Section 146.245 Assessment and Service Plan and Quarterly Evaluation

Section 146

Section 146.245  Assessment

and Service Plan and Quarterly Evaluation

a)         Interview:

The SLP provider shall conduct a standardized interview geared toward the

resident's service needs at or before the time of occupancy but not before the

DON, or successor tool, and other required PAS assessments are completed and

determinations provided to the SLP provider.

b)         Initial Assessment:  The SLP provider shall complete an

initial assessment and service plan within 24 hours after admission that

identifies needs and potential immediate problems.  Each assessment shall be

completed by, or co-signed by, a licensed practical nurse or a registered professional

nurse.

c)         Comprehensive

Resident Assessment:  The SLP provider shall complete a Comprehensive Resident

Assessment Instrument (RAI) within 14 days after admission, annually and upon a

significant change in the resident's mental or physical status.  Each

RAI

shall be completed by, or co-signed by, a registered professional nurse.

d)         Service Plan:  Within seven days after completion of the RAI,

a written service plan shall be developed by, or co-signed by, a registered professional

nurse, with input from the resident and his or her designated representative. This

includes coordination and inclusion of services being delivered to a resident

by an outside entity. The service plan shall include a description of expected

outcomes, approaches, frequency and duration of services provided and whether

the services will be provided by licensed or unlicensed staff.  The service

plan must be individualized to address the health and behavior needs of each

resident.  The service plan shall document any services recommended by the SLP

provider that are refused by the resident.  The service plan shall be reviewed

and updated in conjunction with the quarterly evaluation or as dictated by

changes in resident needs or preferences

y licensed or unlicensed staff.  The service

plan must be individualized to address the health and behavior needs of each

resident.  The service plan shall document any services recommended by the SLP

provider that are refused by the resident.  The service plan shall be reviewed

and updated in conjunction with the quarterly evaluation or as dictated by

changes in resident needs or preferences.

e)         Quarterly Evaluation: A quarterly evaluation of the health and

behavior status of each resident using a Department designated form shall be

completed by, or co-signed by, a registered professional nurse.

f)         Service

Plan for Identified Sex Offenders:  Within seven days after completion of the

RAI, a written service plan shall be developed by, or co-signed by, a

registered professional nurse that addresses the following:

1)         the

amount of supervision required by the individual to ensure the safety of all

residents, staff and visitors; and

2)         determination

of approaches developed in the service plan are appropriate and effective in

dealing with any behaviors specific to the identified offender.

g)         Progress

Notes:  Progress notes shall be completed at least monthly to document decline

or improvement in resident status.  A progress note does not have to be

completed if there is no change in resident status.  Any SLP staff may write

progress notes.

h)         The SLP manager or licensed nursing staff shall alert the

resident, his or her physician and his or her designated representative when a

change in a resident's mental or physical status is observed by staff.  Except

in life-threatening situations, the reporting shall be within 24 hours after the

observation.  Serious or life-threatening situations should be reported to the

physician and the resident's designated representative immediately

alert the

resident, his or her physician and his or her designated representative when a

change in a resident's mental or physical status is observed by staff.  Except

in life-threatening situations, the reporting shall be within 24 hours after the

observation.  Serious or life-threatening situations should be reported to the

physician and the resident's designated representative immediately.  The SLP

staff shall be responsible for reporting only those changes that should be

apparent to observers familiar with the conditions of older persons or persons

with disabilities.