","Take part in case conferences; they are recorded in the patient's record.","Keep the written visit schedule and medication instructions in the home up to date."],"primaryCitation":"LAC 48:I §9123.F","citations":["LAC 48:I §9123.F","LAC 48:I §9123.F.2","LAC 48:I §9127.C","LAC 48:I §9103.B.2.b","LAC 48:I §9103.D.2.b","LAC 48:I §9103.F.2.c","LAC 48:I §9103.F.2.h","LAC 48:I §9103.G.2.c","LAC 48:I §9103.G.2.g","LAC 48:I §9103.I.2.c","LAC 48:I §9103.I.2.h","LAC 48:I §9103.K.2.f","LAC 48:I §9103.K.2.g","LAC 48:I §9103.L.2.c","LAC 48:I §9103.C.2.a","LAC 48:I §9123.E.3"],"federalCitations":["42 CFR §484.60(d)","42 CFR §484.60(e)","42 CFR §484.60(c)(3)","42 CFR §484.105(c)"],"surveyorAsks":["How do the nurse, therapist and aide caring for this patient communicate with one another?","Show me the last case conference for this patient. Who took part?"],"forms":[{"ref":"LA-HH-CC-01-A","title":"Case Conference and Care Coordination Record"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (LAC 48:I §9123.F)","5. Who Coordinates","6. Reporting Changes in Condition","7. Communication with Authorized Healthcare Providers","8. Case Conferences","9. Coordination with Contract Staff and Other Providers","10. Written Instructions for the Patient and Caregiver","11. Patient and Caregiver Education and Training","12. Responsibilities","13. Records and Compliance Monitoring","14. Staff Training","15. References","16. Related Policies and Forms","17. Approval","18. Revision History"],"version":"1.0","sample":false,"pack":"la-hha","state":"Louisiana","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}}