Oregon Administrative Rules › Chapter 333 - OREGON HEALTH AUTHORITY, PUBLIC HEALTH DIVISION › Division 700 - LICENSING STANDARDS FOR OUTPATIENT RENAL DIALYSIS FACILITIES › Section 333-700-0085 - Patient Care Plan

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Each
			 facility shall maintain a written patient care plan for each patient to ensure
			 that patients receive the appropriate treatment modality and the appropriate
			 care within that modality. Provisions shall be made for the patient, or when
			 appropriate, parent or legal guardian to be involved with the health team in
			 the planning of care and in the development of the care plan. Due consideration
			 shall be given to his/her preferences.
(2) The written patient care plan for each
			 patient of a facility (including home dialysis patients under the supervision
			 of the facility) shall be based upon the nature of the patient's illness, the
			 treatment prescribed, and an assessment of the patient's needs.
(3) The patient care plan shall be
			 personalized for the individual, shall reflect the psychological, nutrition,
			 social, and functional needs of the patient, and shall indicate the dialysis
			 and other care required as well as the individualized modifications in approach
			 necessary to achieve the long-term and short-term goals. Any unresolved
			 concerns of the patient and family shall be addressed at the time of each
			 review. Documentation shall reflect that the patient and family has had an
			 opportunity to voice these concerns and the methods utilized to achieve
			 resolution of the concerns.
(4) The
			 plan shall be developed by an interdisciplinary care team consisting of at
			 least the physician responsible for the patient's dialysis care, a qualified
			 nurse responsible for nursing services, a qualified social worker, and a
			 qualified dietitian.
(5) The care
			 plan for a patient whose medical condition is not stable shall be reviewed at
			 least monthly by the interdisciplinary care team. For an adult patient aged 18
			 and older whose condition is stable, the care plan shall be reviewed at least
			 annually. For pediatric patients whose conditions are stable, the care plan
			 shall be reviewed monthly for ages 0-11 months, quarterly for ages 1-5 years,
			 and every six months for ages 6-17 years. The care plan shall be revised as
			 necessary to ensure that it provides for the ongoing needs of the
			 patient.
(6) If the patient is
			 transferred to another facility, the care plan shall be sent to the receiving
			 facility at the time the patient is transferred or within one working day of
			 the transfer.
(7) For a
			 home-dialysis patient whose care is under the supervision of the facility, the
			 care plan shall provide for periodic monitoring of the patient's home
			 adaptation, including provisions for visits to the home by qualified facility
			 personnel to the extent appropriate.
(8) When a dialysis patient uses an anemia
			 management drug in the home, the plan must provide for monitoring home use of
			 the anemia management drug. This monitoring shall include the following:
(a) Review of diet or fluid intake for
			 indiscretions as indicated by hyperkalemia and elevated blood pressure
			 secondary to volume overload;
(b)
			 Review of lab values and medications to ensure adequate management of
			 anemia;
(c) A reevaluation of the
			 dialysis prescription taking into account the patient's increased appetite and
			 red blood cell volume;
(d) A method
			 for physician follow up on blood tests and a mechanism (such as a patient log)
			 for keeping the physician informed of the results; and
(e) Review of the training of the patient to
			 identify the signs and symptoms of hypotension and hypertension.