Except as provided in subsections (5) and (6) of this section, the licensee must:

(1) Develop and implement a written home care plan of care for each client with input and written approval by the client, designated family member, or legal representative;

(2) Ensure each plan of care is developed by appropriately trained or credentialed agency personnel, lists services requested or recommended to meet client needs, and is based on an on-site visit and according to agency policies and procedures;

(3) Ensure the home care plan of care includes:

(a) The client's functional limitations;

(b) Nutritional needs and food allergies for meal preparation;

(c) Home medical equipment and supplies relevant to the plan of care;

(d) Indication that the client has a signed advanced directive or POLST, if applicable;

(e) Nurse delegation tasks, if applicable; and

(f) Specific nonmedical services to be provided and their frequency.

(4) Develop and implement a system to:

(a) Ensure the plan of care is reviewed on-site, updated, approved and signed by appropriate agency personnel and the client, designated family member, or legal representative every twelve months and whenever significant changes to client care needs are identified; and

(b) Inform the supervisor of direct care services regarding changes in the client's condition that indicate a need to update the plan of care.

(5) Home care agencies providing a one-time visit for a client may provide the following written documentation in lieu of the home care plan of care requirements in subsection (3) of this section:

(a) Client name, age, current address, and phone number;

(b) Confirmation that the client was provided a written bill of rights under WAC 246-335-435;

(c) Client consent for services to be provided; and

(d) Documentation of services provided.

(6) Home care agencies that have a contract with the AAA to provide home care services to medicaid eligible clients may use the DSHS CARE assessment details and service summary, or successor assessment tool, as the plan of care if it covers all items in subsection (3) of this section.