(a)  The plan of care shall be established in collaboration with the client and incorporated in the service record.  The plan of care must be reviewed at least every three months by the appropriate agency professional and revised as needed based on the client's needs.  If the client record is thinned, the original and updated authorization or orders for care as appropriate shall be maintained in the client's current record.  All records shall be readily available to Department staff for review if requested.  If physician orders are needed for the services, a home care health professional shall notify the physician of any changes in the client's condition which indicates the need for altering the plan of care or for terminating services.  Based upon the findings of the client assessment, the plan of care shall include at a minimum the following:

(1)           type of service(s) and care to be delivered;

(2)           frequency and duration of service;

(3)           activity restrictions;

(4)           safety measures; and

(5)           service objectives and goals.

(b)  Where applicable, the plan of care shall include, but is not limited to:

(1)           equipment required;

(2)           functional limitations;

(3)           rehabilitation potential;

(4)           diet and nutritional needs;

(5)           medications and treatments;

(6)           specific therapies;

(7)           pertinent diagnoses; and

(8)           prognosis.

(c)  So long as ongoing hands‑on care is being provided to a client, a registered nurse, social worker or other appropriate professional shall visit the client in the client's residence at least quarterly to assess the client's general condition, progress and response to services provided.  Documentation of these visits shall be maintained in the client's service record.

(d)  If the same professional is assigned responsibility for two or more of the following, these functions may be conducted during the same home visit:

(1)           quarterly assessment of client's condition and response;

(2)           provision of regularly scheduled professional services; or

(3)           supervision of in‑home aide or other allied health personnel.


History Note:        Authority G.S. 131E‑140;

Eff. July 1, 1992;

Amended Eff. May 1, 1993;

RRC Objection due to lack of statutory authority Eff. November 16, 1995;

Amended Eff. February 1, 1996.