{"ref":"NC-HC-POC-01","title":"Plan of Care, 90-Day Review, and Changes to Services","category":"Service delivery","summary":"Requires a written plan of care for every client, established with the client from the initial assessment, containing everything 10A NCAC 13J .1202 lists and, for in-home aide services, the level of assistance for each ADL; sets who writes and signs it, the review every 90 days, how changes are made and communicated in advance, and how the licensure plan of care relates to the NC Medicaid PCS service plan.","inShort":["Do only the tasks on the client's plan of care.","Give the level of help the plan says for each activity.","Report changes in the client the same day, and at once for a fall, injury or sudden illness.","The plan is reviewed at least every 90 days.","The client is told before any change and signs the new plan."],"primaryCitation":"10A NCAC 13J .1202","citations":["10A NCAC 13J .1202","10A NCAC 13J .1201","10A NCAC 13J .1001(a)(4)","10A NCAC 13J .1107(a), (b), (c)","10A NCAC 13J .1110(b), (c), (f)","10A NCAC 13J .1302(a)","10A NCAC 13J .1502(b)","10A NCAC 13J .1504(2), (3), (5)","10A NCAC 13J .0901(7), (18), (31)","10A NCAC 13J .1402(a)(2)(B)","G.S. 131E-144.3(1)","NC Medicaid Clinical Coverage Policy 3L, §5.4.6, §6.1.4(f), (l), (m), (n)","DHSR Home Care Frequently Asked Questions, Q48, Q49, Q50, Q51"],"federalCitations":[],"surveyorAsks":["Show me this client's plan of care. Who wrote it, and was it signed by the nurse and the client or responsible party before services started?","Where does the plan of care show the level of assistance for each ADL? Does the aide assigned meet the Nurse Aide Registry requirement for that level?"],"forms":[{"ref":"NC-HC-POC-01-A","title":"Plan of Care"},{"ref":"NC-HC-POC-01-B","title":"90-Day Case Review"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (10A NCAC 13J .1202)","5. Who Writes and Signs the Plan of Care","6. What the Plan of Care Contains","7. Levels of Assistance and Who May Be Assigned","8. Developing the Plan with the Client","9. Telling Workers What to Do","10. The 90-Day Case Review","11. Changing the Plan of Care","12. Clients Whose Services Are Paid by NC Medicaid","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":"nc-hca","state":"North Carolina","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}}