Individualized Plan of Care

Sets out how the Agency builds, with the patient, an individualized written plan of care containing every element of 42 CFR §484.60(a)(2) (and, for Michigan Medicaid patients, the extra elements in the Medicaid Provider Manual), records all orders in it, gets it signed by the physician or allowed practitioner, reviews and revises it at least every 60 days and whenever the patient's condition requires, communicates every revision, and gives the patient and caregiver written instructions with the visit schedule, medications, treatments and the clinical manager's contact information.