| (a) A plan of care is developed by an RN and represents
the treating physician's orders.
(b) The plan of care must be established and periodically
reviewed by the treating physician in consultation with the provider
and the recipient or responsible adult.
(c) The plan of care developed by the RN must be:
(1) submitted with a request for prior authorization
of PDN services;
(2) recommended, signed, and dated by the treating
physician no more than 30 days before the start of care or 30 days
before the end of the prior authorization period; and
(3) reviewed and revised by the treating physician
with each prior authorization, or more frequently as the treating
physician or the PDN services provider deems necessary.
(d) A plan of care developed by the RN must include
the following elements:
(1) a clinical summary that documents active diagnoses
and current clinical condition;
(2) the recipient's mental or cognitive status;
(3) the types of treatments and services, including
amount, duration, and frequency;
(4) a description of any required equipment and/or
supplies;
(5) the recipient's prognosis;
(6) the recipient's rehabilitation potential;
(7) the recipient's current functional limitations;
(8) the activities permitted;
(9) the recipient's nutritional requirements;
(10) the recipient's medications, including dose, route,
and frequency;
(11) the safety measures to protect against injury;
(12) instructions for timely discharge or referral;
(13) the date the recipient was last seen by the treating
physician;
(14) identification of activities of daily living and
health maintenance activities with which the recipient needs assistance,
consistent and in accordance with 22 TAC Chapter 224 (relating to
Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed
Personnel for Clients with Acute Conditions or in Acute Care Environments)
and 22 TAC Chapter 225 (relating to RN Delegation to Unlicensed Personnel
and Tasks Not Requiring Delegation in Independent Living Environments
for Clients with Stable and Predictable Conditions). The plan of care
must indicate whether the tasks must be performed by a licensed nurse
or a qualified aide, or may be performed by a personal care attendant
as described in Subchapter F of this chapter (relating to Personal
Care Services);
(15) a certification statement that an identified contingency
plan exists; and
(16) all other medical orders.
|
