Current through 2024-38, September 18, 2024
8.1
Comprehensive Assessment.
Each consumer attending the program shall have a comprehensive written
assessment. The assessment shall commence no later than the first day of
program participation and shall be completed within thirty (30) calendar
days.
8.2 If the provider does not
use the Department approved assessment tool, the assessment shall include at a
minimum:
8.2.1 Identification and background
information.
8.2.1.1 . Individual's name,
address and Social Security number;
8.2.1.2 . Age, date of birth;
8.2.1.3 . Gender;
8.2.1.4 Marital status;
8.2.1.5 . Living arrangements;
8.2.1.6 Responsible party and emergency
contacts;
8.2.1.7 Advanced
directives;
8.2.1.8 Previous
occupation(s), special interests and hobbies;
8.2.1.9 Primary language spoken;
8.2.1.10 Primary care physician's name,
address and telephone number.
8.2.2 . Medical history.
8.2.2.1 Medical diagnoses;
8.2.2.2 List of prescribed
medications;
8.2.2.3 Professional
medical services;
8.2.2.4 Nursing
treatments or services received at home;
8.2.2.5 Therapies.
8.2.3 Functional status.
8.2.3.1 Vision;
8.2.3.2 Communication/hearing;
8.2.3.3 Nutritional status, including
weight;
8.2.3.4 Oral/dental
status;
8.2.3.5 Skin
condition;
8.2.3.6
Continence;
8.2.3.7 Activities of
daily living performance including locomotion, transfer ability, eating,
personal hygiene, dressing, toilet use and bathing;
8.2.3.8 Use of assistive devices.
8.2.4 . Cognition status.
8.2.4.1 Spatial orientation;
8.2.4.2 Memory for events;
8.2.4.3 Memory and use of
information.
8.2.5 .
Behavior.
8.2.5.1 Sleep patterns;
8.2.5.2 Wandering;
8.2.5.3 Behavioral demands on
others;
8.2.5.4 Danger to self and
others;
8.2.5.5 Awareness of
needs/judgment.
8.2.6 .
Support services.
8.2.6.1 Family caregiver(s)
status;
8.2.6.2 Other informal
support network.
8.3
The assessment process.
8.3.1 The assessment is conducted with the
consumer, guardian and/or designated representative. Upon completion, staff
completing the assessment must date and sign the assessment.
8.3.2 If the assessment is completed by a
designated Department assessor within six (6) weeks prior to the consumer's
participation in the program, the Adult Day Services provider may use this
assessment and shall include a copy of this assessment in the record.
8.4
Review of
assessments. Each consumer assessment must be reviewed as often as
necessary, but not less than once every six (6) months. The assessment shall be
revised to assure continued accuracy of the assessment.
8.4.1
Reassessments. Each
consumer must have a comprehensive assessment completed every twelve (12)
months.
8.5
Service Plan. A service plan must be
developed for each individual admitted to the program. The service plan shall
be developed in cooperation with the consumer, the guardian or designated
representative within seven (7) calendar days of completion of the assessment.
At least one (1) staff person shall be responsible for the development and
monitoring of service plans. The service plan shall be reviewed and updated as
often as necessary, but no less than every six (6) months. Each program shall
have a written policy/procedure to govern the development, implementation and
management of service plans.
8.5.1 The
service plan shall be based on the comprehensive assessment and shall contain
at a minimum:
8.5.1.1 An assessment of the
consumer's problems, needs, strengths and resources;
8.5.1.2 Measurable goals, time frames and
objectives for meeting identified problems and needs;
8.5.1.3 A reflection of staff approach to
maintain or improve functional abilities of the consumer;
8.5.1.4 An accurate reflection of the
consumer's assessment;
8.5.1.5
Plans for coordinating with other health and social service agencies for the
delivery of services, if applicable.
8.6
Progress Notes. Consumer
records shall include at least monthly progress notes noting observations of
the consumer and progress which the consumer has made in relation to the
service plan, as well as any improvement or decline in physical or mental
function. The progress note shall include the signature of the person making
the notation and the actual date of the progress note.
8.7
Consumer Records. In
addition to the assessment, service plan and monthly progress notes, each Adult
Day Services Program shall maintain comprehensive and complete consumer files
which include at a minimum:
8.7.1 Listing of
dates and hours of consumer attendance;
8.7.2 Consumers' records and information
pertaining to their personal, medical and mental health status, which are
confidential. Consumers and their legal representatives shall have access to
all records pertaining to the consumer at reasonable times, in the presence of
the provider or his/her representative, within one (1) business day of the
request. Consumers and their legal representatives are entitled to have copies
made of their record within one (1) business day of the request. The licensee
and employees shall have access to confidential information about each consumer
only to the extent needed to carry out the requirements of the licensing
regulations or as authorized by any other applicable state of federal law. The
written consent of the consumer or his/her legal representative shall be
required for release of information to any other person except authorized
representatives of the Department or the Long Term Care Ombudsman Program. The
Department shall have access to these records for determining compliance with
these regulations. Records shall not be removed from the facility, except as
may be necessary to carry out these regulations. Upon admission, each consumer
shall sign and date a written consent which lists individuals, groups, or
categories with whom the program may share information (e.g., sons, daughters,
family members or duly authorized licensed practitioners, etc.). A written
consent to release of information shall be renewed and dated every thirty (30)
months, pursuant to
22 M.R.S.A.
§1711-C(4). Consent may
be withdrawn at any time.
8.7.3
Signed physician orders for prescribed medications, prescribed diet and
treatments to be administered while at the program;
8.7.4 An assessment of limitations, if any,
to consumer participation in the program;
8.7.5 Transportation arrangements to the
program;
8.7.6 Discharge planning
considerations and date and reason for discharge;
8.7.7 Copies of incident or accident
reports.
8.8
Medication Records. When medications are administered to consumers
during program operation, the following shall be included in the individual
consumer record:
8.8.1 An individual
medication administration record shall be kept for each consumer of all
treatments, drugs and medications ordered by the duly authorized licensed
practitioner, including the name of the drug, the dosage, route and the time(s)
to be given;
8.8.2 An individual
medication administration record shall be kept for each consumer for all
over-the-counter medications administered by program staff and ordered by the
duly authorized practitioner, including the name of the drug, the dosage, route
and time(s) to be given. Written authorization from the consumer or legal
representative must be obtained prior to all medication administration at the
program site;
8.8.3 An entry shall
be made by program staff on the medication administration record to indicate
whenever a medication, including a medication ordered to be administered as
needed, or a treatment is started, given, refused or discontinued. A prescribed
medication shall not be discontinued except with evidence of a stop order. A
stop order shall be signed and dated by the duly authorized licensed
practitioner for prescriptions ordered without an end date;
8.8.4 Medication errors and reactions shall
be recorded in the consumer's record. Medication errors include errors of
omission as well as errors of commission. Errors in documentation or charting
are errors of omission;
8.8.5 No
medication shall be administered without a written order signed by a duly
authorized practitioner or person licensed to prescribe medications.
8.9
Consumer Records.
All consumer records must be kept confidential in controlled access files.
Records shall be kept at the program site or at the agency central office for a
minimum of five (5) years after the consumer ceases to participate in the
program. Should the Adult Day Services Program cease to operate, the provider
is responsible for storing all consumer and program records for five (5) years
and the program license shall be forwarded to the Department within thirty (30)
days of program termination.
