Individualized Plan of Care
Every patient receives services written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, is established, periodically reviewed and signed by a doctor of medicine, osteopathy or podiatry or an allowed practitioner, contains every item in 42 CFR §484.60(a)(2), records all orders, and is reviewed and revised at least once every 60 days, with prompt alerts to the practitioner and communication of every revision; Medicare plan of care rules and Ohio Medicaid’s rule that services not on the plan are not reimbursable also apply.
- Policy number
- OH-HH-CP-01
- Version
- 1.0
- Main rule
- 42 CFR §484.60(a)
- Library
- Ohio home health · 59 policies
- Category
- Patient care
- Sections
- 19
In short
- Give only the care written in the patient’s plan of care, signed by the patient’s doctor or allowed practitioner.
- Build the plan with the patient, using measurable goals, including the patient’s own goals.
- Report any change that suggests the plan is not working; the practitioner is alerted promptly.
- The plan is reviewed at least every 60 days, and every change is shared with the patient, caregivers and practitioners.
- For Ohio Medicaid, services not on the plan of care are not paid.
What's inside
19 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (42 CFR §484.60(a))
- 5. Developing the Plan
- 6. Content of the Plan of Care
- 7. Orders in the Plan
- 8. Carrying Out the Plan
- 9. Reviewing and Revising the Plan
- 10. Signatures and Tracking
- 11. Ohio Medicaid Patients
- 12. Responsibilities
- 13. Records and Compliance Monitoring
- 14. Staff Training
- 15. References
- 16. Related Policies and Forms
- 17. Approval
- 18. Revision History
An inspector may ask
- Show me this patient’s plan of care. Who signed it and when?
- Where are the measurable outcomes and goals, and what were the patient’s own goals?
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