DE RADIACIONES NO IONIZANTES EN TELECOMUNICACIONES

PC.1 ASSESSMENT

The CAH must conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident’s functional capacity. §483.20

SR.1 The assessment must include at least the following: §483.20(b)(1) SR,1a Identification and demographic information. §483.20(b)(1)(i) SR.1b Customary routine. §483.20(b)(1)(ii)

SR.1c Cognitive patterns. §483.20(b)(1)(iii) SR.1d Communication. §483.20(b)(1)(iv) SR.1e Vision. §483.20(b)(1)(v)

SR.1f Mood and behavior patterns. §483.20(b)(1)(vi) SR.1g Psychosocial well-being. §483.20(b)(1)(vii)

SR.1h Physical functioning and structural problems. §483.20(b)(1)(viii) SR.1i Continence. §483.20(b)(1)(ix)

SR.1j Disease diagnoses and health conditions. §483.20(b)(1)(x) SR.1k Dental and nutritional status. §483.20(b)(1)(xi)

SR.1l Skin condition. §483.20(b)(1)(xii) SR.1m Activity pursuit. §483.20(b)(1)(xiii) SR.1n Medications. §483.20(b)(1)(xiv)

SR.1o Special treatments and procedures. §483.20(b)(1)(xv) SR.1p Discharge potential. §483.20(b)(1)(xvi)

SR.1q Documentation of summary information regarding the additional assessment performed through the resident assessment protocols. . §483.20(b)(1)(xvii)

SR..1r Documentation of participation in assessment. . §483.20(b)(1)(xviii)

SR.2 Within 14 calendar days after admission, excluding readmissions in which there is no

significant change in the resident’s physical or mental condition, the CAH must make a comprehensive assessment of a resident’s needs through a process of direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts SR.3 A comprehensive assessment of the resident will be completed not less often than once every 12 months.

Interpretive Guidelines:

The intent of this regulation is to provide the facility with ongoing assessment information necessary to develop a care plan, to provide the appropriate care and services for each resident, and to modify the care plan and care/services based on the resident’s status. The facility is expected to use resident observation and communication as the primary source of information when completing the assessment. In addition to direct observation and communication with the resident, the facility should use a variety of other sources, including communication with licensed and non-licensed staff members on all shifts and may include discussions with the resident’s MD/DO, family members, or outside consultants and review of the resident’s record.

The CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under §483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in §413.343(b). §485.645(d)(6)

“Admission” to the facility is defined as an initial stay or a return stay (not a readmission) in the facility. A “return stay” applies to those residents who are discharged without expectation that they will return to the facility, but who do return to the facility.

A “readmission” is an expected return to the facility following a temporary absence for hospitalization, off-site visit or therapeutic leave.

Items in PC.1; SR.1 would include comprehensive assessments of a resident which were done within 14 days of admission; within 14 days of a significant change in the resident’s physical or mental condition; or done on an annual review. These assessments need to be in the final discharge summary.

PC.2 CARE PLAN

SR.1 The CAH must develop a comprehensive care plan for each resident §483.20(k), §483.20(k)(1) SR.1a to meet a resident’s medical, nursing, mental and psychosocial needs

SR.1b that have been identified in the comprehensive assessment. SR.1c includes measurable objectives goals

SR.1d bedeveloped within 7 days after the completion of the comprehensive assessment §483.20(k)(2), §483.20(k)(2)(i)

SR.1e Prepared by an interdisciplinary team, that includes §483.20(k)(2)(ii) SR.1e(1) the attending physician,

SR.1e(2) a registered nurse with responsibility for the resident, and

SR.1e(3) other appropriate staff in disciplines as determined by the resident’s needs, and, to the extent practicable,

SR.1(e(4) the participation of the resident, the resident’s family or the resident’s legal representative; and

SR.1e(5) Be periodically reviewed and revised by a team of qualified persons after each assessment. §483.20(k)(2)(iii)

SR.2 The care plan must describe the following; §483.20(k)(1),

SR.2a The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being and§483.20(k)(1)(i)

SR.2b Any services that would otherwise be required under §483.25 but are not provided due to the resident’s exercise of rights §483.10,including the right to refuse treatment §483.20(k)(1)(ii)

SR.3 The services provided or arranged by the CAH must--§483.20(k)(3) SR.3a Meet professional standards of quality; and--§483.20(k)(3)(i)

SR.3b Be provided by qualified persons in accordance with each resident’s written plan of care. §483.20(k)(3)(ii)

The requirements reflect the facility’s responsibility to provide necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing, in accordance with the comprehensive assessment and plan of care.

“Interdisciplinary” means that professional disciplines, as appropriate, will work together to provide the greatest benefit to the resident. It does not mean that every goal must have an interdisciplinary approach. The mechanics of how the interdisciplinary team meets its responsibilities in developing an interdisciplinary care plan (e.g., a face-to-face meeting, teleconference, written communication) are at the discretion of the facility.

An interdisciplinary team, in conjunction with the resident, resident’s family, surrogate, or representative, as

appropriate, should develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment. The care plan must reflect intermediate steps for each outcome objective if identification of those steps will enhance the resident’s ability to meet his/her objectives. Facility staff will use these objectives to follow resident progress. Facilities may, for some residents, need to prioritize needed care. The MD/DO must participate as part of the interdisciplinary team, and may arrange with the facility for alternative methods, other than attendance at care planning conferences, of providing his/her input, such as one-to-one discussions and conference calls. The resident has the right to refuse specific treatments and to select among treatment options before the care plan is instituted. The facility should encourage residents, surrogates, and

representatives to participate in care planning, including encouraging attendance at care planning conferences if they so desire

In some cases, a resident may wish to refuse certain services or treatments that professional staff believe may be indicated to assist the resident in reaching his or her highest practicable level of well-being. Desires of the resident should be documented in the clinical record.

“Professional standards of quality” means services that are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Standards regarding quality care practices may be published by a professional CAH, licensing board, accreditation body or other regulatory agency. Recommended practices to achieve desired resident outcomes might also be found in clinical literature.

Surveyor Guidance:

In sampling of resident records, verify

that the care plan address the needs, strengths and preferences identified in the comprehensive assessment interdisciplinary expertise utilized to develop a plan to improve the resident’s functional abilities

the care plan oriented toward preventing avoidable declines in functioning or functional levels the care plan evaluated and revised as the resident’s status changes

If there is resident has refused treatment, does the care plan reflect the facility’s efforts to find alternative means to address the problem

Validate that schedule care plan meetings are at the best time of the day for residents and their families. Interview residents to determine if

facility staff attempt to make the process understandable to the resident/family

they had concerns or questions about your care and brought them to the attention of facility staff?” If yes, “What happened as a result?”

the facility has provided adequate information to the resident so that the resident was able to make an informed choice regarding treatment.

Review the care plan of new resident to determine if the assessment and care planning is sufficient to meet the needs of newly admitted residents.

Verify that staff can describe the care, services and expected outcomes of the care they provide.