Initiation of Care Orders: The rehabilitation agency must receive a written referral from the client’s primary HIV medical provider or dental provider before the initiation of care. The provider must be a licensed practitioner to include the following:

• Dentist (DDS or DMD)
• Doctor of Medicine (MD)
• Doctor of Osteopathy (OD)
• Advanced Practice Registered Nurse (APRN)
• Clinical Nurse Specialist (CNS)
• Physician Assistant (PA)

1. Percentage of clients with documentation that a qualified licensed practitioner signed a referral for rehabilitation services before the initiation of services.

Comprehensive Assessment: The rehabilitation agency staff will complete a comprehensive assessment within five business days of the initiation of services to include the following:

• Presenting issue
• Physical examination and evaluation performed by the therapist relevant to the type of therapy prescribed
• Diagnosis
• Prognosis

2. Percentage of clients with a comprehensive assessment within five business days of the initiation of services that includes the following: 
   1. Presenting issue
   2. Physical examination as applicable
   3. Diagnosis
   4. Prognosis

Plan of Care: Staff will develop a plan of care in collaboration with the client within 10 business days of completing the comprehensive assessment.

The agency must maintain the plan in the client’s primary record. The agency must offer a copy of the plan of care to the client and document this in the client’s record.

The plan of care must include:

• The objective of rehabilitation services
• Client-centered goals
• The type of therapy
• The estimated number of sessions
• The estimated duration of services

Staff must review the plan of care every six months at a minimum and update it as needed.

3. Percentage of clients with a plan of care developed within 10 business days of the completed comprehensive assessment that includes the following
   1. Objective of rehabilitation services
   2. Goals of services for client
   3. Type of therapy
   4. Estimated number of sessions
   5. Estimated duration of services
       
4. Percentage of clients with a plan of care reviewed and updated every six months.

Provision of Services: Professionals must document all services provided to clients, including:

• The types of services provided
• The location of services
• The date of services
• The duration of service

If the agency cannot meet the client’s needs, it must refer the client to an appropriate care provider. The agency or provider must document any referral and its outcome in the client’s primary record.

5. Percentage of client charts with documentation of services, including: (Pilot measure 2025-2026)
   1. Types of services provided
   2. Location of services
   3. Date of services
   4. Duration of services
       

Transfer and Discharge: The agency must develop a planned and progressive process for transferring and discharging clients from rehabilitation services.  The transfer and discharge processes must consider the needs and desires of the client, caregiver(s), family, and support network.

Agencies must develop a transfer or discharge plan when one or more of the following occur:
 

• The agency no longer meets the level of care required by the client.
• The client transfers services to another service program.
• The client is not stable enough to receive services outside of the acute care setting as determined by the agency and the client's primary medical care provider.
• The client no longer has a stable home environment appropriate for the provision of rehabilitation services as determined by the agency.
• The client is unable or unwilling to adhere to agency policies.
• An employee of the agency has experienced a real or perceived threat to safety during a visit to a client's home, in the company of an escort or not. The agency may discontinue services or refuse the client for as long as the threat is ongoing. 
   

6. Percentage of clients with documentation of a discharge or transfer plan developed in coordination with the client, caregiver(s), and multidisciplinary team, as applicable.

Notification of Transfer or Discharge: When an agency transfers or discharges a client from services, they must:

• Provide written notification to the client or the client’s parent, family, spouse, significant other, or legal representative.
• Provide written notification to the client’s attending physician or practitioner.

Agencies must deliver the written notification no later than five days before the date on which the agency will transfer or discharge the client.

7. Percentage of clients with documentation of notification of transfer or discharge within five days before the date of transfer or discharge to the following parties, as applicable:
   1. The client or legal representative. 
   2. The client’s referring and attending practitioner.