Current through Register Vol. 51, No. 19, September 20, 2024
A. An
interdisciplinary team shall complete or revise as necessary a
resident-specific care plan for each resident within 7 calendar days following
completion of assessments, including:
(1)
Admission assessment;
(2) Annual
assessment;
(3) Quarterly
assessment; and
(4) Significant
change in the resident's condition.
B. Care Plan Meeting. The nursing home shall,
with the resident's consent:
(1) Give an
interested and appropriate family member or resident's representative 7
calendar days advance notice, in writing, of the location, date, and time of a
care planning conference for a resident;
(2) Strive to accommodate the schedules of
invited family members and resident's representatives when scheduling care plan
meetings; and
(3) Include an
invitation for the family member or resident's representative to attend the
conference.
C. The
nursing home shall hold the care planning conference not later than 7 calendar
days after completing the assessment, but may hold the conference sooner if
agreed to by the resident, a family member, or a resident's
representative.
D. Organization of
Care Plan.
(1) Resident's problems and needs
shall be identified, based upon the interdisciplinary assessment. The care plan
shall address all of the resident's special care requirements necessary to
improve or maintain the resident's status. The interdisciplinary team shall
incorporate resident input into the care plan.
(2) The team shall establish goals for each
problem or need identified, or a combination thereof. The goals shall be
realistic, practical, and tailored to the resident's needs. Goal outcomes shall
be measurable in time or degree, or both.
(3) Approaches to accomplishing each goal
shall be established. Approaches shall indicate the work to be done, who is to
do it, and how frequently it is to be done.
E. Disciplines shall update the care plans as
the resident's assessment warrants, but not less than quarterly.
F. Availability of Resident Care Plan.
Resident care plans shall be readily available for use by all health care
personnel.
