Current through Register No. 40, October 3, 2024
(a) At the time of
admission, personnel of the ADP shall:
(1)
Provide, both verbally and in writing, to the participant, guardian, agent, and
personal representative, as applicable:
a.
The ADP's policies on participant rights and responsibilities;
b. The scope and type of services to be
provided by the ADP;
c. The ADP's
complaint procedure and rules; and
d. Obtain written confirmation acknowledging
receipt of these policies and rules;
(2) Collect and record in the participant
record the following information:
a.
Participant's name, home address, home telephone number, and date of
birth;
b. Name, address, and
telephone number of an emergency contact;
c. Participant's primary licensed
practitioner's name, address, and phone number;
d. Copies of any executed legal directives
such as guardianship orders for health care issues under RSA 464-A, durable
power of attorney, or a living will; and
e. The name of the participant's guardian,
agent, or personal representative, if any;
(3) Require the participant to have a
physical examination by a licensed practitioner that has been completed no more
than one year prior to admission or within 72 hours after admission and
includes:
a. Diagnoses, if any;
b. The medical history;
c. Medical findings, including the presence
of communicable disease;
d. Vital
signs;
e. Prescribed and
over-the-counter medications;
f.
Allergies, if any;
g. Dietary
needs, if any; and
h. Functional
abilities and limitations;
(4) Have the RN, or LPN who is directly or
indirectly supervised by an RN, complete a nursing assessment within 7 days of
attendance to determine the level of services required by the
participant;
(5) Have the
administrator, licensed nurse, or activities coordinator complete a
recreational assessment;
(6) Have
the administrator, licensed nurse, or social worker complete a social
history;
(7) Complete an emergency
data sheet that, at a minimum, lists the following information:
a. The participant's full name, address,
telephone number, and date of birth;
b. The name, address, and telephone number of
the participant's family or the person legally responsible for the
participant;
c. The participant's
diagnosis;
d. Medications
administered to or by the participant at the ADP, including the last dose taken
and when;
e. Any known
allergies;
f. The participant's
functional level and needs requirements as assessed by the ADP staff;
g. Copies of any advanced directives,
guardianship, or durable powers of attorney, if applicable;
h. The participant's health insurance
information; and
i. Any other
pertinent information not specified in a.-h. above; and
(8) Obtain orders from a licensed
practitioner for medications, prescriptions, and diets.
(b) A written daily medication record shall
be utilized for all medication taken by participants at the ADP.
(c) A care plan shall be completed within the
first 30 days of attendance based upon the results of all of the participant's
assessments listed above and shall include:
(1) The date any specific problem or need was
identified;
(2) A description of
services to let caregivers and personnel know what problem(s) or need(s) was
identified as a result of the assessments;
(3) The goals for the participant;
(4) The action or approach to be taken by the
ADP to meet needs identified by the assessment(s);
(5) The party responsible for implementing
the action or approach to be taken;
(6) The date the next re-evaluation is to
occur; and
(7) Written
documentation to verify that the participant, family, or caregiver was offered
the opportunity to be involved in the development of the care plan and any
revisions made thereafter.
(d) The licensed nurse and other personnel as
deemed necessary by the licensed nurse shall review the care plan at least
every 6 months and revise it whenever necessary.
(e) The care plan referenced in (c) above
shall be:
(1) Reviewed and updated within 5
business days following the completion of each future assessment; and
(2) Made available to personnel who assist
participants in the implementation of the plan.
(f) If the nursing assessment, developed in
accordance with (a) (4) above, or the care plan, developed in accordance with
(c) above, is completed by an LPN, the assessment and care plan shall be
reviewed and co-signed by an RN or physician that is supervising the LPN prior
to the implementation of the participant's care plan.
(g) The direct care personnel of the ADP
shall implement the care plan.
(h)
The participant record shall contain written notes as follows:
(1) Notes on all medical, nursing,
rehabilitative, or therapeutic care and services provided at the ADP shall
include the:
a. Date and time that the care or
services were provided;
b.
Description of the care or services provided;
c. Participant's response to the care or
services provided; and
d. Signature
and title of the person providing the care or service;
(2) Progress notes shall include at a
minimum:
a. Care plan outcomes;
b. Changes in the participant's physical,
functional, and mental abilities;
c. Changes in behavior;
d. Summary of protective care that has been
provided; and
e. Summary of
assistance provided with ADLs; and
(3) Progress notes in (2) above shall be
written at least every 30 days for the first 90 days and then quarterly
thereafter.
(i) The use
of chemical or physical restraints shall be prohibited except as allowed by
RSA
151:21, IX.
(j) Immediately after the use of a physical
or chemical restraint, the participant's guardian or agent, if any, and the
department shall be notified of the use of such restraints.
(k) The ADP shall:
(1) Have policies and procedures on the use
of restraints in an emergency:
a. What type
of restraints may be used;
b. When
restraints may be used; and
c. What
personnel may authorize the use of restraints, which shall be limited to the
administrator, medical director, director of nursing, and other licensed
personnel; and
(2)
Provide personnel with education and training on the limitations and the
correct use of restraints.
(l) The use of mechanical restraints shall be
allowed.
(m) The participant shall
be discharged, as defined under
RSA
151:19, I-a, in accordance
with RSA
151:26 and
RSA
151:21, V.
(n) The licensee shall develop a discharge
plan for each participant with the input of the participant and the guardian or
agent, if any.
(o) Transfers to a
medical facility for emergency medical treatment may occur without prior
notification to the guardian, agent pursuant to an activated POA, or the
licensed practitioner, when the participant is in need of immediate emergency
care.
(p) For each participant
accepted for care and services at the ADP, a current and accurate record shall
be maintained and include, at a minimum:
(1)
The written confirmation required by He-P 818.16(a) (1);
(2) The identification data required by He-P
818.16(a) (2);
(3) Consent and
medical release forms, as applicable;
(4) The record of a physical examination as
required by He-P 818.16(a) (3);
(5)
All orders from a licensed practitioner, including the date and signature of
the licensed practitioner;
(6) All
assessments;
(7) All care plans,
including documentation that the participant or person legally responsible
participated in the development of the care plan if they chose to;
(8) All written notes required by He-P
818.16(h);
(9) All daily medication
records;
(10) A discharge plan as
required by He-P 818.16(n);
(11)
The emergency data sheet required by He-P 818.16(a) (7);
(12) Documentation of reportable incidents
involving the participant, including the information required by
He-P
818.14(s) ; and
(13) Documentation of the refusal of a
participant to follow the prescribed orders of the licensed practitioner
including the date and time the licensed practitioner was notified of the
refusal.
(q) Participant
records shall be safeguarded against loss, damage, or unauthorized use by being
stored in locked containers, cabinets, rooms, or closets except when being used
by the ADP's personnel.
(r)
Participant records shall be retained for a minimum of 4 years after
discharge.
(s) Prior to the ADP
cessation of operations, it shall arrange for the storage of and access to
participant records for 4 years after the date of closure, which shall be made
available to the department and past participants, their designees, or both
upon request.
#9106, eff
3-18-08
