OAR 411-086-0060
Comprehensive Assessment and Care Plan
(1)
Comprehensive Assessment:(a)
An RN shall ensure completion and documentation of a comprehensive assessment of the resident’s capabilities and needs for nursing services within 14 days of admission. Comprehensive assessments shall be updated promptly after any significant change of condition and reviewed no less often than quarterly. This assessment shall be on a form specified by the Division. The assessment shall include the following:(A)
Medically defined conditions and medical history;(B)
Medical status measurement;(C)
Functional status;(D)
Sensory and physical impairments;(E)
Nutritional status and requirements;(F)
Treatments and procedures;(G)
Psychosocial status (see OAR 411-086-0240 (Social Services));(H)
Discharge potential (see OAR 411-086-0160 (Nursing Services: Discharge Summary));(I)
Dental condition;(J)
Activities potential (see OAR 411-086-0230 (Activity Services));(K)
Rehabilitation and restorative potential (see OAR 411-086-0150 (Nursing Services: Restorative Care) and 411-086-0220 (Rehabilitative Services));(L)
Cognitive status; and(M)
Drug therapy.(b)
Social services, activities and dietary personnel shall complete an assessment within 14 days of admission.(2)
Care Plan Preparation and Implementation. The facility, through the nursing services department and the interdisciplinary staff, shall provide services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident in accordance with a written, dated, care plan:(a)
The plan shall be completed within seven days after completion of the comprehensive assessment. The care plan shall be reviewed and updated whenever the resident’s needs change, but no less often than quarterly;(b)
The care plan shall describe the medical, nursing, and psychosocial needs of the resident and how the facility will actively meet those needs. This description of needs shall include measurable objectives and time frames in which the objectives will be met;(c)
The plan shall provide for and promote personal choice and independence of the resident;(d)
The plan shall be reviewed and completed at an interdisciplinary care planning conference with participation from the resident’s RN care manager and personnel from dietary, activities and social services. The resident’s attending physician will participate in the development and any revision of the care plan. Physician participation may be in person, through communication with the DNS or RN Care Manager, or via telephone conference;(e)
The resident, the resident’s legal representative, and anyone designated by the resident shall be requested to participate. The request shall be documented in the resident’s clinical record;(f)
The plan shall be prepared and implemented with participation of the resident and in accordance with the resident’s wishes;(g)
The plan shall include an assessment of the resident’s potential for discharge and the facility’s efforts to work toward discharge;(h)
The plan shall be available to and followed by all staff involved with care of the resident.(3)
Documentation:(a)
The care plan shall be written in ink and made a part of the resident’s clinical record;(b)
Participation in development of the care plan by interdisciplinary staff will be clearly documented.
Source:
Rule 411-086-0060 — Comprehensive Assessment and Care Plan, https://secure.sos.state.or.us/oard/view.action?ruleNumber=411-086-0060.