Policy Manual sample

MDT Home Health Care Agency, Inc. CARE PLANNING, COORDINATION OF SERVICES, AND QUALITY OF CARE (Coordination of Care) POLICY: The Patient’s Plan of Care (POC) is developed and documented by the Registered Nurse, Registered Therapist and/or Social Worker, in coordination with the participation of the patient/family/significant other. The plan of care is communicated to the Case Manager/Clinical Supervisor and other members of the healthcare team. When a patient is receiving more than one service, each discipline develops interventions and goals that are complementary to those of other team members providing care, treatment and /or services. PURPOSE:  To facility appropriate communication, coordination and continuity of care to promote positive patient outcomes when the Agency provides more than one service, whether those services are provided directly or through written agreement.  To clearly outline each professional responsibilities to avoid duplication of care, treatment and/or services.  To promote awareness among all professionals involved in patient care, including those providing contracted services, of the patient’s needs and goals, and care, treatment or services and interventions to be provided by each individual. Patients are accepted for treatment on the reasonable expectation that our HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care will be specific to the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that our HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care will also specific to the patient and caregiver education and training. Services will be furnished in accordance with accepted standards of practice. Plan of care . (1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is stablished, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. (2) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; Home Health Agency Nursing Manual J-53