Except as provided in subsections (5) and (6) of this section, the licensee must:

(1) Develop and implement a written home health plan of care for each patient with input from the patient, designated family member, or legal representative and authorizing practitioner;

(2) Ensure each plan of care is developed by appropriately trained or credentialed agency personnel and is based on a patient assessment;

(3) Ensure the home health plan of care includes:

(a) Current diagnoses and information on health status;

(b) Goals and outcome measures which are individualized for the patient;

(c) Types and frequency of services to be provided;

(d) Palliative care, if applicable;

(e) Use of telehealth or telemedicine, if applicable;

(f) Home medical equipment and supplies used by the patient;

(g) Orders for treatments and their frequency to be provided and monitored by the licensee;

(h) Special nutritional needs and food allergies;

(i) Orders for medications to be administered and monitored by the licensee including name, dose, route, and frequency;

(j) Medication allergies;

(k) The patient's physical, cognitive and functional limitations;

(l) Discharge and referral plan;

(m) Patient and family education needs pertinent to the care being provided by the licensee;

(n) Indication that the patient has a signed advanced directive or POLST, if applicable. Include resuscitation status according to advance directives or POLST, if applicable; and

(o) The level of medication assistance to be provided.

(4) Develop and implement a system to:

(a) Ensure and document that the plan of care is reviewed and updated by appropriate agency personnel according to the following time frames:

(i) For patients requiring acute care services, every two months;

(ii) For patients requiring maintenance services, every six months; and

(iii) For patients requiring only professional medical equipment assessment services or home health aide only services, every twelve months.

(b) Ensure the plan of care is signed or authenticated and dated by appropriate agency personnel and the authorizing practitioner, according to the time frames in (a) of this subsection;

(c) Ensure the signed or authenticated plan of care is returned to the agency within sixty days of the initial date of service or date of review and update;

(d) Inform the authorizing practitioner regarding changes in the patient's condition that indicate a need to update the plan of care;

(e) Obtain approval from the authorizing practitioner for additions and modifications;

(f) Ensure all verbal orders for modification to the plan of care are immediately documented in writing and signed or authenticated and dated by an agency individual authorized within their scope of practice to receive the order and signed or authenticated by the authorizing practitioner and returned to the agency within sixty days of the date the verbal orders were received.

(5) Home health agencies providing only home health aide services to a patient:

(a) May develop a modified plan of care by providing only the following information on the plan of care:

(i) Types and frequency of services to be provided;

(ii) Home medical equipment and supplies used by the patient;

(iii) Special nutritional needs and food allergies;

(iv) The patient's physical, cognitive and functional limitations; and

(v) The level of medication assistance to be provided.

(b) Do not require an authorizing practitioner signature on the plan of care.

(6) Home health agencies providing a one-time visit for a patient may provide the following written documentation in lieu of the home health plan of care requirements in subsection (3) of this section:

(a) Patient name, age, current address, and phone number;

(b) Confirmation that the patient was provided a written bill of rights under WAC 246-335-535;

(c) Patient consent for services to be provided;

(d) Authorizing practitioner orders; and

(e) Documentation of services provided.