{"ref":"PA-HH-CC-01","title":"Coordination of Patient Services, Case Conferences, and 60-Day Summary Reports","category":"Service delivery","summary":"Sets out how all staff and contractors caring for a patient keep in touch so that their work fits together and supports the plan of treatment, how case conferences are held and recorded, how the registered nurse coordinates services and informs the physician, how services under arrangement are integrated, and how a written summary report for each patient is sent to the attending physician at least every 60 days, as 28 Pa. Code §601.21(h) requires.","inShort":["Read the other disciplines’ latest notes before each visit, and write your own note the same day.","Report any change in the patient’s condition to the coordinating registered nurse the same day, or at once if urgent.","Each patient has a case conference at least once every 60 days and after any significant change.","A written summary report goes to the patient’s doctor at least every 60 days.","Share patient information only through the Agency’s secure channels, never by personal text or social media."],"primaryCitation":"28 Pa. Code §601.21(h)","citations":["28 Pa. Code §601.21(h)","28 Pa. Code §601.6","28 Pa. Code §601.32(b)","28 Pa. Code §601.35(b)","28 Pa. Code §601.36(a)","28 Pa. Code §601.21(a)"],"federalCitations":["42 CFR §484.60(d)","42 CFR §484.75(b)","42 CFR §484.80(g)(4)","42 CFR §484.105(c)"],"surveyorAsks":["How do the nurse, the therapist and the aide on this case share information?","Show me the case conference notes for this patient. Who attended?"],"forms":[{"ref":"PA-HH-CC-01-A","title":"Case Conference Record"},{"ref":"PA-HH-CC-01-B","title":"Summary Report to the Attending Physician"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (28 Pa. Code §601.21(h))","5. The Coordinating Registered Nurse","6. Day-to-Day Communication","7. Case Conferences","8. The 60-Day Summary Report to the Attending Physician","9. Services Under Arrangement and Other Providers","10. Involving the Patient and Caregivers","11. Responsibilities","12. Records and Compliance Monitoring","13. Staff Training","14. References","15. Related Policies and Forms","16. Approval","17. Revision History"],"version":"1.0","sample":false,"pack":"pa-hha","state":"Pennsylvania","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}}