Oregon Oregon Health Authority, Public Health Division
Plan of Treatment
The primary agency is responsible for the patient’s plan of treatment including home health services provided to the patient through contractual arrangements with other organizations or individuals. A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient. When rehabilitation therapy service (speech therapy, physical therapy or occupational therapy) is the only service ordered in the plan of treatment and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional.(1) The agency shall ensure that the plan of treatment is developed in consultation with the agency personnel and established at the time of, or prior to, acceptance of the patient.(2) The agency shall ensure that the plan of treatment is transmitted to the patient’s physician or allowed practitioner for signature within 10 calendar days of admission to service.(3) The plan of treatment shall cover the following:(a) All pertinent diagnoses, mental status, types of services and equipment required;(b) Frequency of visits;(c) Prognosis;(d) Rehabilitation potential;(e) Functional limitations;(f) Activities permitted;(g) Nutritional requirements;(h) Medications and treatments;(i) Safety measures to protect against injury;(j) Instructions for timely discharge or referral; and(k) Any other appropriate items.(4) If a patient is accepted under a plan of treatment that cannot be completed until after an evaluation visit, the physician or allowed practitioner shall be consulted to approve revisions to the original plan.(5) Orders for therapy services shall include the specific procedures and modalities to be used and, as appropriate, the amount, frequency, and duration.(6) The therapist and other agency personnel shall participate in developing the plan of treatment.(7) The plan of treatment shall be signed by the physician or allowed practitioner and included in the patient’s clinical record within the time period specified in the agency’s policy but no longer than 30 calendar days after admission.(8) The agency shall submit all plans of treatment to the physician or allowed practitioner and shall send copies to other practitioners involved in the patient’s care.(9) To receive reimbursement by the Centers for Medicare and Medicaid Services, agencies may be subject to additional or more restrictive requirements beyond what is required in OAR 333-027-0000 (Purpose) through 333-027-0190 (Civil Penalties). Agencies should refer to 42 CFR Part 484 to review applicable conditions of participation, including limitations on allowed practitioners.