Plan of Care

All CSN services must be provided under an individualized plan of care developed for the member. The physician or ordering non-physician practitioner must sign the plan of care before services are provided to the member. On request, the independent nurse must make the plan of care available to the member and/or the member’s representative. (A) Providers Qualified to Establish a Plan of Care. (1) The member’s physician or the ordering non-physician practitioner in consultation with the independent nurse must establish a written plan of care, and the physician or ordering non-physician practitioner must recertify, sign, and date the plan of care every 60 calendar days. (2) The independent nurse may establish an additional plan of care, when appropriate, that may be incorporated into the physician’s or ordering non-physician practitioner’s plan of care or be prepared separately. The additional plan of care does not substitute for the physician’s or ordering non-physician practitioner’s plan of care. (3) If an independent nurse is co-vending a case with other providers, each provider is responsible for establishing a separate plan of care signed by the member’s physician or ordering non-physician practitioner. (B) Content of the Plan of Care. The orders on the plan of care must specify the total number of CSN hours that MassHealth agency or its designee has authorized to be provided to the member. The physician or ordering non-physician practitioner must sign and date the plan of care before the independent nurse submits the claim for the services to the MassHealth agency for payment. Alternatively, the physician or ordering non-physician practitioner must comply with the verbal order provisions in 130 CMR 414.412(D). Any increase in the total number of CSN hours must be requested in advance by the physician or ordering non-physician practitioner with verbal or written orders and authorized by the MassHealth agency or its designee. If the member is enrolled in the Primary Care Clinician (PCC) Plan, the independent nurse must communicate with the member’s PCC both when the goals of the care plan are achieved and when there is a significant change in a member’s health status. The plan of care must also include (1) the member’s name and date of birth; (2) all pertinent diagnoses, including the member’s mental, psychosocial, and cognitive status; (3) types of medical supplies and DME required; (4) the member’s prognosis, rehabilitation potential, functional limitations, permitted activities, nutritional requirements, medications, and treatments; (5) the total number of nursing hours requested by the independent nurse, if different from the total number of CSN hours authorized by the MassHealth agency or its designee; (6) any teaching activities to be conducted by the nurse to teach the member, family member, or caregiver how to manage the member’s treatment regimen (ongoing teaching may be necessary where there is a change in member’s condition or treatment); (7) all skilled nursing interventions to be provided, including the frequency, clinical assessment(s), and clinical parameters triggering escalation to the treating provider; (8) a description of the patient’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors; (9) a plan for medical emergencies; (10) goals toward discharge planning from CSN services when appropriate; and (11) any additional items the independent nurse or physician or non-physician practitioner chooses to include. (C) Certification Period. The plan of care required under 130 CMR 414.412(A)(1) must be reviewed, signed, and dated by a physician or ordering non-physician practitioner at least every 60 days, unless the provider follows the verbal order provisions in 130 CMR 414.412(D). (D) Physician Verbal Orders. Notwithstanding the requirements of 130 CMR 414.412(A), services that are provided from the beginning of the certification period (see 130 CMR 414.412(C)) and before the ordering physician or ordering non-physician practitioner signs the plan of care are considered to be provided under a plan of care established and approved by the physician or ordering non-physician practitioner if (1) the clinical record contains a documented verbal order from the ordering physician or ordering non-physician practitioner for the care before the services are provided; or (2) the physician or ordering non-physician practitioner signature is on the 60-day plan of care either before the claim is submitted or within 60 days after a claim is submitted for that period. (E) Corrections to the Plan of Care. When correcting errors on a paper copy of the plan of care before it is signed by the physician, the independent nurse must cross out the error with a single line and place their initials and the date next to the correction. The use of correction fluid or correction tape on a plan of care is not permitted. (F) MassHealth Members Enrolled in the Primary Care Clinician Plan. If a member is enrolled in the PCC Plan, the independent nurse must provide the PCC with a copy of the member’s plan of care for each certification period.