Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-31 - HOME HEALTH AGENCIES › Rule 111-8-31-.09 - Standards for Patient Care

Current through Rules and Regulations filed through June 27, 2024
Patients shall be accepted for treatment on the basis of a
				  reasonable expectation that the patient's medical, nursing, and social needs
				  can be met adequately by the agency in the patient's place of residence.
				  Patients shall not be denied services because of their age, sex, race,
				  religion, or national origin. Care shall follow a written plan of treatment
				  established and periodically reviewed by a physician, and shall continue under
				  the supervision of a physician.
(a)
				Plan of Treatment. An individual plan of treatment shall be developed for each
				patient in consultation with agency staff, and shall cover all pertinent
				diagnosis, including mental status, types of services and equipment required,
				frequency of visits, prognosis, rehabilitation potential, functional
				limitations, activities permitted, nutritional requirements, medications and
				treatments, safety measures to protect against injury, instructions for timely
				discharge or referral, and other appropriate items. If a physician refers a
				patient under a plan of treatment which cannot be completed until after an
				evaluation visit, the physician shall be consulted to approve additions or
				modifications to the original plan. Orders for therapy services shall specify
				the procedures and modalities to be used, and the amount, frequency, and
				duration.
(b) Periodic Review of
				Plan of Treatment. The total plan of treatment shall be reviewed by the
				attending physician and home health agency personnel as often as the severity
				of the patient's condition requires, but at least once every sixty (60) days.
				Date of the review and approval of the plan shall be documented by the
				physician's signature. Agency professional staff shall promptly alert the
				physician to any changes that suggest a need to alter the plan of
				treatment.
(c) Conformance with
				Physician's Orders. Drugs and treatment shall be administered by agency staff
				only as ordered by the physician. The nurse or therapist shall immediately
				record and sign oral orders and forward the written order within five (5)
				business days to the physician for countersignature. Documentation of the
				physician's countersignature must appear in the patient's medical record within
				thirty (30) days of the verbal order. Professional agency staff shall check all
				medicines a patient may be taking to identify possible ineffective drug therapy
				or adverse reactions, significant side effects, drug allergies, and
				contraindicated medication, and shall promptly report any problems to the
				physician.
(d) Clinical Records.
1. A clinical record shall be established and
				maintained on each patient in accordance with accepted professional standards
				and shall contain:
(i) pertinent past and
				current findings;
(ii) plan of
				treatment;
(iii) appropriate
				identifying information;
(iv) name
				of physician;
(v) drug, dietary,
				treatment and activity orders;
(vi)
				signed and dated clinical and progress notes (clinical notes are written the
				day service is rendered by the providing member of the health team and
				incorporated no less often than weekly);
(vii) copies of case conferences;
(viii) copies of summary reports sent to the
				physician; and
(ix) a discharge
				summary.