• The physician must estimate the length of time skilled services will be required. The length of service must be individualized to the patient/client and reflect a realistic expectation of patient’s/client’s need for care. For example, a slow healing wound may realistically require 120 days. It is not acceptable to have a recurring 60 day expectation on each plan of care. It must be clear that the last two bullets are from the physician/physician’s office and not the clinician. Recertification Documentation The following documentation is completed at the time of recertification: • A new comprehensive assessment, including OASIS. • A thorough review of all medications with an update of the medication profile. • A plan of care is developed for the new episode of care, including the certification statement from the physician with the estimate of how much longer the skilled services will be required. • The aide care plan is reviewed and revised as needed. • A written summary may be required by the Agency to summarize the care provided in the current episode and to explain the ongoing need for the new episode. Ask the supervisor for the Agency’s process.
