Plan of Care, Treatment Order Review, and Patient Participation

Requires an individualized plan of care for every patient, prepared by the case manager with each discipline and in consultation with the physician, physician assistant, or advanced practice registered nurse, with specific goals for each skilled discipline and implementation plans covering the level of staff, the frequency of visits, and case management. Staff follow the treatment orders in the plan; changes need the practitioner's approval and verbal changes are put in writing, signed, and dated. The patient is told of the right to be informed of the plan, to participate in it, and to have a copy, and receives every assigned visit. The plan is reviewed as often as the patient's illness requires and, if the Agency is Medicare-certified, at least every 60 days, with the content and written patient information 42 CFR §484.60 requires.