N.J. Admin. Code § 8:43D-7.2

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:43D-7.2 - Policies and procedures for resident assessment and interdisciplinary care plans

(a) A physician shall issue orders for each resident's medical care prior to or beginning on the day of admission.

(b) Each primary care provider's order shall be carried out in accordance with professional standards of practice by nursing, dietary, social work, resident activities, rehabilitation or pharmacy personnel, as appropriate.

(c) A physician shall examine each resident five days before, or 48 hours after, admission.

(d) An initial nursing assessment and care plan shall be developed on the day of admission and include at least personal hygiene, immediate dietary needs, medications, and ambulation.

(e) Within 10 days of admission, a facility shall formulate an interdisciplinary care plan for each resident that reflects the following:

1. Assessments performed by nursing, dietary, activities, and social work staff and other health care professionals, as prescribed by a resident's physician;

2. Measurable objectives and interventions that are based on a resident's care needs; and

3. Updates that are documented quarterly, or more frequently, as indicated by a change in the resident's health status based on a registered professional nurse's assessment of the resident.

(f) Each comprehensive health care assessment by the registered professional nurse shall include, at a minimum, evaluation of the following:

1. Cognitive patterns;

2. Communication/hearing patterns;

3. Vision patterns;

4. Physical functioning and structural problems;

5. Continence;

6. Psychosocial well-being;

7. Mood and behavior patterns;

8. Activity pursuit patterns;

9. Disease diagnoses;

10. Health conditions;

11. Oral/nutritional status;

12. Oral/dental status;

13. Skin conditions;

14. Medications use;

15. Special treatment and procedures;

16. Psychosocial development; and

17. Education.

N.J. Admin. Code § 8:43D-7.2

Amended by 48 N.J.R. 2336(a), effective 11/7/2016