N.Y. Comp. Codes R. & Regs. Tit. 10 § 415.11 - Resident assessment and care planning
Upon admission and periodically thereafter the facility shall conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. Based on the results of these assessments, the facility shall develop and keep current an individualized comprehensive plan of care to meet each resident's needs.
(a) Comprehensive assessments.
(1) The facility shall conduct a comprehensive
assessment of each resident's needs, which describes the resident's capability to
perform daily life functions and identifies significant impairments in functional
capacity. All comprehensive assessments completed after April 1, 1991 shall be
recorded on a uniform data instrument designated by the Department of
Health.
(2) The comprehensive
assessment shall include at least the following information:
(i) medically defined conditions and prior
medical history;
(ii) medical status
measurement;
(iii) physical and
mental functional status;
(iv)
sensory and physical impairments;
(v)
nutritional status and requirements;
(vi) special treatments or
procedures;
(vii) discharge
potential;
(viii) mental and
psychosocial status;
(ix) dental
condition;
(x) activities
potential;
(xi) rehabilitation
potential;
(xii) cognitive status;
and
(xiii) drug therapy.
(3) Frequency. Comprehensive
assessments shall be conducted:
(i) no later
than 14 days after the date of admission;
(ii) promptly after a significant improvement
or decline in the resident's physical, mental or psychosocial status in
accordance with generally accepted standards of care and services; and
(iii) in no case less often than once every 12
months for each resident.
(4) Review of assessments. Professional staff
shall examine each resident no less than once every three months, and as
appropriate, revise the resident's comprehensive assessment to assure the
continued accuracy of the assessment.
(5) Use. The results of the comprehensive
assessment shall be used by the interdisciplinary care team as defined in
subparagraph (c)(2)(ii) of this section to develop, review, and revise the
resident's comprehensive plan of care, under subdivision (c) of this
section.
(b) Accuracy of
assessments.
(1) Coordination.
(i) Each assessment shall be conducted or
coordinated, with the participation of appropriate health
professionals.
(ii) Each assessment
shall be conducted, or coordinated, by a registered professional nurse who signs
and certifies the completion of the assessment.
(2) Certification. Each individual who
completes a portion of the assessment shall sign and certify the accuracy of that
portion of the assessment.
(3)
Penalty for falsification. An individual who willfully and knowingly certifies
(or causes another individual to certify) a material and false statement in a
resident assessment shall be subject to civil money penalties under Federal
statutes and regulations.
(4) Use of
independent assessors. If the department determines, under a survey or otherwise,
that there has been a knowing and willful certification of false statements under
paragraph (3) of this subdivision, the department shall require remedial
measures, which may include but not be limited to requiring that resident
assessments under this section be conducted and certified at the facility's
expense by individuals who are independent of the facility and who are approved
by the department.
(c)
Comprehensive care plans.
(1) The facility
shall develop a comprehensive care plan for each resident that includes
measurable objectives and timetables to meet each resident's medical, nursing and
mental and psychosocial needs that are identified in the comprehensive
assessment.
(i) The care plan shall reflect a
consideration of the resident's ability to self-administer drugs
safely.
(ii) The facility shall
clearly document those instances in which recommended items or services are not
made part of the comprehensive care plan due to the stated contrary wishes of a
competent resident or a designated representative who has the authority to make
health care decisions for a resident who lacks capacity.
(2) A comprehensive care plan shall be:
(i) developed within seven working days after
completion of the comprehensive assessment;
(ii) prepared by an interdisciplinary team that
includes the attending physician, a registered professional nurse with
responsibility for the resident, and other appropriate staff in disciplines as
determined by the resident's needs, and with the participation of the resident
and the resident's family or legal representative to the extent practicable;
and
(iii) periodically reviewed and
revised as necessary by an interdisciplinary team of qualified persons after each
comprehensive assessment or reassessment.
(3) The services provided or arranged by the
facility shall:
(i) meet generally accepted
standards of care and service; and
(ii) be provided by qualified persons in
accordance with each resident's written plan of care.
(d) Discharge summary. When the
facility anticipates discharge, the facility shall prepare a discharge summary
that includes:
(1) a recapitulation of the
resident's stay;
(2) a final summary
of the resident's status to include information set forth in paragraph (a)(2) of
this section, at the time of the discharge that shall be available for release to
authorized persons and agencies, with the consent of the resident or legal
representative; and
(3) a
post-discharge plan of care that shall be developed with the participation of the
resident and his or her family, which will assist the resident to adjust to his
or her new living environment and assure that needed medical and supportive
service have been arranged and are available to meet the identified needs of the
resident.
(e) Patient
assessment and annual resident review (PASARR). The facility shall conduct, at
least annually, a review of residents with known or suspected mental impairment
of mental retardation utilitizing the pertinent portions of the SCREEN instrument
set forth in section
400.12 of
this Title. Residents screened as mentally impaired or mentally retarded by this
process shall be referred to the commissioner's designee for evaluation of the
need for active treatment for mental impairment or mental retardation and for
need for nursing home services.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.