16 Del. Code Regs. § 4406-6.0 - Patient care management for home health agencies

Home health agencies must provide services in accordance with a written plan of care established by a registered nurse.  Before admission, a registered nurse must perform all assessments of the patient.  A plan of care must be developed upon admission based on the initial assessment of the patient. The original plan of care must be retained in the patient’s medical record and a copy of the plan of care must be kept at the patient’s residence.
 
Home health agencies must keep medical records for each patient. The medical records must contain a patient’s personal information, health status, care plan, the patient’s informed consent, and treatment notes. Patient records must be retained for 6 years from the last date of service. In the case of minor patients, patient records must be retained for 6 years after the patient reaches 18 years of age. All records must be disposed of by shredding, burning, or other similar protective measure in order to preserve the patients’ rights of confidentiality. Records must be protected from loss, damage, and unauthorized use.
 
This section also establishes discharging guidelines. The patient has the right to participate in the discharge planning. The home health agency shall develop a written plan of discharge which includes a summary of services provided and outlines the services needed by the patient upon discharge.