Initiation of Care Orders: The rehabilitation agency must receive written orders from the clients’ primary HIV medical provider before initiation of care by the agency. The provider must be a licensed practitioner to include the following:

• Dentists
• Doctor of Medicine (MD)
• Doctor of Osteopathy (OD)
• Nurse Practitioner (NP)
• Clinical Nurse Specialist (CNS)
• Physician Assistant (PA)

1. Percentage of clients with documentation of signed orders for rehabilitation services by a qualified licensed practitioner before initiation of care by the rehabilitation agency.

Comprehensive Assessment: The rehabilitation agency staff will complete a comprehensive assessment within 5 business days of the referral to include:

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

2. Percentage of clients with documentation of comprehensive assessment within 5 business days of referral that includes the following: (Pilot Measure)
   1. Presenting issue
   2. Physical examination as applicable
   3. Diagnosis
   4. Prognosis

Plan of Care: In collaboration with the client, staff will develop a plan of care within 10 business days of the completed comprehensive assessment.

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

The plan of care should include:

• Objective for rehabilitation services
• Client-centered goals
• Estimated number of sessions
• Type of therapy
• Estimated duration

Documentation that the plan of care is being followed will include the date therapy was received, therapy performed, and progress toward meeting objectives in the client’s primary record.

Staff must review the plan of care every 6 months at minimum with updates as needed.

3. Percentage of clients with documentation of a plan of care developed within 10 business days of the completed comprehensive assessment and includes the following components: (Pilot Measure)
   1. Objective for rehabilitation services
   2. Goals of services for client
   3. Type of therapy or therapies
   4. Estimated number of sessions
   5. Estimated duration of client’s need for rehabilitation services to meet goals.
       
4. Percentage of clients with documentation that the plan of care was reviewed every 6 months at a minimum.

Referrals: If the needs of the client are beyond the scope of the services provided by the agency or provider, the agency or provider should place an appropriate referral to another level of care.

Staff should document the referral and outcome of the referral in the client’s primary record as applicable.

5. Percentage of clients with documentation of referrals as applicable for ancillary services necessary to meet goals.
    
6. Percentage of clients with documentation of the outcome of the referral.

Transfer and Discharge: Transfer and discharge of clients from rehabilitation services should result from a planned and progressive process that considers the needs and desires of the client and the caregiver(s), family, and support network.

Staff should develop a transfer plan when one or more of the following criteria are met:

• 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 be cared for 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. 

Notification of Transfer or Discharge: When a client is transferred or discharged from services, agencies must:

• Provide written notification to the client or the client’s parent, family, spouse, significant other, or legal representative.
• Notify the client’s attending physician or practitioner.
• Deliver written notification no later than 5 days before the date on which the client will be transferred or discharged.

7. Percentage of clients with documentation of a transfer plan developed in coordination with the client, caregiver(s) and multidisciplinary team, with a referral to an appropriate service provider agency as applicable. (Pilot Measure)
    
8. Percentage of clients with documentation of a discharge plan developed with client, caregiver(s), and multidisciplinary team as applicable.
    
9. Percentage of clients with documentation of notification of transfer or discharge within 5 days before the date of transfer or discharge as applicable to the following parties: (Pilot Measure)
   1. The client or legal representative as applicable.
   2. The client’s referring and attending practitioner as applicable.