Plan of care; treatment and care; discharge planning – Ohio Admin. Code 3701-17-14

An interdisciplinary team, including the resident and his family or sponsor, must develop a plan of care for each resident in a nursing home that fulfills the following requirements:

• The plan of care must be consistent with the comprehensive assessment, with recognition of the capabilities and preferences of the resident;
• The plan of care must contain a written description of what services are needed, when, how often, and by whom provided and the measurable goals or outcomes;
• The plan of care must be reviewed quarterly and when the needs of the resident warrant a change in the services to be provided, and must be updated as appropriate; and
• Each resident shall have access to his or her assessment and plan of care at any time upon request.

When transferring or discharging a resident, the nursing home must prepare the following information:

• An updated assessment that addresses applicable criteria and accurately identifies the resident’s condition and continuing care need at the time of transfer and discharge;
• A plan that is developed with the resident and family members that describes what services are needed, how needed services can be accessed, and how to coordinate care if multiple care givers are involved. The plan must identify need for the resident and care givers’ education, and any accommodations to the physical environment to meet the needs of the resident; and
• The nursing home will arrange or confirm the services, equipment and supplies in advance of discharge or transfer of the resident, with the resident’s consent.

This information will be provided to the following:

• The home, hospital or health care system to which the resident is being transferred;
• To other appropriate persons and agencies with consent of the resident; and 
• As required by law, rule or third-party payment contract.

If the nursing home resident is a patient of a hospice care program, the nursing home must communicate and work with the hospice in developing and implementing a coordinated plan of care, based on the assessment of the resident.  The hospice care program will retain professional management of the resident’s plan of care related to the resident’s terminal illness as long as the resident is receiving hospice care. The nursing home will take directions from the hospice regarding implementation of the coordinated plan of care related to the resident’s terminal illness.