Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 117 - END STAGE RENAL DISEASE FACILITIES › Subchapter D - MINIMUM STANDARDS FOR PATIENT CARE AND TREATMENT › Section 117.45 - Provision and Coordination of Treatment and Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Patient plan of care.
(1) A facility shall develop, implement, and
				  enforce policies and procedures on the patient's plan of care process which
				  specifies the services necessary to address the patient's comorbid conditions
				  and other needs based on the patient's interdisciplinary assessment. The
				  patient services are coordinated using an interdisciplinary team approach. The
				  interdisciplinary team shall consist of the patient, the patient's primary
				  dialysis physician, registered nurse, social worker, and dietitian.
(2) The interdisciplinary team shall engage
				  in an interactive conference in order to develop a written, individualized,
				  comprehensive patient plan of care that specifies the services necessary to
				  address the patient's medical, psychological, social, and functional needs, and
				  includes treatment goals.
(3) The
				  plan of care shall include measurable and expected outcomes and estimated
				  timetables to achieve these outcomes. The plan of care shall include, but not
				  be limited to, the patient's current dose of dialysis, dialysis adequacy, other
				  medical comorbidity issues, nutritional status, mineral metabolism, anemia,
				  vascular access, psychosocial status, modality, transplantation status,
				  rehabilitation status, patient's goals, and patient education and
				  training.
(4) The patient plan of
				  care shall include evidence of coordination with other service providers (e.g.,
				  hospitals, long term care facilities, home and community support services
				  agencies, or transportation providers) as needed to assure the provision of
				  continuity of safe care.
(5) The
				  patient plan of care shall include evidence of the patient's (or patient's
				  legal representative's) input and participation, unless they refuse to
				  participate. At a minimum, the patient plan of care shall demonstrate that the
				  content was discussed with the patient or the patient's legal representative by
				  a member of the interdisciplinary team.
(6) The patient plan of care shall be
				  developed and implemented within 30 calendar days or 13 outpatient dialysis
				  treatments from the patient's admission to the facility. The plan of care shall
				  be revised due to the patient's lack of progress towards the goals of the plan
				  of care, marked deterioration in health status, significant changes in the
				  patient's psychosocial needs, or changes in the patient's nutritional
				  condition, as needed but no less than annually after the date of the patient's
				  last plan of care.
(7) The facility
				  shall monitor the plan of care at least monthly to recognize and address any
				  deviations from the plan of care as follows:
(A) implement changes in interventions due to
				  the lack of progress toward the goals of the plan of care;
(B) document as to the reasons why the
				  patient was unable to achieve the goals; and
(C) implement changes to address the revised
				  plan of care.
(8) An
				  interdisciplinary team conference may be conducted via phone conferencing. A
				  phone plan of care conference conducted with the interdisciplinary team and the
				  patient (or their legal representative) shall be documented as a phone
				  conference.
(9) In the case of
				  disruptive patients or family members or patients who do not conform to the
				  treatment plan, the facility shall develop, implement, and enforce a process
				  for more intensive interdisciplinary team intervention with this patient to
				  include assessment of needs and planned interventions to assist the patient in
				  adjusting to the requirements for safe care.