Medicare regulations specify that completion and implementation of the individualized plan of care for each renal dialysis patient be properly documented and signed by all members of the patient’s interdisciplinary care team (IDT) — including the patient or their representative.

During ACHC Renal Dialysis Accreditation surveys, providers continue to be cited for failing to properly document the plan of care.

The most common reasons for this deficiency? Failing to secure the patient’s, or their designated representative’s, signature on the plan of care and/or incomplete documentation of the patient’s or their representative’s participation in the development and implementation of the plan of care.

Standard Requirements

ACHC Standards include Medicare Conditions for Coverage (CfCs), keeping you in compliance with all regulatory requirements.

Standard RD5-J: Written policies and procedures are established and implemented in regard to the interdisciplinary team developing and implementing a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment. (494.90) V540-541, (494.90(a)(1-8)) V542-555, (494.90(b)(1)) V556, (494.90(b)(2)) V557-558, (494.90(b)(3)) V559, (494.90(b)(4)) V560, (494.90(c)) V561, (494.90(d)) V562

Medicare Condition for Coverage 494.90(b)(1)(i-ii) V556 requires that the patient’s plan of care be completed by the IDT, including the patient, if the patient desires, and signed by the team members, including the patient or the patient’s designee. If the patient chooses not to sign the plan of care, the choice must be documented on the plan of care, along with the reason the signature was not provided.

Documentation validates that the IDT worked collaboratively to assess, develop, and implement the patient’s individualized comprehensive plan of care to meet the patient’s needs.

The patient’s, or their representative’s, signature acknowledges that they have reviewed their individualized treatment plan and expectations for care. If the patient chooses not to sign their plan of care, the reason for refusal must be documented.

Tips for Compliance

• Patients should be offered multiple ways to participate in the plan of care meetings (e.g., in person, by phone, or at chair side, with the patient’s permission). Suggestions to increase patient participation include:
  • Scheduling meetings in advance.
  • Presenting a letter or invitation for a specific date and time.
  • Posting a calendar of when plan of care meetings will be held.
  • Notifying patients who want to participate by phone that the staff will call within a certain time frame.
• Patients have the right to refuse participation in IDT discussions about their care and/or choose not to sign their plan of care. If the patient or the patient’s designee refuses to participate or sign the plan of care, the facility is responsible for documenting the patient’s choice and the reason for not signing.
• The facility must ensure that every plan of care has either a patient’s or patient designee’s signature or documents the reason for the patient’s refusal to sign.

ACHC recommends that you encourage the patient or patient’s designee to participate in the development and implementation of the plan of care. Benefits include keeping the patient actively involved in decisions about their care process and better able to communicate goals and concerns with all IDT members.

Here to Help

ACHC is more than an accreditor. We are your partner. For more information, contact your Account Advisor, email [email protected], or call (855) 937-2242, ext. 457.