Current through Register 1531, September 27, 2024
(A) Facilities
providing Level I, II or III care shall establish a medical director who shall
be responsible for the implementation of resident care policies and the
coordination of medical care in the facility.
(1) Supervisory and advisory functions shall
include: advice on the development of medical and resident care policies
concerning resident admissions and discharge, medical records, responsibilities
of primary care providers, supportive and preventive services, emergency
medical care, and the review of the facility's overall program of resident
care.
(2) Staff physicians or the
medical director shall spend at least four hours per month in the facility
devoted to supervisory and advisory functions.
(3) A SNCFC shall appoint a pediatrician with
experience in developmental disabilities who shall participate in the
development of resident care policies, familiarize himself or herself with the
condition, needs and care of each resident, and participate in periodic staff
conferences.
(4) In a SNCFC,
services of a neurologist, orthopod, psychiatrist, psychologist or any other
consultant services shall be provided as needed to those individuals requiring
such services.
(B) Every
resident shall have a primary care provider who is responsible for his or her
continuing medical care and periodic reevaluation.
(1) Each resident or resident's guardian
shall on admission designate a primary care provider. If the resident does not
have a primary care provider, the facility shall designate a primary care
provider with the approval of the resident or the resident's
guardian.
(2) The addresses and
telephone numbers of the resident's primary care provider shall be recorded in
the resident's record and be readily available to personnel on duty in case of
emergencies.
(C) All
facilities shall have written arrangements for emergency physician services
when the resident's own primary care provider is not immediately available.
(1) A list of the names and telephone numbers
of emergency physicians.
(2) If
medical orders for the immediate care of a resident are not available at the
time of admission, the emergency physician or medical director shall be
contacted to provide temporary orders until the primary care provider assumes
responsibility.
(3) Facilities
shall establish and follow procedures covering immediate care of the resident,
persons to be notified and reports to be prepared in the case of
emergencies.
(4) The date, time and
circumstances surrounding each call to an emergency physician and his or her
findings, treatment, and recommendations shall be recorded in the resident's
clinical record. The facility shall notify the resident's primary care provider
and record such notification in the clinical record.
(D) All medical, psychiatric and other
consultations shall be recorded in the resident's clinical record and dated and
signed by the consulting practitioner.
(E) Every resident shall have a complete
admission physical exam and medical evaluation. Based on this information, the
resident's primary care provider shall develop a medical care plan that shall
include such information as the following:
(1)
Primary Diagnosis.
(a)
Other Diagnoses or Associated
Conditions.
1. Pertinent findings
of physical exam (including vital signs and weight, if ambulatory);
2. Weight shall be included for
non-ambulatory patients in a SNCFC;
3. Significant past history;
4. Significant special conditions,
disabilities or limitations;
5.
Prognosis;
6. Assessment of
physical capability (ambulation, feeding assistance bowel and bladder
control);
7. Assessment of mental
capacity.
(b)
Treatment Plan Including.
Medications;
Special treatments or procedures;
Rehabilitation services;
Dietary needs;
Order of ambulation and activities;
Special requirements necessary for the individual's health or
safety;
Preventive or maintenance measures;
Short and long term goals;
Estimated length of stay;
Documented advance directives, if available.
The care plan for residents in a SNCFC shall include in
addition to the above, a developmental history, including evaluation of the
patient's physical, emotional and social growth and development, immunization
status, and assessments of hearing, speech and vision. Each resident's medical
care plan shall include a schedule of appropriate immunizations as recommended
by the American Academy of Pediatrics.
(2) The medical care plan shall be completed
and recorded in the resident's clinical record as follows:
(a) Level I or II, within five days prior to
admission, up to 48 hours following admission.
(b) Level III or IV, within 14 days prior to
admission, up to 72 hours following admission.
(3) If the care plan is completed within the
specified time limits prior to admission by the provider who will continue as
the the resident's primary care provider, a repeat examination and evaluation
following admission to the facility is not required.
(F) Each resident shall be re-examined and
re-evaluated, and his or her care plan reviewed and revised, if indicated, by
the primary care provider to ensure appropriate medical services and resident
placement. Reviews shall be recorded in the clinical record at least as often
as follows:
(1)
Level II, Every 30
Days. If after 90 days following admission in the opinion of the
primary care provider it is deemed unnecessary to see the resident with such
frequency, an alternate schedule not to exceed 60 days between visits may be
adopted providing the justification is documented in the resident's medical
record.
(2)
Level III,
Every 60 Days. If after 90 days following admission in the opinion
of the primary care provider it is deemed unnecessary to see the resident with
such frequency, an alternate schedule not to exceed 90 days between visits may
be adopted providing the justification is documented in the resident's medical
record.
(3) Level IV, every six
months unless the primary care provider documents fewer visits are
necessary.
