Initial Visit, Start of Care, and Admission Documentation
Sets out how the Agency makes the initial visit, by a registered nurse or appropriate therapist, within 24 hours of referral unless otherwise ordered by the authorized healthcare provider; what happens at that visit (assessment, instruction about home care services, rights, consent and orientation); how the initial plan of care is completed by an RN or appropriate therapist and placed in the record within seven days from the start of care; and the documentation that Louisiana requires at admission (LAC 48:I §9123.B.3). If the Agency is Medicare-certified, the visit also meets 42 CFR §484.55(a).
- Policy number
- LA-HH-ADM-02
- Version
- 1.0
- Main rule
- LAC 48:I §9123.B
- Library
- Louisiana home health · 57 policies
- Category
- Service delivery
- Sections
- 18
In short
- The first visit is made within 24 hours of referral unless the provider ordered another date.
- Only an RN or the ordered therapist makes the first visit; never an LPN, assistant or aide.
- Give rights, advance directive information and consent forms before any care.
- Complete every admission item on the checklist, including all ADLs, medications, caregivers and barriers.
- The initial plan of care must be in the record within seven days of the start of care.
What's inside
18 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (LAC 48:I §9123.B)
- 5. Timing of the Initial Visit
- 6. Who Makes the Initial Visit
- 7. What Happens at the Initial Visit
- 8. Admission Documentation (LAC 48:I §9123.B.3)
- 9. Initial Plan of Care
- 10. Clinical Manager Review of Each Admission
- 11. Responsibilities
- 12. Records and Compliance Monitoring
- 13. Staff Training
- 14. References
- 15. Related Policies and Forms
- 16. Approval
- 17. Revision History
An inspector may ask
- When was this patient referred and when was the initial visit made? Who made it?
- Show me the admission documentation. Where is the functional assessment listing all ADLs? The caregiver's ability and willingness? The barriers to care?
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