Section 11-100.1-88 - Case management qualifications and services(a) Case management services shall be provided for each expanded ARCH resident to plan, locate, coordinate and monitor comprehensive services to meet the individual resident's needs based on a comprehensive assessment. Case management services shall be provided by a registered nurse who: (1) Possesses a bachelor's degree in nursing and current license to practice in the State of Hawaii; and(2) Has at least two years experience with client care coordination responsibilities and possesses knowledge and skills pertaining to the long term care needs of the geriatric population. The department may allow substitution of two additional years of client care coordination experience for a bachelor's degree.(b) When the care plan goal cannot be met by the registered nurse, a social worker shall be available to the resident and primary care giver for areas that include, but are not limited to, counseling, access to community services, financial matters, and behavior management. These services shall be provided by a social worker who: (1) Possesses a master's degree in social work and current license to practice in the State of Hawaii; and(2) Has at least two years experience with client care coordination responsibilities and possesses knowledge and skills pertaining to the long term care needs of the geriatric population. The department may allow substitution of two additional years of client care coordination experience for a master's degree.(c) Case management services for each expanded ARCH resident shall be chosen by the resident, resident's family or surrogate in collaboration with the primary care giver and physician or APRN. The case manager shall: (1) Conduct a comprehensive assessment of the expanded ARCH resident prior to placement in an expanded ARCH, which shall include, but not be limited to, physical, mental, psychological, social and spiritual aspects;(2) Develop an interim care plan for the expanded ARCH resident within forty eight hours of admission to the expanded ARCH and a care plan within seven days of admission. The care plan shall be based on a comprehensive assessment of the expanded ARCH resident's needs and shall address the medical, nursing, social, mental, behavioral, recreational, dental, emergency care, nutritional, spiritual, rehabilitative needs of the resident and any other specific need of the resident. This plan shall identify all services to be provided to the expanded ARCH resident and shall include, but not be limited to, treatment and medication orders of the expanded ARCH resident's physician or APRN, measurable goals and outcomes for the expanded ARCH resident; specific procedures for intervention or services required to meet the expanded ARCH resident's needs; and the names of persons required to perform interventions or services required by the expanded ARCH resident;(3) Review the care plan monthly, or sooner as appropriate;(4) Update the care plan as changes occur in the expanded ARCH resident care needs, services and/or interventions;(5) Promote continuity of care and appropriate integration and utilization of services necessary to implement the care plan;(6) Coordinate care giver training, hospital discharge, respite, home transfers and other services as appropriate. Facilitate, advocate and mediate for expanded ARCH residents, care givers and service providers to ensure linkages and provision of quality care for the optimal function of the expanded ARCH resident;(7) Arrange and participate in the expanded ARCH resident's case conferences. Ensure that the expanded ARCH resident, resident's family or surrogate, expanded ARCH resident's physician and the primary care giver are represented at the case conferences;(8) Have face-to-face contacts with the expanded ARCH resident at least once every thirty days, with more frequent contacts based on the resident's needs and the care giver's capabilities;(9) Provide ongoing evaluation and monitoring of the expanded ARCH resident's status, care giver's skills, competency and quality of services being provided;(10) Conduct comprehensive reassessments of the expanded ARCH resident every six months or sooner as appropriate;(11) Make arrangements with a case manager and/or registered nurse who meets the requirements of this subchapter (a) to provide coverage in the event that the case manager takes leave or is unable to provide services as required in this chapter; and(12) Inform the department of any change in quality of services being provided to the expanded ARCH resident. Case management services shall be subject to all applicable state regulations.
(d) The department in collaboration with the expanded ARCH resident family or surrogate may require a change in case management services when it has been determined through review of resident records, care plans and interventions that the case manager is unable to provide adequate services as outlined in this subchapter.(e) When a change in case management services occurs, the new case manager shall perform a comprehensive reassessment of the expanded ARCH resident, review the care plan and make necessary amendments. The expanded ARCH resident, resident's family or surrogate, physician or APRN and primary care giver shall be notified if a change in case management services is contemplated.Haw. Code R. § 11-100.1-88
[Eff SEP 18 2006] (Auth: HRS §§ 321-1, 321-9, 321-10, 321-11, 321-15.1, 321-15.6, 321-15.61, 321-15.62) (Imp: HRS §§ 321-1, 321-9, 321-10, 321-11, 321-15.1, 321-15.6, 321-15.61, 321-15.62)