{"ref":"TX-HH-CP-01","title":"Plan of Care and Care Planning","category":"Patient care","summary":"Sets out how the Agency develops, gets signed, carries out, reviews, and revises each patient’s individualized plan of care (or, where no skilled care is ordered, the care plan), how orders are recorded in the plan, how changes are communicated, and the written instructions every patient receives.","inShort":["Give only the care written in the patient’s plan of care, and only as a practitioner has ordered.","Build the plan with the patient, using their own goals and measurable outcomes, and send it for signature promptly.","Tell the practitioner the same day about any change that means the plan is not working or should change.","The plan of care is reviewed at least every 60 days from the start of care.","Give the patient written instructions with the visit schedule, medications, treatments, and the clinical manager’s contact, and update them whenever anything changes. Verbal orders are signed by the practitioner within 14 days."],"primaryCitation":"42 CFR §484.60","citations":["26 TAC §558.281","26 TAC §558.401","26 TAC §558.243","26 TAC §558.2","26 TAC §558.301"],"federalCitations":["42 CFR §484.60","42 CFR §484.60(a)(3)","42 CFR §484.60(b)","42 CFR §484.60(e)(2)","42 CFR §409.43"],"surveyorAsks":["Show me this patient’s plan of care. Does it include every item the rule requires, including the risk of hospitalization and the patient’s own goals?","When was the plan last reviewed with the practitioner, and when is the next review due?"],"forms":[{"ref":"TX-HH-CP-01-A","title":"Patient Visit, Medication, and Treatment Instructions"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §484.60)","5. Which Plan Applies","6. Developing the Plan of Care","7. Content of the Plan of Care","8. The Care Plan Where No Skilled Care Is Ordered","9. Carrying Out the Plan","10. Reviewing and Revising the Plan","11. Written Instructions to the Patient","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":"tx-lhhs","state":"Texas","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 Home Health Agency","legalName":"Sample Home Health Agency, LLC","logo":null}}