{"ref":"NC-HH-CP-01","title":"Plan of Care: Development, 90-Day Review, Physician Notification, and Patient Instructions","category":"Service delivery","summary":"Requires an individualized written plan of care for every patient, developed with the patient from the comprehensive assessment, signed by the physician or allowed practitioner, containing everything North Carolina and Medicare list; reviewed and revised by the practitioner and the Agency at least every 60 days (which also meets the North Carolina 90-day review by the health care practitioner) and whenever the patient’s condition requires; with prompt notice to the practitioner of changes, communication of every revision, advance notice to the patient of changes, and written visit, medication and treatment instructions with the clinical manager’s contact details.","inShort":["Every patient has a written plan of care, made with the patient and signed by the doctor or allowed practitioner.","Give care only as the plan and orders say. Report a missed or refused visit to the supervising nurse the same day.","Tell the doctor the same day when the patient’s condition changes, and tell the patient before any change in care.","The plan is reviewed at least every 60 days; that review also meets North Carolina’s 90-day review.","Leave the patient written instructions: visit schedule, medicines, treatments and the clinical manager’s name and number."],"primaryCitation":"10A NCAC 13J .1202","citations":["10A NCAC 13J .1001(a)(4)","10A NCAC 13J .1107(a)","10A NCAC 13J .1107(b)","10A NCAC 13J .1201","10A NCAC 13J .1202","10A NCAC 13J .1302","NC Medicaid Clinical Coverage Policy 3A"],"federalCitations":["42 CFR §484.60","42 CFR §409.43"],"surveyorAsks":["Show me this patient’s plan of care. Who signed it, and when?","How do you make sure the plan is reviewed at least every 60 days and every 90 days?"],"forms":[{"ref":"NC-HH-CP-01-A","title":"Patient Visit, Medication, and Treatment Instructions"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (10A NCAC 13J .1201, .1202(a); 42 CFR §484.60)","5. Developing the Plan of Care","6. What the Plan of Care Contains","7. The Home Health Aide Plan of Care","8. Carrying Out the Plan","9. Review and Revision","9.1 At least every 60 days, and the North Carolina 90-day review","9.2 When the patient’s condition changes","9.3 Communicating revisions","10. Written Instructions for the Patient","11. When the Plan of Care Ends","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":"nc-hha","state":"North Carolina","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}}