Assessment and Plan of Care

The current Conditions of Participation are not specific about the scope of the assessment or the plan of care, but most agencies are already meeting the CoP’s due out in January.  In the current CoP’s, the scope of practice for each discipline is defined, followed by a section on clinical records.  It reads:

A clinical record containing pertinent past and current findings in accordance with accepted professional standards is maintained for every patient receiving home health services. In addition to the plan of care, the record contains appropriate identifying information; name of physician; drug, dietary, treatment, and activity orders; signed and dated clinical and progress notes; copies of summary reports sent to the attending physician; and a discharge summary. The HHA must inform the attending physician of the availability of a discharge summary. The discharge summary must be sent to the attending physician upon request and must include the patient’s medical and health status at discharge.

The new Conditions of Participation have details about what is expected to be in your assessment and plan of care.

Assessment:

The condition reads: Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment

The standards that fall under this condition are as follows as I understand them.  They are not verbatim.

1. The RN must conduct an initial assessment to determine the immediate care and support needs of the patient and for Medicare patients, determine eligibility, including homebound status. This visit must occur within 48 hours of referral or return to the home or on the specific date ordered by the MD.
2. When nursing isn’t ordered, Physical Therapy, Speech Therapy or Occupational Therapy can perform the initial assessment. This is later clarified to read that Occupational Therapy can perform the assessment if the need for OT services establishes the need for services.
3. The initial assessment must be completed in a manner consistent with the immediate needs of the patient but no later than five days after the start of care.
4. Content of the plan of care is expected to include:
   1. Patient strengths, goals and care preferences – including information that may be used to demonstrate patient progress to the patient’s goals and measurable outcomes identified by the agency.
   2. The patient’s continuing need for home care
   3. Medical, nursing, rehab, social and discharge planning needs
   4. Medication review of all drugs the patient is using to include
      1. Potentially adverse effects
      2. Drug reactions

• Ineffective drug therapy

1. Significant side effects
2. Significant drug interactions
3. Duplicate drug therapy
4. Non-compliance with therapy

1. The patient’s primary caregiver(s) and other support including their willingness and ability to provide care, their availability and schedules and the patient’s representatives, if any.
2. Incorporation of the OASIS dataset into the comprehensive assessment.

5. The assessment must be updated at least every 60 days and also at the time of a significant change in condition, beneficiary elected transfer, transfer and discharge to the same agency within the same 60-day period, within 48 hours of return to home after a hospitalization and discharge.

Surely you have realized by now that most of these criteria are already written into the OASIS regulations, prior Conditions of Participation and sound clinical principles.   Now they are Conditions of Participation and while similar to what we already do, note that Occupational Therapy can now perform OASIS assessments.  Also, it’s worth noting that whenever the comprehensive assessment is mentioned, it is followed by the assessment of Medicare eligibility for Medicare patients including homebound status.

Careplanning, Coordination of Care and Quality of Care

 This is a new condition and while many agencies already do most of this, there are some standards that some agency’s haven’t done in the past.

The actual condition is:

Patients are accepted for treatment on the reasonable expectation that an 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 must specify 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 the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice.

The standards that agency’s will follow to ensure and demonstrate compliance are as follows:

1. Each patient must receive services that are written in a patient specific plan of care identifying patient goals and outcomes, established and reviewed periodically and signed by a doctor of medicine, osteopathy or podiatry acting within his or her scope of practice.
2. If the physician refers a patient and the plan of care cannot be completed until after an evaluation visit, the physician is consulted to approve additional orders.

Contents of the Plan of Care

1. The individualized plan of care must include the following:

• All pertinent diagnoses;
• (mental, psychosocial, and cognitive status;
• The types of services, supplies, and equipment required;
• The frequency and duration of visits to be made;
• Prognosis;
• Rehabilitation potential;
• Functional limitations;
• Activities permitted;
• Nutritional requirements;
• All medications and treatments;
• Safety measures to protect against injury;
• Risk assessment for emergency room visits and rehospitalizations and all necessary interventions to address the risk factors.
• Patient and caregiver education and training to facilitate timely discharge;
• Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient;
• Information related to any advanced directives; and
• Orders, including verbal orders

2. Drugs, services and treatments are administered only as ordered by a physician
3. Flu and pneumonia vaccines may be administered per agency policy developed in consultation with a physician and after the assessment of a patient to determine contraindications.
4. Verbal orders must be accepted only in accordance with state laws pertaining to verbal orders. When a verbal order is obtained, services are to be carried out as ordered without waiting on the signed order. Verbal orders must include the signature, date and time that the order was received and be placed in the clinical record.  They are to be authenticated and dated by the physician who gave the orders in accordance with state laws and regulations as well as agency policies.

Review and Revision of the Plan of Care

1. The plan of care is reviewed and revised by the physician who is responsible for the for the home health plan of care as often as indicated by the patient’s condition but at least every 60 days. The agency  must promptly alert the relevant physician(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered.
2. The revised plan of care must reflect current information from the patient’s updated comprehensive assessment and contain information concerning progress towards goals identified by the agency and patient in the plan of care.
3. Any revisions to the pan of care due to a change in health status must be communicated to the patient, representative (if any) and all physicians writing orders for the patient.
4. Any revisions to discharge plans must be communicated to the patient, representative (if any) and all physicians ordering care, the patient’s primary care practitioner or other health care professional who will provide care to the patient after discharge from the agency.

Ensuring Care Coordination involves:

1. Communication with all physicians involved in the plan of care.
2. Integration of orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient.
3. Integration of services provided by the agency or under arrangement to assure the identification of patient needs and factors that affect patient safety and treatment and coordination of care.
4. Involvement of the patient, representative (if any), and caregivers as appropriate in coordination of care activities.
5. Ensure that education is provided by the agency to the patient and caregivers regarding care and services in the Plan of Care and to ensure a timely discharge.

The agency must provide written information to the patient that includes:

1. Visit schedule of all agency and contracted personnel
2. Patient Medications and instructions on how to take meds including medication name, dosage and frequency and which meds will be administered by the agency or contracted personnel.
3. Al pertinent instructions related to the patient’s care and treatments that the agency will provide specific to the patient needs.
4. The name and contact information of the agency’s clinical manager.

So that’s a lot.  Agencies who choose to wait will be working weekends and holidays to be in compliance by mid-January.  The first thing I might do is call my software vendor.  The plan of care requirements haven’t changed but the information that is required to be given to the patient has.  Could a patient friendly medication sheet containing frequency as well as the name and strength of the med be generated?  Depending on your patient population, there may be questions about whether or not you want to leave the entire plan of care in the home.  Will the computer generate a separate form?

Notice that teaching must be specific to the patient.  This may seem self-evident but I have seen nurses teach that Neurontin is for seizures when the patient never had a seizure in their life but was taking Neurontin for neuropathy.  Still, the patient verbalized understanding.

Care coordination and communication is an ongoing Condition and an ongoing problem.  I thought that software messaging would reduce the problem but sadly it has not.  The software accounts I have for clients have so many emails in the inboxes and the vast majority of them do not concern me. One of you has a better idea.  Care to share?

Look for more next week.  Meanwhile, get through these Conditions before moving on to the next.