{"ref":"MO-HH-CP-01","title":"Plan of Care and Care Planning","category":"Clinical tasks","summary":"Sets out how each patient's individualized written plan of care is developed from the comprehensive assessment with the patient, established and signed by a physician or allowed practitioner, and kept current: the sixteen required elements, patient-specific measurable outcomes and goals, recording every order, sending and tracking the plan for signature, review and revision at least every 60 days, the Missouri requirement that a physician review the plan of treatment at least once every six months, MO HealthNet plan of care rules, and how revisions are communicated.","inShort":["Every patient has a written plan of care with all required items and measurable goals.","Give only care that is in the plan or ordered. Record every order, including verbal orders.","The plan is reviewed at least every 60 days. A physician reviews it at least every six months.","Report any change that means the plan is not working to the practitioner the same day.","Tell the patient, caregiver and all ordering practitioners about every revision."],"primaryCitation":"42 CFR §484.60(a) to (c) (adopted by 19 CSR 30-26.010(1)(A))","citations":["19 CSR 30-26.010(1)(A)","RSMo §197.400(3), (10), (11)","RSMo §197.445.2","13 CSR 70-90.010(1)(B), (7)"],"federalCitations":["42 CFR §484.60(a)","42 CFR §484.60(b)","42 CFR §484.60(c)","42 CFR §484.75(b)(2)","42 CFR §484.80(g)(1)","42 CFR §409.43","42 CFR §424.22(d)"],"surveyorAsks":["Show me this patient's plan of care. Does it include every element in 42 CFR §484.60(a)(2)?","Where are the patient-specific measurable outcomes and goals, and how is progress shown?"],"forms":[{"ref":"MO-HH-CP-01-A","title":"Plan of Care Review and Revision Checklist"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §484.60(a) to (c); RSMo §197.400(3), (10); 19 CSR 30-26.010(1)(A))","5. Who May Establish and Sign the Plan","6. Required Content","7. Outcomes and Goals","8. Developing the Plan","9. Recording Orders","10. Sending the Plan for Signature and Tracking It","11. Care Only as Ordered","12. Review and Revision","13. Communicating Revisions","14. MO HealthNet Participants","15. The Home Health Aide Care Instructions","16. Responsibilities","17. Records and Compliance Monitoring","18. Staff Training","19. References","20. Related Policies and Forms","21. Approval","22. Revision History"],"version":"1.0","sample":false,"pack":"mo-hha","state":"Missouri","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}}