12.A.
Pre-Admission Screening
Facilities may not admit any resident who has not had a
pre-admission screening for mental illness and/or mental retardation.
12.A.1.
Definition: For the
purposes of this Chapter:
a. Mental Illness
An individual is considered to be mentally ill if the
individual has a primary or secondary diagnosis of a mental disorder as defined
in the American Psychiatric Association Diagnostic and Statistical
Manual (DSM-III 1R), 4th edition, and which
does not include dementia.
b. Mental Retardation
An individual is considered to be "mentally retarded" if
there is "significantly subaverage general intellectual functioning existing
concurrently with deficits in adaptive behavior and manifested during the
developmental period".
12.A.2.
Individuals With a Diagnosis or
Suspicion of Mental Illness
Prior to admission, the state mental health authority must
determine, based on biopsychosocial evaluation performed by a person or entity
other than the State mental health authority whether the individual has a
diagnosis of mental illness and whether the individual requires acute and/or
"specialized services".
12.A.3.
Individuals With Mental
Retardation or Related Condition(s)
The Department of Mental Health, Mental Retardation and
Substance Abuse Services determines prior to admission whether the individual
requires "specialized services" for mental retardation.
12.B.
Comprehensive
Assessment
Each resident of a nursing facility shall have a
comprehensive assessment which will enable facility staff to develop a plan of
care designed to assist the resident to reach the highest practicable level of
physical, mental, and psychosocial functioning.
12.B.1.
Definitions
a. Comprehensive Assessment
1. The comprehensive assessment includes the
resident's medical, nursing and psychosocial history before admission and
current medical diagnoses.
2. The
comprehensive assessment must include:
a.
Identification and demographic information:
b. Customary routine;
c. Cognitive patterns;
d. Communication;
e. Vision;
f. Mood and behavior patterns;
g. Psychosocial well-being;
h. Physical functioning and structural
problems;
i. Continence;
j. Disease diagnosis and health
conditions;
k. Dental and
nutritional status;
l. Skin
conditions;
m. Activity
pursuit;
n. Medications;
o. Special treatments and
procedures;
p. Discharge
potential;
q. Documentation of
summary information regarding the additional assessment performed through the
resident assessment protocols;
r.
Documentation of participation in assessment.
b. Minimum Data Set (MDS)
The Minimum Data Set (MDS) is the state approved assessment
instrument which is the current core set of screening, clinical and functional
status elements that forms the foundation of the comprehensive assessment for
all residents in nursing facilities.
The MDS must be completed up to, and no later than, fourteen
(14) calendar days after the date of admission.
The assessment is conducted or coordinated by a Registered
Professional Nurse with participation by other appropriate health
professionals. Upon completion, the Registered Professional Nurse must sign,
date and certify the completion of the assessment.
Each individual who completes a portion of the assessment
must sign and certify the accuracy of that portion of the assessment..
c. Resident Assessment Protocol
(RAPs)
A component of the utilization guidelines, the RAPs are
structured, problem-oriented frameworks for organizing MDS information and
examining additional clinically relevant information about an individual. RAPs
help identify social, medical and psychological problems and form the basis for
individualized care planning.
The Resident Assessment Protocols must be completed by the
14th calendar day after the admission, or according
to other Federal and State requirements. Upon completion, the Registered
Professional Nurse must sign and date the RAP summary sheet.
12.B.2.
Frequency of
Assessments
a. The annual
comprehensive assessment must be completed within twelve (12) months of the
most recent full assessment. The annual reassessment may be initiated at any
point prior to the end of the 1-year follow-up date, but must be completed by
the end of the 365th calendar day after the most recent comprehensive
assessment. If a significant change reassessment is completed in the interim,
the clock "restarts", with the next assessment due within 365 days of the
significant change reassessment. Routinely scheduled comprehensive assessments
may be scheduled early if a facility wants to stagger due dates for
assessments.
b. Nursing facilities
have an ongoing responsibility to assess resident status and intervene to
assist the resident to meet his or her highest practicable level of physical,
mental and psychological well-being. If interdisciplinary team members identify
a significant change (either improvement or decline) in a resident's condition,
they should share this information with the resident's physician, whom they may
consult about the permanency of change. The facility's medical director may
also be consulted when differences of opinion about a resident's status occur
among team members.
Document the initial identification of a significant change
in terms of the resident's clinical status in the progress notes. Complete a
full comprehensive assessment as soon as needed to provide appropriate care to
the individual, but in no case, later than fourteen (14) days after determining
that a significant change has occurred.
