Plan of Care

(a) The plan of care shall be established in collaboration with the client and incorporated in the service record.
The plan of care must be reviewed at least every three months by the agency’s Registered Nurse and revised as needed based on the client’s needs. If the client record is thinned, the original and updated authorization or orders for care, as deemed appropriate, shall be maintained in the client’s current record. All records shall be readily available to DHHS’s staff for review if requested. If physician orders are needed for the services, the agency’s RN or health professional shall notify the physician of any changes in the client’s condition, which indicates the need for altering the plan of care or for terminating services. Based on the findings of the client assessment, the plan of care shall include, at a minimum, the following:

1. Type of service(s) and care to be delivered
2. Frequency and duration of service
3. Activity restrictions
4. Safety measures
5. Service objectives and goals

(b) Where applicable, the plan of care shall include, but is not limited to:

1. equipment required;
2. functional limitations;
3. rehabilitation potential;
4. diet and nutritional needs;
5. medications and treatments;
6. specific therapies;
7. pertinent diagnoses; and
8. prognosis.

For more information, please feel free to contact us at your convenience.