1. (a) A facility shall develop, implement, and enforce policies and procedures regarding the patient's plan of care process, which specifies the services necessary to address the patient's comorbid conditions and other needs based on the patient's interdisciplinary assessment. The facility shall coordinate patient services using an interdisciplinary team approach, per CMS guidance. The interdisciplinary team shall consist of the patient, the patient's primary dialysis physician, registered nurse, social worker, and dietitian.
2. (b) The interdisciplinary team shall engage in an interactive conference to develop a written, individualized, comprehensive patient plan of care that specifies the services necessary to address the patient's medical, psychological, social, and functional needs, and includes treatment goals.
3. (c) The patient plan of care shall include measurable and expected outcomes and estimated timetables to achieve these outcomes. The patient plan of care shall include the patient's current dose of dialysis, dialysis adequacy, other medical comorbidity issues, nutritional status, mineral metabolism, anemia, vascular access, psychosocial status, modality, transplantation status, rehabilitation status, goals, and education and training.
4. (d) The patient plan of care shall include evidence of coordination with other service providers (e.g., hospitals, long term care facilities, home and community support services agencies, and transportation providers) as needed to ensure continuity of safe care.
5. (e) The patient plan of care shall include evidence of the patient's (or patient's legal representative's) input and participation unless they refuse to participate. If the patient refuses to participate, the facility shall document the patient refusal in the patient's record. At a minimum, the patient plan of care shall demonstrate an interdisciplinary team member discussed the content with the patient or the patient's legal representative.
6. (f) Facility staff shall develop and implement the patient plan of care within 30 calendar days, or 13 outpatient dialysis treatments from the patient's admission to the facility, whichever occurs later. Facility staff shall revise the patient plan of care due to changes in the patient's personal treatment goals, lack of progress towards the patient's plan of care goals, marked deterioration in health status, significant changes in the patient's psychosocial needs, or changes in the patient's nutritional condition, as needed, but no less than annually after the date of the patient's last plan of care.

7. (g) The facility shall monitor the patient plan of care at least monthly to recognize and address any deviations from the patient plan of care by:

   1. (1) implementing changes in interventions due to the lack of progress toward the patient's plan of care goals;
   2. (2) documenting the reasons why the patient was unable to achieve the goals; and
   3. (3) implementing changes to address the revised patient plan of care.
8. (h) Facility staff may conduct an interdisciplinary team conference via telehealth or telemedicine, which may include audio-only telecommunications. A telehealth or telemedicine patient plan of care conference conducted with the interdisciplinary team and the patient (or their legally authorized representative) shall be documented as such.

9. (i) In the case of disruptive patients or family members or patients who do not conform to the treatment plan, the facility shall develop, implement, and enforce a process for more intensive interdisciplinary team intervention with this patient to include assessment of needs and planned interventions to assist the patient in adjusting to the requirements for safe care.

   1. (1) The facility shall contact the End Stage Renal Disease Network for assistance with these patients before considering an involuntary discharge of the disruptive patient.
   2. (2) The facility shall establish, implement, and enforce a policy allowing a disruptive or noncompliant patient or family member the opportunity and assistance to improve any problematic behavior before their dismissal from the facility, in accordance with the requirements of this section.
10. (j) A facility shall not violate Texas Occupations Code Chapter 102 (relating to Solicitation of Patients).

Source Note:The provisions of this §507.45 adopted to be effective December 23, 2025, 50 TexReg 8289.