441—177.6 (249) Health care plan. The nurse shall complete the health care plan with the physician’s approval. The health care plan shall include the specific types of services required, the method of providing those services, and the expected duration of services.
	 177.6(1) Transfer from medical facility. When the client is being transferred from a medical hospital or long-term care facility, the service worker shall obtain a transfer document describing the client’s current care plan, to be provided to the nurse supervising the in-home care plan.
	 177.6(2) Medical records.
	  a.   	 Medical records shall include, whenever appropriate, transfer forms, physician’s certification and orders, interdisciplinary case plan, interdisciplinary progress notes, drug administration records, treatment records, and incident reports. The nurse shall be responsible for ensuring that record requirements are met.
	  b.   	 Medical records shall be located in the nurse’s case file, with a copy of the interdisciplinary plan of care and physician’s plan of service in the service worker’s file, and all other records available to the service worker. Upon termination of the in-home care plan, the records shall be maintained in the county office of the department of human services, or in the office of the public health nurse and available to the service worker, for five years or until completion of an audit.
	  c.   	 The client or legal representative shall have the right to view the client’s medical records.
	 177.6(3) Review. The continuing need for in-home health care services shall be reviewed:
	  a.   	 At a minimum of every 60 days by the physician, including a written recertification of continuing appropriateness of the plan;
	  b.   	 At a minimum of every three months by the service worker, including a review of the total care plan; and
	  c.   	 At a minimum of every 60 days by the nurse who shall review the nursing plan.
More frequent reviews may be required by the physician, the service worker, or the nurse.
	 177.6(4) Annual physical. The client shall obtain a physical examination report annually and shall be under the regular supervision of a physician.