{"ref":"MO-HC-SP-02","title":"Changes in Condition and Coordination with Physicians and Other Providers","category":"Service delivery","summary":"Requires the Agency to monitor each participant's overall physical care needs; sets out what workers report and how fast, how the administrative supervisor and the Agency's registered nurse respond, when the participant's physician is contacted and DSDS informed, and how the Agency coordinates with home health agencies, hospices, Division of Developmental Disabilities support coordinators and other providers, including during hospital and nursing facility stays. Every contact is recorded in the participant record.","inShort":["Watch for changes: new pain, falls, confusion, skin problems, not eating, trouble walking or problems at home.","In an emergency, call 911 first.","Otherwise, call the office before you leave the home and say what you saw. After hours, call (573) 555-0199.","Write what you saw, not what you think the cause is.","Do not give medical advice. The supervisor and nurse decide whether to call the doctor or DSDS."],"primaryCitation":"13 CSR 70-91.010(3)(D)","citations":["13 CSR 70-91.010(3)(D)","13 CSR 70-91.010(6)(C), (6)(F)","19 CSR 15-7.021(16)(B)","19 CSR 15-7.021(20)(D)","19 CSR 15-7.021(21)(C)","19 CSR 15-7.021(24)(A)4, 5","19 CSR 15-7.010(9)(B)","RSMo 192.2475.14","MO HealthNet Personal Care Provider Manual §§2.1 (Coordination with Division of Developmental Disabilities; Service Limitations), 2.6, 2.7, 2.16"],"federalCitations":[],"surveyorAsks":["Tell me about the last time a worker reported a change in a participant's condition. What happened next, and where is it recorded?","When does your nurse contact a participant's physician, and where are those contacts documented?"],"forms":[{"ref":"MO-HC-SP-02-A","title":"Change in Condition Report"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (13 CSR 70-91.010(3)(D))","5. What Workers Watch For","6. What the Worker Does","7. What the Supervisor and the Registered Nurse Do","8. Contacting the Participant's Physician","9. Telling DSDS","10. Coordinating with Other Providers","11. Hospital and Nursing Facility Stays","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":"mo-hca","state":"Missouri","service":"Home care","guides":[{"path":"/guides/home-care-agency-policies/","h1":"What policies does a home care agency need?"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}