HCSSAs providing home dialysis services must ensure that client care plans are developed after consultation with the client and the client's family by the interdisciplinary team and that they address all medical orders. Client care plans must also identify problems, interventions and persons assigned to provide specific services.  

The initial client care plan must be completed by the interdisciplinary team within ten calendar days after the first home dialysis treatment.

Home dialysis agencies must ensure that client care plans:

• are written, personalized, and addressed to ongoing medical, psychological, social, nutritional, and functional needs of the client, including treatment goals;
• include written evidence of coordination with the client's other services providers; and
• include written evidence that the client's legal representative is aware of the plan and/or participated in the design of the plan.

Furthermore, client care plans of each clinically unstable client must be reviewed and revised at least monthly and whenever there are significant changes in client conditions or circumstances.

Finally, care plans of each stabilized client must be reviewed and revised at least every six months to address significant changes in client conditions or circumstances.

Source: 40 TAC §97.405(q)