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Plan of Treatment and Care Planning

Sets out how each patient’s written plan of treatment is developed with the patient and all disciplines, what it must contain under 28 Pa. Code §601.31(b), 42 CFR §484.60(a) and, for Medical Assistance recipients, 55 Pa. Code §1249.42(2), how it is established, signed and reviewed by the attending physician at least every 60 days, how the physician is alerted to changes, how revisions are communicated, and the written instructions the patient receives.

Preview: full text with a package
About this policy
Policy number
PA-HH-CP-01
Version
1.0
Main rule
28 Pa. Code §601.31
Library
Pennsylvania home health · 56 policies
Category
Patient care
Sections
20

In short

  • Give only the care in the plan of treatment, at the frequency ordered; any change needs a doctor’s order.
  • Write the plan with the patient, using their own goals, and with every discipline involved.
  • The doctor reviews and signs the plan at least every 60 days.
  • Tell the doctor promptly about any change that suggests the plan should change: at once if serious, the same day otherwise.
  • Leave written visit, medication and treatment instructions (Form PA-HH-CP-01-A) with the patient and update them when anything changes.

What's inside

20 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 (28 Pa. Code §601.31)
  • 5. Developing the Plan
  • 6. Content of the Plan
  • 7. Establishing and Signing the Plan
  • 8. Following the Plan
  • 9. Alerting the Physician to Changes
  • 10. Review and Revision
  • 11. Communicating Revisions
  • 12. Written Instructions for the Patient
  • 13. Responsibilities
  • 14. Records and Compliance Monitoring
  • 15. Staff Training
  • 16. References
  • 17. Related Policies and Forms
  • 18. Approval
  • 19. Revision History

An inspector may ask

  • Show me this patient’s plan of treatment. Where are the measurable goals and the safety measures?
  • When did the physician last review and sign this plan? When is the next review due?

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