N.J. Admin. Code § 8:43F-5.4

Current through Register Vol. 56, No. 23, December 2, 2024

Section 8:43F-5.4 - Development and implementation of plan of care, and discharge

(a) A written interdisciplinary plan of care shall be developed, based on the initial and interdisciplinary assessment, within 30 days of the date the participant first attends the program. The plan of care shall include, but not be limited to, the following:

1. The participant's scheduled days of attendance;

2. The specific goals of care, if appropriate;

3. The participant's needs and preferences for himself or herself;

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

5. The time intervals at which the participant's response to treatment will be reviewed.

(b) The interdisciplinary plan of care shall be based on the comprehensive assessments provided by nursing, dietary, activities, and social work staff; and when ordered by the physician, advanced practice or physician assistant, other health professionals, including pharmacy consultation, shall also provide assessments. The plan of care shall include measurable objectives with interventions based on the participant's care needs and means of achieving each goal. The complete plan of care shall include, if appropriate, rehabilitative/restorative measures, preventive intervention, and training and teaching of self-care.

(c) There shall be a scheduled review and evaluation in each service involved in the initial assessment, and in other areas that the physician, advanced practice nurse or physician assistant, or interdisciplinary team indicates are necessary. Reassessments shall be performed as necessary, based on participant's needs, but at least quarterly for adult participants.

(d) The plan of care shall include documented discharge planning, which shall address the participant's changing status that may alter the appropriateness of day care and necessitate helping the caregiver to access alternative resources.

1. The plans for discharge shall be in compliance with N.J.A.C. 10:164, regarding Medicaid eligibility criteria, if applicable.

2. As part of the documented plans for discharge, the facility shall assist the participant and, if applicable, the participant's caregiver and/or family members, in accessing alternative resources.

(e) The participant and, if indicated, the participant's caregiver and/or family members shall assist in developing the plans for discharge.

(f) The facility shall maintain signed attestations by the participant or the participant's authorized representative that the facility has provided him or her with a written explanation of the facility's policies and procedures regarding discharge planning, and that he or she agrees with it.

N.J. Admin. Code § 8:43F-5.4

Public Notice: Moratorium Affecting Licensure of Adult Day Health Care Facilities and Services.
See: 40 N.J.R. 6487(d).
Public Notice: Moratorium Affecting Licensure of Adult Day Health Care Facilities and Services.
See: 41 N.J.R. 4328(b).
Notice of readoption with technical change, effective 12/20/2021.
See: 53 N.J.R. 2204(a).