Current through Bulletin 2024-06, March 15, 2024
(1) The licensee
shall, upon resident admission, obtain physician orders for the resident's
immediate care.
(2) The licensee
shall:
(a) complete a comprehensive assessment
of each resident's needs including a description of the resident's capability
to perform daily life functions and significant impairments in functional
capacity that includes the following:
(i)
medically defined conditions and prior medical history;
(ii) medical status measurement;
(iii) physical and mental functional
status;
(iv) sensory and physical
impairments;
(v) nutritional status
and requirements;
(vi) special
treatments or procedures;
(vii)
mental and psychosocial status;
(viii) discharge potential;
(ix) dental condition;
(x) activities potential;
(xi) rehabilitation potential;
(xii) cognitive status; and
(xiii) drug therapy;
(b) ensure the initial assessment is
completed within 14 calendar days of admission and any revisions to the initial
assessment within 21 calendar days of admission;
(c) ensure that an interdisciplinary team
review any significant change in a resident's physical or mental health and the
team may require a new assessment within 14 days of the condition
change;
(d) complete three
quarterly reviews and one full assessment in each 12-month period;
and
(e) use the results of the
assessment to develop, review, and revise the resident's comprehensive care
plan.
(3) The licensee
shall ensure each individual who completes a portion of the assessment signs
and certifies the accuracy of that portion of the assessment.
(4) The licensee shall develop a
comprehensive care plan for each resident that includes measurable objectives
and timetables to meet a resident's medical, nursing, and mental and
psychosocial needs as identified in the comprehensive assessment.
(5) The licensee shall ensure the
comprehensive care plan is:
(a) developed
within seven days after completion of the comprehensive assessment;
(b) prepared with input from an
interdisciplinary team that includes the attending physician, the registered
nurse having responsibility for the resident, and other appropriate staff in
disciplines determined by the resident's needs, and with the participation of
the resident, and the resident's family or guardian, to the extent practicable;
and
(c) periodically reviewed and
revised by a team of qualified persons at least after each assessment and as
the resident's condition changes.
(6) The licensee shall ensure the services
provided or arranged meet professional standards of quality and be provided by
qualified persons in accordance with the resident's written care
plan.
(7)
(a) The licensee shall ensure a final summary
of the resident's status, to include items in Subsection
R432-150-13(2)(a),
is prepared at the time of discharge and is available for release to authorized
persons and agencies, with the consent of the resident or representative.
(b) The licensee shall ensure the
final summary includes a post-discharge care plan developed with the
participation of the resident and resident's family or guardian.
(c) If the licensee discharges a resident
because they cannot meet the resident's needs, the licensee shall include a
detailed explanation of why the resident's needs could not be met in the final
summary.
