Title 7 . Health and Social Services

Chapter 12 . Assistance for Community Health Facilities

Section 513. Plan of care

7 AAC 12.513. Plan of care

(a) A home health agency shall, in consultation with the patient and the patient's attending physician, develop a plan of care for each patient accepted by the agency. The plan of care must

(1) be reviewed by the attending physician and the professional staff of the agency as often as the patient's condition requires, but at least every 62 days;

(2) be signed by the attending physician and included in the patient's clinical record within 21 days of the start of care or the recertification date of the agency;

(3) identify long and short term goals of patient care that provide measurable indices of performance;

(4) address all pertinent diagnoses, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, safety measures to protect against injury, planning for discharge, instructions for timely discharge or referral, and any other factors relevant to the care of that patient.

(b) The agency shall promptly alert the attending physician of conditions that may require a change to the plan of care. The attending physician must approve any changes to the plan of care.

(c) The agency shall discuss the following information with the patient and document the discussion in the patient's clinical record:

(1) the plan of care;

(2) the services that the agency will provide;

(3) alternate services available when the agency is unable to meet identified needs of the patient.

History: Eff. 9/6/96, Register 139

Authority: AS 18.05.040