A "significant change" is defined as a major change in the
resident's status that:
1. Is not
self-limiting. A condition is defined as "self-limiting" when the condition
will normally resolve itself without further intervention or by staff
implementing standard disease-related clinical interventions;
2. Impacts on more than one area of the
resident's health status; and
3.
Requires interdisciplinary review or revision of the care plan.
c. If a resident returns to a
facility following a temporary absence for hospitalization or therapeutic
leave, it is considered a readmission. Facilities are not required to assess a
resident if they are readmitted, unless a significant change (as defined in
Section 12. B.2.b.) in the resident's condition has occurred.
d. The quarterly assessment is used to track
resident status between comprehensive assessments, and to ensure monitoring of
critical indicators of the gradual onset of significant changes in resident
status. At a minimum, three (3) quarterly reviews and one full assessment are
required in each 12 month period.
12.C.
Comprehensive Care Plan
12.C.1.
Definitions
"Comprehensive Care Plan" is the specific document which has
been developed by the multidisciplinary team (including the resident or
guardian) to address residents' medical, nursing, mental and psychosocial needs
that are identified in the comprehensive assessments. The comprehensive care
plan must include measurable objectives and timetables.
Before completion of a comprehensive care plan, there must be
evidence of ongoing assessments and care planning to assure care and services
are being provided from the date of admission/readmission.
12.C.2. Each resident shall have an
integrated comprehensive care plan that is developed by a multidisciplinary
team (including the resident and/or guardian) and which is based on a
comprehensive assessment using the MDS resident assessment protocols, the
utilization guidelines and other assessments as necessary.
12.C.3. The comprehensive care plan shall be
developed by a multidisciplinary team consisting of physician, registered
Professional Nurse, and other appropriate staff in conjunction with the
resident, resident's family or legal representative as appropriate.
12.C.4. The comprehensive care plan shall be
developed within seven (7) days after the completion of the Resident Assessment
Protocols and:
a. is periodically reviewed
and revised as necessary by the multidisciplinary team after each assessment
and reassessment;
b. must have
measurable goals and timeframes, as appropriate, for the highest practicable
level of functioning the resident may achieve;
c. must accurately reflect the resident's
assessment;
d. must be oriented
toward preventing decline in functioning and/or functional levels within the
parameters of normal aging and any disease processes which are
present;
e. must address identified
risk factors;
f. must reflect
standards of current professional practice.
g. must reflect a multidisciplinary team
approach to maintain or improve functional abilities of the resident.
12.C.5. The comprehensive care
plan must be continually and actively implemented by all staff.
12.C.6. The comprehensive care plan must be
available at the nurses station for review and implementation as appropriate by
staff on each shift. The procedures to implement the care plan need not be
included in the care plan, but there must be a format, as chosen by the
facility, which provides direction to the resident care staff of each shift.
Eff. 2/1/01
12.D.
Documentation
12.D.1. There must
be ongoing documentation as necessary, but at least monthly, which reflects the
resident's condition, implementation and effectiveness of the care plan and
interventions by the staff.
12.D.2.
There must be documentation by the CNA of the specific tasks carried out to
implement the part of the care plan assigned to the CNA.
12.E.
Specialized Therapy
Services
Based upon the resident's comprehensive assessment, the
facility must provide or obtain specialized therapy services, i.e., physical
therapy, speech/language therapy, occupational therapy, and mental health
services for each resident as needed and prescribed in the plan of care.
12.E.1.
Care Plan
a. Based on the resident's comprehensive
assessment, these services shall be integrated into the resident's
comprehensive multidisciplinary care plan, as necessary.
b. The resident's care plan, progress and
continued need for specialized therapy is reevaluated as necessary, and
recommendations made to the physician and the multidisciplinary team.
12.E.2.
Therapists'
Responsibilitiesa. Specialized therapy
is provided only on written orders of the physician.
b. The therapist shall evaluate each resident
referred and recommend a rehabilitative treatment regimen, if
appropriate.
c. The therapist, in
consultation with the physician, shall initiate the therapy and reevaluate the
continuing need for therapy as needed.
d. The therapist shall provide training for
staff and supervise the provision of care to assure acceptable level of
performance for qualified support personnel.
e. The therapist shall document each
treatment and progress noted in the residents' records.
12.E.3.
Space and Equipment
a. Space that shall serve the needs of the
residents shall be made available for specialized therapies.
b. Equipment necessary for the provision of
specialized therapy services shall be available and used as needed.
