Patient Care Plan
(1)Each facility shall maintain a written patient care plan for each patient to ensure that patients receive the appropriate treatment modality and the appropriate care within that modality. Provisions shall be made for the patient, or when appropriate, parent or legal guardian to be involved with the health team in the planning of care and in the development of the care plan. Due consideration shall be given to his/her preferences.
(2)The written patient care plan for each patient of a facility (including home dialysis patients under the supervision of the facility) shall be based upon the nature of the patient’s illness, the treatment prescribed, and an assessment of the patient’s needs.
(3)The patient care plan shall be personalized for the individual, shall reflect the psychological, nutrition, social, and functional needs of the patient, and shall indicate the dialysis and other care required as well as the individualized modifications in approach necessary to achieve the long-term and short-term goals. Any unresolved concerns of the patient and family shall be addressed at the time of each review. Documentation shall reflect that the patient and family has had an opportunity to voice these concerns and the methods utilized to achieve resolution of the concerns.
(4)The plan shall be developed by an interdisciplinary care team consisting of at least the physician responsible for the patient’s dialysis care, a qualified nurse responsible for nursing services, a qualified social worker, and a qualified dietitian.
(5)The care plan for a patient whose medical condition is not stable shall be reviewed at least monthly by the interdisciplinary care team. For an adult patient aged 18 and older whose condition is stable, the care plan shall be reviewed at least annually. For pediatric patients whose conditions are stable, the care plan shall be reviewed monthly for ages 0-11 months, quarterly for ages 1-5 years, and every six months for ages 6-17 years. The care plan shall be revised as necessary to ensure that it provides for the ongoing needs of the patient.
(6)If the patient is transferred to another facility, the care plan shall be sent to the receiving facility at the time the patient is transferred or within one working day of the transfer.
(7)For a home-dialysis patient whose care is under the supervision of the facility, the care plan shall provide for periodic monitoring of the patient’s home adaptation, including provisions for visits to the home by qualified facility personnel to the extent appropriate.
(8)When a dialysis patient uses an anemia management drug in the home, the plan must provide for monitoring home use of the anemia management drug. This monitoring shall include the following:
(a)Review of diet or fluid intake for indiscretions as indicated by hyperkalemia and elevated blood pressure secondary to volume overload;
(b)Review of lab values and medications to ensure adequate management of anemia;
(c)A reevaluation of the dialysis prescription taking into account the patient’s increased appetite and red blood cell volume;
(d)A method for physician follow up on blood tests and a mechanism (such as a patient log) for keeping the physician informed of the results; and
(e)Review of the training of the patient to identify the signs and symptoms of hypotension and hypertension.
Rule 333-700-0085 — Patient Care Plan,