Current through Register Vol. 50, No. 9, September 20, 2024
A. A written
plan of care is developed for each patient/family by the physician, the medical
director or physician designee and the IDT. The care provided to an individual
must be in accordance with the POC.
B. At least one of the persons involved in
developing the POC must be the registered nurse who conducted the initial
assessment. Within three days of the assessment, the IDT must establish the
POC. The POC shall be signed by the physician and an appropriate member of the
IDT.
C. At a minimum the POC will
include:
1. an assessment of the individual's
needs and identification of services;
2. detailed description of the scope and
frequency of services needed to meet the patient's and family's
needs;
3. identification of
problems with realistic and achievable goals and objectives;
4. medical supplies and appliances, including
drugs and biologicals needed for the palliation and management of the
life-limiting illness and related conditions;
5. patient/family understanding, agreement
and involvement with the POC; and
6. recognition of the patient/family's
psychological, social, religious and cultural variables, values, strengths, and
risk factors.
D. The POC
shall be incorporated into the clinical record within one week of its
completion.
E. The CRCC shall
designate a registered nurse to coordinate the implementation of the POC for
each patient.
F. The plan of care
shall be reviewed and updated when the patient's condition changes, and at a
minimum every 90 days for home care and every 14 days for inpatient care,
collaboratively with the IDT and the physician.
G. the agency shall have documented policies
and procedures for the following:
1. the
physician's participation in the development, revision, and approval of the
POC. This is evidenced by a change in patient orders and documented
communication between CRCC staff and the physician;
2. physician orders must be signed and dated
in a timely manner, not to exceed 30 days.
H. The agency shall have documentation that
the patient's condition and POC is reviewed and the POC updated, even when the
patient's condition does not change.
I. The CRCC shall adhere to the following
additional principles and responsibilities:
1. an assessment of the patient/family needs
and desire for services and the CRCC programs' specific admission, transfer,
and discharge criteria to determine any changes in services;
2. core services routinely available to CRCC
patients on a 24-hour basis, seven days a week;
3. all other covered services available to
the extent necessary to meet the needs of individuals for care that is
reasonable and necessary for the palliation and management of a life-limiting
illness and related conditions;
4.
case-management provided and an accurate and complete documented record of
services and activities describing care of patient/family is
maintained;
5. collaboration with
other providers to ensure coordination of services;
6. maintenance of professional management
responsibility and coordination of the patient/family care regardless of the
setting;
7. maintenance of
contracts/agreements for the provision of services not directly provided by the
CRCC;
8. provision or access to
emergency medical care;
9. when the
patient is admitted to a setting where CRCC care cannot be delivered, CRCC
adheres to standards, policies and procedures on transfer and discharge and
facilitates the patient's transfer to another care provider;
10. maintenance of appropriately qualified
IDT health care professionals and volunteers to meet the patient's
need;
11. maintenance and
documentation of a volunteer staff that provide administrative and/or direct
patient care. The CRCC must document a continuing level of volunteer activity;
and
12. coordination of the IDT, as
well as of volunteers, by a qualified health care professional, to assure
continuous assessment, continuity of care and implementation of the
POC.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
40:2175.14(B).
