including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and non-compliance. All medications are reconciled with orders. Once the comprehensive assessment is completed (within five days of the initial visit) and the plan of care is approved by the responsible physician, the medication schedule/instructions will be provided to the patient/client. The medication administration instructions must be written in plain language, avoiding the use of medical abbreviations and include medication name, dosage, frequency, and if to be administered by agency personnel or contracted personnel. In the event the orders are for therapy only, the therapist will be responsible for documenting medications which the RN will review as above, and date and co-sign. Plan of Care (POC) Each patient/client must receive the home health services that are written in an individualized Plan of Care that identifies patient/client-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathic medicine, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician refers a patient/client under a Plan of Care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. Each patient/client must participate in developing an individualized Plan of Care, including any revisions or additions. The individualized Plan of Care must specify the care and services necessary to meet the patient/client-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the Agency anticipates will occur as a result of implementing and coordinating the Plan of Care. The individualized Plan of Care must also specify the patient/client and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. Review the following policy and procedure: Online Bookmark Title of Policy Provision of Care (PC) Plan of Care The content of the individualized Plan of Care is listed in the above policy. Further explanation of some items: • The patient’s/client’s mental status is most generally screened by asking questions on orientation to time, place, and person. • Psychosocial status may include, as relevant to the Plan of Care, interpersonal relationships in the immediate family, financial status, homemaker/household needs, vocational rehabilitation needs, family social problems, transportation needs, and cognitive status. • The risk of ER visits and hospitalizations is greatly influenced by increased concerns or needs identified in status elements (1), (2), (6), (7), (9), and (10). • A measurable outcome is defined as a change in health status, functional status, or knowledge, which occurs over time in response to a healthcare intervention. For example, a patient’s/client’s goal may be to be able to walk to the kitchen and prepare a light meal. The
