400.487  Patient assessment; establishment and review of plan of care; provision of services; orders not to resuscitate.--

(1)  The home health agency providing skilled care must make an assessment of the patient's needs within 48 hours after the start of services.

(2)  The attending physician for a patient who is to receive skilled care must establish treatment orders. The treatment orders must be signed by the physician within 24 days after the start of care and must be reviewed, at least every 62 days or more frequently if the patient's illness requires, by the physician in consultation with home health agency personnel that provide services to the patient.

(3)  If a client is accepted for home health aide services or homemaker or companion services and such services do not require a physician's order, the home health agency shall establish a service provision plan and maintain a record of the services provided.

(4)  Each patient or client has the right to be informed of and to participate in the planning of his or her care. Each patient must be provided, upon request, a copy of the plan of care or service provision plan established and maintained for that patient or client by the home health agency.

(5)  When nursing services are ordered, the home health agency to which a patient has been admitted for care must provide the initial admission visit, all service evaluation visits, and the discharge visit by qualified personnel who are on the payroll of, and to whom an IRS payroll form W-2 will be issued by, the home health agency. Services provided by others under contractual arrangements to a home health agency must be monitored and managed by the admitting home health agency. The admitting home health agency is fully responsible for ensuring that all care provided through its employees or contract staff is delivered in accordance with this part and applicable rules.

(6)  The skilled care services provided by a home health agency, directly or under contract, must be supervised and coordinated in accordance with the plan of care.

(7)  Home health agency personnel may withhold or withdraw cardiopulmonary resuscitation if presented with an order not to resuscitate executed pursuant to s. 401.45. The agency shall adopt rules providing for the implementation of such orders. Home health personnel and agencies shall not be subject to criminal prosecution or civil liability, nor be considered to have engaged in negligent or unprofessional conduct, for withholding or withdrawing cardiopulmonary resuscitation pursuant to such an order and rules adopted by the agency.