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Initiation of Care and the Initial Assessment Visit

Sets out how care begins: the registered nurse (or, for therapy-only cases, the therapist) makes the initial assessment visit within 48 hours of referral, within 48 hours of the patient's return home, or on the ordered start of care date, and within the Agency's own start-of-care time frame; gives the rights packet and other notices before any care; determines immediate care and support needs and, for Medicare patients, eligibility and homebound status; confirms orders; and starts the comprehensive assessment and plan of care.

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About this policy
Policy number
MO-HH-ADM-02
Version
1.0
Main rule
42 CFR §484.55(a) (adopted by 19 CSR 30-26.010(1)(A))
Library
Missouri home health · 57 policies
Category
Service delivery
Sections
21

In short

  • The first visit is made by a registered nurse within 48 hours of referral or return home, or on the ordered date.
  • In therapy-only cases, the therapist may make the first visit.
  • Give the rights packet and other notices before any hands-on care or teaching.
  • Find the patient's immediate needs and, for Medicare patients, check homebound status.
  • Give only care that has been ordered. Call the practitioner if orders are missing or unclear.
  • Tell the clinical manager the outcome the same day.

What's inside

21 sections. The full text comes with the One-time Policy Pack.

Full text with a package
  • Terms of Reference
  • 1. Purpose
  • 2. Scope
  • 3. Definitions
  • 4. Policy Statement (42 CFR §484.55(a); 42 CFR §484.50(a); 42 CFR §484.60(a)(1), (b))
  • 5. When the Visit Must Be Made
  • 6. If the Visit Cannot Be Made on Time
  • 7. Who Makes the Visit
  • 8. Before the Visit
  • 9. At the Visit
  • 10. When the Plan Cannot Be Completed Until After the Visit
  • 11. Immediate Needs, Emergencies and Safety
  • 12. After the Visit
  • 13. Documentation
  • 14. Responsibilities
  • 15. Records and Compliance Monitoring
  • 16. Staff Training
  • 17. References
  • 18. Related Policies and Forms
  • 19. Approval
  • 20. Revision History

An inspector may ask

  • For this patient, when was the referral received and when was the initial assessment visit made?
  • Who made the initial assessment visit? For a therapy-only patient, which therapist, and why?

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