La. Admin. Code tit. 50 § II-10125

Current through Register Vol. 50, No. 11, November 20, 2024

Section II-10125 - Comprehensive Care Plan

A. Basis for the Comprehensive Care Plan. All services in a facility shall be provided in accordance with a physician's written order which shall be developed either before admission or before authorization for payment. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment.

1. The comprehensive assessment shall be developed for residents within 14 days of admission. Written comprehensive care plans shall be developed within seven days of the comprehensive assessment and no later than 21 days of admission. Thereafter, care plans must be updated at least quarterly or when a significant change in the resident's condition occurs.

2. Individual comprehensive care plans shall:

a. be prepared by an interdisciplinary (ID) team that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs;

b. include the resident, resident's family or legal representative, to the extent practicable in the participation of the care planning process;

c. be periodically reviewed and revised by a team of qualified persons after each assessment and/or quarterly review. This requirement is a review for both ICF and SNF. Neurological Rehabilitative Treatment Program (NRTP) levels of care shall be reviewed every 30 days;

d. be located in the medical record and accessible for use by all licensed nursing personnel and any staff directly involved in the integrated care;

e. serve as the primary communication tool among disciplines to ensure that services are coordinated and that the approaches of the various disciplines are integrated;

f. be written in a language understandable to all staff directly involved in the resident's care and the resident in so far as possible; and

g. document that all services ordered are being rendered and properly recorded.

3. Documentation of quarterly staffing must be on the MDS quarterly Review Form as a comparable computerized document. The documentation shall indicate the date of the staffing and who was in attendance.

B. Contents of the Comprehensive Plan of Care

1. The plan of care shall include the following information:

a. identification of all problems and needs according to the resident assessment protocol document as well as any other identified problems;

b. the goals to be accomplished by the resident. These goals shall be:

i. specific;

ii. reasonable; and

iii. measurable;

c. the specific goals regarding discharge. The discharge plans shall:

i. reflect exploration of likely discharge possibilities;

ii. ensure that residents have planned programs of post discharge continuing care which take their needs into account to the extent practicable;

iii. be developed and reviewed in accordance with the facility's written discharge planning procedures;

d. the expected resolution or review date specified for each problem or need;

e. the prescribed integrated, resident specific therapies and treatments designed to help residents achieve their goals;

f. individual or professional services staff responsible for each service prescribed in the plan;

g. all participating staff shall be identified by name and title, when signing the plan of care;

h. all participating staff and the resident, whenever possible, sign and date the following:

i. the initial plan of care; and

ii. each subsequent review. If the resident refuses to sign the plan of care, this fact should be documented for the medical record;

i. physician orders for diet;

j. the daily and weekly time frames for each service included in the plan for residents receiving either complex care or rehabilitation under NRTP (Neurological Rehabilitation Treatment Program).

C. Discharge Summary. When a facility anticipates a discharge, a resident must have a discharge summary that includes:

1. a recapitulation of the resident's stay;

2. a final summary of the resident's status to include medical history, current diagnosis/condition, medical status measurements, functional status, cognitive status, any impairments, nutritional status/requirements, drug therapy, special treatment, procedures, psychosocial status and rehabilitation potential;

3. must be legible and available for release to authorized persons and agencies with the consent of the resident and/or legal representative; and

4. must be developed with the participation of the resident and his/her family, which will assist the resident in adjusting to a new living environment to the extent practicable.

D. Physician Involvement and Responsibilities in the Comprehensive Plan of Care. A physician is responsible for approving each resident's initial integrated plan of care and each subsequent revision.

1. The physician's approval shall be documented in one of the following places:

a. the plan of care;

b. the order sheet;

c. the progress notes.

2. The documentation referred to above shall be signed and fully dated. The physician may use initials to document review of the plan only if an original legend sheet with a full signature and the initials which will be used is placed on each record.

3. The physician shall review the comprehensive care plan at 90 day intervals.

E. Quarterly Assessment and Optional Progress Notes. The nursing facility must examine each resident no less than once every three months (quarterly) and, as appropriate, to revise the resident's assessment to assure the continued accuracy of the assessment.

1. The quarterly assessments are recorded on the minimum data set quarterly assessment form and may be supplemented by progress notes which reflect the on-going condition and needs of the residents. The quarterly assessments replace all other monthly summaries.

La. Admin. Code tit. 50, § II-10125

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 22:34 (January 1996).

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:153.