1 TAC § 363.313. Plan of Care

(a) A plan of care is developed by an RN and represents the treating physician's orders.

(b) The plan of care must be established and periodically reviewed by the treating physician in consultation with the provider and the recipient or responsible adult.

(c) The plan of care developed by the RN must be:

(1) submitted with a request for prior authorization of PDN services;

(2) recommended, signed, and dated by the treating physician no more than 30 days before the start of care or 30 days before the end of the prior authorization period; and

(3) reviewed and revised by the treating physician with each prior authorization, or more frequently as the treating physician or the PDN services provider deems necessary.

(d) A plan of care developed by the RN must include the following elements:

(1) a clinical summary that documents active diagnoses and current clinical condition;

(2) the recipient's mental or cognitive status;

(3) the types of treatments and services, including amount, duration, and frequency;

(4) a description of any required equipment and/or supplies;

(5) the recipient's prognosis;

(6) the recipient's rehabilitation potential;

(7) the recipient's current functional limitations;

(8) the activities permitted;

(9) the recipient's nutritional requirements;

(10) the recipient's medications, including dose, route, and frequency;

(11) the safety measures to protect against injury;

(12) instructions for timely discharge or referral;

(13) the date the recipient was last seen by the treating physician;

(14) identification of activities of daily living and health maintenance activities with which the recipient needs assistance, consistent and in accordance with 22 TAC Chapter 224 (relating to Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments) and 22 TAC Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions). The plan of care must indicate whether the tasks must be performed by a licensed nurse or a qualified aide, or may be performed by a personal care attendant as described in Subchapter F of this chapter (relating to Personal Care Services);

(15) a certification statement that an identified contingency plan exists; and

(16) all other medical orders.