{"ref":"MI-HH-CP-01","title":"Individualized Plan of Care","category":"Patient care","summary":"Sets out how the Agency builds, with the patient, an individualized written plan of care containing every element of 42 CFR §484.60(a)(2) (and, for Michigan Medicaid patients, the extra elements in the Medicaid Provider Manual), records all orders in it, gets it signed by the physician or allowed practitioner, reviews and revises it at least every 60 days and whenever the patient's condition requires, communicates every revision, and gives the patient and caregiver written instructions with the visit schedule, medications, treatments and the clinical manager's contact information.","inShort":["Build the plan of care with the patient, from the assessment, with measurable goals the patient agrees with.","Record every order, including verbal orders, in the plan of care. Give care only as ordered.","The practitioner reviews and signs the plan at least every 60 days and whenever the patient's condition changes.","Tell the patient, caregiver and every ordering practitioner about each change to the plan.","Give the patient written instructions: visit schedule, medicines, treatments and the clinical manager's name and phone."],"primaryCitation":"42 CFR §484.60(a)","citations":["Michigan Medicaid Provider Manual, Home Health, Sections 1, 3, 8, 8.1.L, 10, 10.1 and 11"],"federalCitations":["42 CFR §484.60(a)","42 CFR §484.60(b)","42 CFR §484.60(c)","42 CFR §484.60(e)","42 CFR §484.50(c)(5)","42 CFR §484.75(b)(2)","42 CFR §409.43","42 CFR §484.105(c)(5)"],"surveyorAsks":["Show me this patient's plan of care. Where are the measurable outcomes and goals the patient identified?","Where does the plan of care describe the patient's risk for emergency department visits and readmission, and the interventions for it?"],"forms":[{"ref":"MI-HH-CP-01-A","title":"Michigan Medicaid Plan of Care Elements Checklist"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §484.60(a))","5. Building the Plan of Care","6. Required Content","7. Michigan Medicaid Elements","8. Following the Plan of Care","9. Review and Revision","10. Communicating Revisions","11. Written Instructions for the Patient and Caregiver","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":"mi-hha","state":"Michigan","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}}