Resident assessments and care plans | NJ

RESIDENT ASSESSMENTS AND CARE PLANS

 

8:36-7.1         Initial assessments and resident service plans

 

• Upon admission, each resident shall receive an initial assessment by a registered professional nurse to determine the resident’s

 

• If this initial assessment indicates the resident has general service needs, a general service plan shall be developed within 14 days of the resident’s admission.

 

• The general service plan shall include, but not be limited to, the following:

 

1. The resident’s need, if any, for assistance with activities of daily living (ADL);

 

2. The resident’s need, if any, for assistance with recreational and other activities; and

 

3. The resident’s need, if any, for assistance with

 

8:36-7.2         Health care assessment and health service plan

 

• Within 30 days prior to admission to the assisted living residence, comprehensive personal care home, or assisted living program, a physician, advanced practice nurse or physician assistant shall specify in writing that the resident is appropriate for this level of

 

• At the time of admission, arrangements shall be made between the administrator and the resident, guardian, or responsible person regarding the physician and dentist to be called in case of illness, or the individual to be called for a resident who, because of religious affiliation, is opposed to medical treatment.

 

• If the initial assessment in N.J.A.C. 8:36-7.1(a) indicates that the resident requires health care services, a health care assessment shall be completed within 14 days of admission by a registered professional nurse using an assessment instrument available from the Department, or an assessment instrument that has been adopted by the facility or program, equivalent to the instrument available from the Department, and which meets the requirements of

 

• Each health care assessment by the registered professional nurse shall include, at a minimum, evaluation of the following:

 

1. Need for assistance with “activities of daily living”;
2. Cognitive patterns;
3. Communication/hearing patterns;
4. Vision patterns;
5. Physical functioning and structural problems;
6. Continence;
7. Psychosocial well-being;
8. Mood and behavior problems;
9. Activity pursuit patterns;
10. Disease diagnoses;
11. Health conditions and preventive health measures, including, but not limited to, pain, falls, and lifestyle;
12. Oral/nutritional status;
13. Oral/dental status;
14. Skin conditions;
15. Medication use;
16. Special treatment and procedures;
17. Restraint use; and
18. Outside service

 

• Based on the health care assessment, a written health service plan shall be developed. The health service plan shall include, but not be limited to, the following:

 

1. Orders for treatment or services, medications, and diet, if needed;

 

2. The resident’s needs and preferences for himself or herself;

 

3. The specific goals of treatment or services, if appropriate;

 

4. The time intervals at which the resident’s response to treatment will be reviewed; and

 

5. The measures to be used to assess the effects of

 

• The initial health care assessment shall be documented by the registered nurse and shall be updated as required, in accordance with the rules of this chapter and professional standards of

 

• The facility shall make reasonable effort to have documentation of services provided by outside health care professionals entered in the resident record.

 

8:36-7.3         General and health service plans

 

• The resident general service plan shall be reviewed and, if necessary, revised semi-annually, and more frequently as needed based upon the resident’s response to the care provided and any changes in the resident’s physical or cognitive status.

 

• The resident health service plan shall be reviewed, and if necessary, revised quarterly, and as needed, based upon the resident’s response to the care provided and any changes in the resident’s physical or cognitive

 

• Documentation in the resident’s record shall indicate review and any necessary revision of the resident service plan and/or health service

 

• The resident shall participate in and, if the resident agrees, family members shall be invited to participate in, the development of the resident service plan and health service plans, if plans are Participation shall be documented in the resident’s record.

 

• If the resident does not have any general service needs or health services needs, a general or health service plan is not

 

• The facility shall be responsible for reassessing residents who have neither a general service or health service plan in response to changes in the resident’s functional and/or cognitive status at least annually and more frequently if such reassessment is predicated on a change in the resident’s functional and/or cognitive status.

 

8:36-7.4         Health care services

 

• The assisted living residence, comprehensive personal care home, or assisted living program shall ensure that the resident receives “health care services” under the direction of a registered professional nurse, in accordance with the health service

 

• A registered professional nurse shall be responsible for developing nursing practice policies and procedures and the coordination of all health care services required in the resident’s health service

 

• Written policies and procedures shall be developed and implemented to ensure, but not be limited to, the following:

 

1. Assessment of all residents with a general service plan at least semi- annually, and those residents who have a health service plan shall be reassessed at least quarterly and more often on an as-needed basis, including and upon the resident’s return to the facility from the hospital;

 

2. Monitoring of the condition of all residents on an as needed basis;

 

3. Notification of the registered professional nurse if there are significant changes in a resident’s condition;

 

4. Assessment of the resident’s need for referral to a physician, advanced practice nurse or physician assistant, or community agencies as appropriate; and

 

5. Maintenance of records as

 

8:36-7.5         Provision of health care services

 

• The facility or program shall arrange for health care services to be provided to residents as needed, in accordance with assessments and with the health service plan. The administrator shall develop a system to identify the residents receiving health care

 

• If a resident who has not been receiving a health care service requires a health care service on a temporary basis (meaning a period of time reasonably expected to be 14 days or less and not involving a significant change in condition or a life-threatening illness), neither a health care assessment nor a health service plan shall be required. The administrator shall develop a system to identify the residents receiving a health care service on a temporary

 

• The registered professional nurse shall be called at the onset of illness, injury or change in condition of any resident to arrange for assessment of the resident’s nursing care needs or medical needs and for needed nursing care intervention or medical

 

• The resident’s physician or the physician’s designee, that is, another physician or an advanced practice nurse or physician assistant, shall be notified by the licensed professional nurse of any significant changes in the resident’s physical or cognitive/mental condition and any intervention by the physician shall be

 

• Each resident shall have an annual physical examination by a physician, advanced practice nurse or physician assistant, which shall be documented in the resident’s record. The physician, advanced practice nurse or physician assistant shall certify annually that the resident does not have needs which exceed the care that the facility or program is capable of

 

• If it is determined that there is a medical need for a transfer of a resident to another health care facility because the assisted living residence, comprehensive personal care home or assisted living program cannot meet the resident’s needs, such transfers shall be initiated promptly, in accordance with

N.J.A.C. 8:36-5.1(d). The registered professional nurse shall be notified to ensure that the resident is receiving appropriate care during the transfer period.

 

• If the resident is not transferred within seven days, the Department shall be notified and assistance shall be requested from the Department to arrange for transfer of the Resident.