measurable outcome may be to improve ambulation if ambulation is the reason the patient/client is currently unable to go to the kitchen. Or the outcome may be to improve dyspnea if the reason is shortness of breath. The Agency’s interventions will allow the patient/client to progress toward the Agency’s goals (increase strength to ambulate twenty feet or complies with energy conservation measures to ambulate twenty feet). The Agency’s goals, as met, help the patient/client improve their outcome of ambulation or dyspnea. Home Health Aide Care Plan If the patient/client requires the services of an aide, a care plan must be completed prior to the patient/client receiving personal care. The copy of the care plan may be left in the patient’s/client’s home folder. Assignment of aide duties must indicate tasks and frequency of each. Assigning “per patient/client request” is not generally recommended, however, it is acceptable to allow patient/client choice if it is also documented that the patient/client is cognitively capable of making the decision and functionally able to complete the task. Note any special problems or services the patient/client may have and instruct the aide on patient/client specific care. Indicate parameters of blood pressure, temperature, etc., so the aide is aware when to notify the supervising clinician. The care plan should be updated as the patient’s/client’s condition changes (e.g., a patient/client discharged from the hospital initially may require a bed bath, but as improvement is made the patient/client may be able to shower). The aide should not perform any services that are not ordered on the care plan. If the patient/client requests other tasks not assigned, the aide must notify the supervising clinician to revise the aide care plan. Recertification Process At the end of the initial 60-day episode, a decision must be made as to recertify the patient/client for a subsequent 60 day episode or not. According to the regulations at 42 CFR §424.22(b)(1), recertification is required at least every 60 days when there is a need for continuous home health care after an initial 60-day episode. Unless there is a 1) patient/client-elected transfer or 2) discharge with goals met and/or no expectation of a return to home health care (these situations trigger a new certification), Medicare does not limit the number of continuous episodes of recertification for patients/clients who continue to be eligible for the home health benefit. Recertification Requirements per MLN Matters Number: SE1436 • The recertification documentation must be signed and dated by the physician who reviews the plan of care. • The physician must indicate the continuing need for skilled services (the need for OT may be the basis for continuing services that were initiated because the individual needed SN, PT, or SLP services).
