For any delivered home health service to be payable, the medicaid agency requires home health providers to develop and implement an individualized plan of care (POC) for the client.
(1) The POC must:
(a) Be documented in writing and be located in the client's home health medical record;
(b) Be developed, supervised, and signed by a licensed registered nurse or licensed therapist;
(c) Reflect the ordering physician's orders and client's current health status;
(d) Contain specific goals and treatment plans;
(e) Be reviewed and revised by an ordering physician at least every sixty calendar days, signed by the ordering physician within forty-five days of the verbal order, and returned to the home health agency's file; and
(f) Be available to medicaid agency staff or its designated contractor(s) on request.
(2) The provider must include all the following in the POC:
(a) The client's name, date of birth, and address (to include name of residential care facility, if applicable);
(b) The primary diagnosis (the diagnosis that is most related to the reason the client qualifies for home health services) or the diagnosis that is the reason for the visit frequency;
(c) All secondary medical diagnoses, including date or dates of onset or exacerbation;
(d) The prognosis;
(e) The type or types of equipment required, including telemedicine as appropriate;
(f) A description of each planned service and goals related to the services provided;
(g) Specific procedures and modalities;
(h) A description of the client's mental status;
(i) A description of the client's rehabilitation potential;
(j) A list of permitted activities;
(k) A list of safety measures taken on behalf of the client; and
(l) A list of medications which indicates:
(i) Any new prescription; and
(ii) Which medications are changed for dosage or route of administration.
(3) The provider must include in or attach to the POC:
(a) A description of the client's functional limits and the effects;
(b) Documentation that justifies why the medical services should be provided in any setting where the client's life activities take place instead of an ordering physician's office, clinic, or other outpatient setting;
(c) Significant clinical findings;
(d) Dates of recent hospitalization;
(e) Notification to the department of social and health services (DSHS) case manager of admittance;
(f) A discharge plan, including notification to the DSHS case manager of the planned discharge date and client disposition at time of discharge; and
(g) Order for the delivery of home health services through telemedicine, as appropriate.
(4) The individual client medical record must comply with community standards of practice, and must include documentation of:
(a) Visit notes for every billed visit;
(b) Supervisory visits for home health aide services as described in WAC 182-551-2120
(c) All medications administered and treatments provided;
(d) All physician's orders, new orders, and change orders, with notation that the order was received before treatment;
(e) Signed physician's new orders and change orders;
(f) Home health aide services as indicated by a registered nurse or licensed therapist in a home health aide care plan;
(g) Interdisciplinary and multidisciplinary team communications;
(h) Inter-agency and intra-agency referrals;
(i) Medical tests and results;
(j) Pertinent medical history; and
(k) Notations and charting with signature and title of writer.
(5) The provider must document at least the following in the client's medical record:
(a) Skilled interventions per the POC;
(b) Client response to the POC;
(c) Any clinical change in client status;
(d) Follow-up interventions specific to a change in status with significant clinical findings;
(e) Any communications with the attending ordering physician; and
(f) Telemedicine findings, as appropriate.
(6) The provider must include the following documentation in the client's visit notes when appropriate:
(a) Any teaching, assessment, management, evaluation, client compliance, and client response;
(b) Weekly documentation of wound care, size (dimensions), drainage, color, odor, and identification of potential complications and interventions provided;
(c) If a client's wound is not healing, the client's ordering physician has been notified, the client's wound management program has been appropriately altered and, if possible, the client has been referred to a wound care specialist; and
(d) The client's physical system assessment as identified in the POC.