CMS SOM App. H, Tag V541

written, individualized comprehensive plan of care that specifies the services necessary to

address the patient’s needs, as identified by the comprehensive assessment and changes in

the patient’s condition, and must include measurable and expected outcomes and estimated

timetables to achieve these outcomes. The outcomes specified in the patient plan of care

must be consistent with current evidence-based professionally-accepted clinical practice

standards.

Interpretive Guidance § 494.90

The IDT consists of, at a minimum, the patient or the patient’s designee (if the patient chooses),

a registered nurse, a physician who is treating the patient for ESRD, a social worker, and a

dietitian (see § 494.80). Each team member must meet the qualifications outlined in the

Condition for Personnel qualifications at § 494.140.

The facility must recognize the patient or their designee as a member of the IDT and encourage

the patient’s participation in developing and updating the plan of care. The patient’s needs,

wishes, and goals must be considered in making decisions about the plan of care. If a patient

chooses to use a designee, written authorization from the patient must be obtained for the

sharing of protected health information with the designee.

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A registered nurse must serve as a member of the team and should have knowledge of the

patient. The registered nurse participating in the plan of care for home dialysis patients should

work in the home dialysis program and have knowledge of the specific needs of home dialysis

patients.

The written patient plan of care must be individualized for the patient, built on the

comprehensive assessment as outlined at V502-515 under the Condition for patient assessment,

and include at a minimum: problem(s) identified at assessment/reassessment, measurable

goals/outcomes, planned interventions for achieving the goals, timetables, and reassessment

date(s). A review of the plan of care, treatment records, progress notes, laboratory reports, and

other relevant documents should demonstrate the implementation of the plan of care.

The patient plan of care encompasses all the care, services, and treatment interventions that the

IDT determines to implement to meet the patient's specific needs. The written patient plan of care

may be a single document or composed of separate sections, but it must be congruent and reflect

the integration of comprehensive assessments contributed by all members of the IDT. Electronic

or paper formats are acceptable.

Timelines for meeting the specified targets should be based on setting reasonable targets for the

individual patient, considering the severity of the problem and the extent of the planned

interventions (e.g., acute issues should have shorter timelines).

The measurable outcomes specified in each patient’s plan of care must be current, evidence-based, and professionally accepted. Goals and outcomes for some patients may need to be

initially different from these targets, then incrementally changed to the standard target value as

the patient's outcome improves. For example, to maintain fluid balance and adequate blood

pressure control, a target treatment time for an individual patient may be identified as 3 hours;

however, longer hemodialysis times may be necessary when the patient experiences large

intradialytic weight gains or uncontrolled blood pressure.