Current through Register Vol. 24-18, September 15, 2024
Except as provided in subsections (5) and (6) of this
section, the licensee must:
(1)
Develop and implement a written home health plan of care for each patient with
input from the patient, designated family member, or legal representative and
authorizing practitioner;
(2)
Ensure each plan of care is developed by appropriately trained or credentialed
agency personnel and is based on a patient assessment;
(3) Ensure the home health plan of care
includes:
(a) Current diagnoses and
information on health status;
(b)
Goals and outcome measures which are individualized for the patient;
(c) Types and frequency of services to be
provided;
(d) Palliative care, if
applicable;
(e) Use of telehealth
or telemedicine, if applicable;
(f)
Home medical equipment and supplies used by the patient;
(g) Orders for treatments and their frequency
to be provided and monitored by the licensee;
(h) Special nutritional needs and food
allergies;
(i) Orders for
medications to be administered and monitored by the licensee including name,
dose, route, and frequency;
(j)
Medication allergies;
(k) The
patient's physical, cognitive and functional limitations;
(l) Discharge and referral plan;
(m) Patient and family education needs
pertinent to the care being provided by the licensee;
(n) Indication that the patient has a signed
advanced directive or POLST, if applicable. Include resuscitation status
according to advance directives or POLST, if applicable; and
(o) The level of medication assistance to be
provided.
(4) Develop
and implement a system to:
(a) Ensure and
document that the plan of care is reviewed and updated by appropriate agency
personnel according to the following time frames:
(i) For patients requiring acute care
services, every two months;
(ii)
For patients requiring maintenance services, every six months; and
(iii) For patients requiring only
professional medical equipment assessment services or home health aide only
services, every twelve months.
(b) Ensure the plan of care is signed or
authenticated and dated by appropriate agency personnel and the authorizing
practitioner, according to the time frames in (a) of this subsection;
(c) Ensure the signed or authenticated plan
of care is returned to the agency within sixty days of the initial date of
service or date of review and update;
(d) Inform the authorizing practitioner
regarding changes in the patient's condition that indicate a need to update the
plan of care;
(e) Obtain approval
from the authorizing practitioner for additions and modifications;
(f) Ensure all verbal orders for modification
to the plan of care are immediately documented in writing and signed or
authenticated and dated by an agency individual authorized within their scope
of practice to receive the order and signed or authenticated by the authorizing
practitioner and returned to the agency within sixty days of the date the
verbal orders were received.
(5) Home health agencies providing only home
health aide services to a patient:
(a) May
develop a modified plan of care by providing only the following information on
the plan of care:
(i) Types and frequency of
services to be provided;
(ii) Home
medical equipment and supplies used by the patient;
(iii) Special nutritional needs and food
allergies;
(iv) The patient's
physical, cognitive and functional limitations; and
(v) The level of medication assistance to be
provided.
(b) Do not
require an authorizing practitioner signature on the plan of care.
(6) Home health agencies providing
a one-time visit for a patient may provide the following written documentation
in lieu of the home health plan of care requirements in subsection (3) of this
section:
(a) Patient name, age, current
address, and phone number;
(b)
Confirmation that the patient was provided a written bill of rights under WAC
246-335-535;
(c) Patient consent for services to be
provided;
(d) Authorizing
practitioner orders; and
(e)
Documentation of services provided.