Policy & Procedures for Comprehensive Assessment and Care Planning

  With SAEnCompass

Policy for Comprehensive Assessment

Initially and periodically, our facility will conduct a comprehensive, accurate, standardized, reproducible assessment of each resident’s functional capacity.  This assessment will provide the facility with the information necessary to develop a care plan and to provide the appropriate care and services for each resident.

The guidelines for resident assessment are consistent with the requirements for the State-specified Resident Assessment Instrument (RAI).

Admission Orders

At the time each resident is admitted, the facility will have physician’s orders for the resident’s immediate care to ensure the resident receives necessary care and services.  These orders will include dietary, drugs (if necessary), and routine care to maintain or improve the resident’s functional abilities until staff can conduct a Comprehensive Interdisciplinary Assessment and develop an interdisciplinary Care Plan.

The Comprehensive Assessment

1.    The Comprehensive Assessment will describe both the resident’s capability to perform daily life functions and significant impairments in functional capacity.  It will address all the resident’s needs and strengths, regardless of whether the issue is included in the Minimum Data Set (MDS) or Care Area Assessment and Analysis (CAA).

2.    The assessment will include at least the following:

a.    Medically-defined conditions and prior medical history

b.    Medical status measurement

c.    Physical and mental functional status

d.    Sensory and physical impairments

e.    Nutritional status

f.      Special treatments or procedures

g.    Mental and psychosocial status

h.    Discharge potential

i.      Dental condition

j.      Activities potential

k.    Rehabilitation potential

l.      Cognitive status

m.   Drug therapy

n.    Resident preferences

3.    Comprehensive Interdisciplinary Assessments will be conducted:

a.    No later than 14 days after the date of admission;

b.    Promptly after a significant change in the resident’s physical or mental condition; and

c.    In no case less often than once every 12 months.

4.    Comprehensive Interdisciplinary Assessment consists of:

a.    The scheduled MDS

b.    SA Supplement to the MDS which contains Team Assessments for each Care Area that may be triggered.  This Team Assessment is an analysis of the triggered Care Area and follows the Specific Resources from Appendix C of the RAI Manual in accordance with Chapter 2 of the RAI Manual.  Each data element required by the CAA is referenced in the Team Assessment and Analysis for that CAA.

c.    Data required by the triggered Care Area Resources is documented in the following Assessment Editor Forms and the MDS 3.0, as well as other documents, such as physician and consultant documentation and progress notes, physician orders, diagnostic studies, and records of observations such as those recorded in Shift Entries

1.    Long-Term Care Physical Assessment

2.    Risk Assessments for Falls and Skin Breakdown

3.    History and assessment of Pain

4.    Mobility  Assessment

5.    Bowel and Bladder Assessment and Evaluation

6.    Psychosocial Assessment

7.    Nutrition Assessment and Evaluation

8.    Activities Assessment

d.    Review and update of the above assessments and a quarterly MDS will be completed no less than once every three (3) months.                                                                                                                                                                                                                                                                                                                                                                                                      

e.    The most recent Comprehensive Assessment data will be retained until the next Comprehensive Assessment and identified by the assessor’s name and date completed.  Data added with each review will also be identified by the assessor’s name and date completed.

f.      As appropriate, our facility will revise the resident’s care plan to assure its continued accuracy.

General Issues of Security

1.    Each user will be assigned a unique password kept confidential from all other users.  The System Administrator will assign an initial password and teach the user how to change his or her password.  Thereafter, only the user will be able to know or change his or her password.

2.    The SAEnCompass software program will utilize this confidential password database to link the password to the signature that is also part of the user database.

3.    The System Administrator has access to a report that logs the user’s activity within the SAEnCompass files.  Comparison of this report to the date of the signature provides authentication of the signature as that of the person who actually edited the portion of the MDS attested to as the signature associated with the document.

4.    Signatures associated with charting, assessments, provider orders and consents can be similarly authenticated.

5.    Provider Orders will be entered directly by the provider and electronically signed, or, if transcribed by an authorized person, the signature associated with each order will be authenticated with a scanned attachment or directly by the provider.

6.    The electronic medical record is protected by the following back-up system and maintained by the information technology department (or contractor): __________.

Procedure for Use of SAEnCompass Medical Records System

1.     These medical record documents will be maintained in electronic form with appropriate safeguards to assure that each document can be printed or electronically transmitted to any authorized person or agency:

a.    All MDS 3.0 forms, CAA analysis and associated assessments

b.    All vital signs and weights

c.    ______________________________________________________________

2.    These medical record documents will be in printed form and stored in the active or archived paper medical record: ________________________________________.

3.    During the period that the facility continues to maintain medical records with paper and electronic components, the facility will close charts of discharged and deceased residents with directions for retrieving the electronic portion of the record.

4.    Upon admission, the resident’s name and all data required shall be entered into the Face Sheet section of SAEnCompass. 

5.    Current orders will be documented, including:

a.    Diagnoses

b.    Allergies

c.    Physician’s orders

d.    Medication sheet or electronic medication administration records

e.    Treatment sheet or electronic treatment administration records.

6.    Nursing will complete the Long-Term Care Physical Assessment in the Assessment Editor. If this is completed by more than one nurse, each nurse will sign, date and lock the form. If the data from the previous assessment is copied forward each nurse who signs, dates and locks the form reviews and verifies that all data is accurate.

7.    Nursing will also complete a Skin Risk Assessment, Fall Risk Assessment, and Pain History and Assessment, and will work with Therapy to complete the Mobility Assessment.

8.    Each incontinent resident will be evaluated for rehabilitation or restorative care related to elimination.

9.    Each discipline will complete their assessments in the Assessment Editor prior to the Assessment Reference Date of the MDS.

10. Nursing will enter an admission nurse’s note in Charting.

11. The Interdisciplinary Team (IDT) consists of the following:

a.    MDS Coordinator

b.    Other nursing personnel as follows: DON, staff nurses

c.    Social Services

d.    Dietary

e.    Activities

f.      Therapies as appropriate

g.    Each of these persons will interview the resident and perform assessment appropriate to his or her professional responsibility.

12. Residents and their families will be included in the process and will be fully invested as active participants in the determination of the resident’s health care services.

a.    The resident and the resident’s legal representative will be advised by the Social Worker of their rights and responsibilities related to assessment and care planning.

b.    Consultation with the resident and the resident’s legal representative will determine who else should be included in the process, and this will be recorded in the chart.  This information will be used by all IDT members when performing assessment and care planning activities and by the personnel who schedule the care plan conferences.

13. Departments will edit their sections of the MDS and SA Supplement as follows:

a.    Social Services        

b.    Dietary                       

c.    Activities                   

d.    Nursing                      

14. All departments will provide the information in compliance with the designated assessment reference date for the assessment.

15. The RN Coordinator will review the document prior to locking the assessment.

16. If the resident’s condition has changed, a Significant Change of Condition assessment will be completed.  If the resident does not meet the criteria for a Significant Change of Condition assessment, the next assessment will be the one due.

Care Plan Policy

Our facility will develop a comprehensive Care Plan for each resident, including measurable objectives and timetables to meet a resident’s medical nursing, mental and psychosocial needs as identified in the Comprehensive Assessment.

Care Plan Procedure

1.    The Care Plan consists of the following documents:

a.    Problem sheets

b.    Medication administration sheets (MAR) or electronic medication administration data

c.    Treatment administration sheets (TAR) or electronic treatment administration data.

d.    Physician’s order sheets

e.    Behavior care plan as recorded in Orders and Conditions

2.    An Admission Care Plan will be created on the day of admission..

3.    The physician’s orders sheet and MAR will be initiated on the day of admission.

4.    Within three (3) days of admission, each discipline will review the existing problem sheets and edit or add a new problem to provide all essential services.

5.    The list of triggered CAAs will be reviewed, and the RN Coordinator will record the IDT’s decision of whether or not to proceed to care plan for each one.  The RN Coordinator will then enter any decisions to proceed to care plan in section V of the MDS.  On or prior to the 21^st day after admission; the IDT will meet to edit the Comprehensive Care Plan.

6.    During the Comprehensive Assessment and Care Planning process, each team member will consult with the resident, resident’s family, and other persons significant to the resident to obtain information, consents, desires and priorities for care.

7.    The resident and, if the resident desires, those persons designated will be invited to the meeting of the IDT.

8.    Final editing of each problem will be done by the IDT member who has taken responsibility for that problem.  Each problem will be linked to each Care Area that is addressed by the problem sheet.  This linkage will be displayed in the Care Manager and the RN Coordinator will assure that each triggered Care Area that has been designated “proceed” is addressed by at least one care plan problem.  Problems that were not triggered will be linked to the Care Area as appropriate.  This will be done within 24 hours of the meeting, and a revised document will be communicated to all caregivers per facility practice.

9.    The Care Plan will be reviewed as often as changes occur in the resident’s condition and will be revised to maintain accuracy.  The discipline recording the change in condition shall be responsible for making the appropriate changes to the Care Plan.

10. Each resident’s Comprehensive Assessment and Care Plan will be reviewed at least every three (3) months by all members of the IDT including the resident and family, who will then meet to discuss any change in service required.

Rev. 9/28/2010