Ala. Admin. Code r. 560-X-53-.07

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-53-.07 - Participant Assessment And Plan Of Care

(1) An initial comprehensive assessment and a detailed written plan of care must be established for each participant immediately upon his or her enrollment in the PACE program. The Interdisciplinary Team is responsible for implementing, coordinating, monitoring, and documenting the assessments, reassessments, and the plan of care in the participant's medical records.

(2) The assessment of the participant for the plan of care must be conducted in person by the following members of the Interdisciplinary Team: primary care physician, registered nurse, social worker (Master's level), physical and occupational therapists, recreational therapist or activity coordinator, dietitian, and home care coordinator ( 42 CFR 460.104 ). Other members of the Team may be included in the assessment as recommended by the initial members of the Team conducting the assessments. The assessments are to be compiled into a single plan of care once completed. During the assessment, female participants must be informed they can choose a qualified specialist to provide routine and preventive health services for women. The assessment must include documentation on the following:

(a) Participant's physical and cognitive function and ability, status of health, behavior, and language;

(b) Medications and treatment needs;

(c) Participant and caregiver's preferences for services;

(d) Availability of socialization and family support;

(e) Nutritional, medical, and dental status;

(f) Environment of and access in to the home;

(g) Psychosocial status.

(3) The plan of care must be evaluated every six months to ensure necessary changes in care are made, as well as documenting outcomes of care that were provided during the six-month period. Reassessments may be conducted more often if required by the condition of the participant. Reassessments are to be conducted in person by the primary care physician, registered nurse, social worker (Master's level), recreational therapist or activity coordinator, and other Team members involved in the development and implementation of the plan of care. Annual reassessments are to be conducted in person by the physical therapist, occupational therapist, dietitian, and home care coordinator.

(4) Unscheduled reassessments may be required in addition to scheduled reassessments if there is a change in the health or psychosocial status of a participant, or if the participant or their representative requests that a service be implemented, eliminated, or continued. These assessments must also be conducted in person by the appropriate members of the Team. Detailed procedures regarding requests for the implementation, elimination, or continuation of services are to be in place for timely resolution of the requests. Refer to 42 CFR 460.104 for guidelines regarding the resolution of requests for reassessments by the participant or their representative.

(5) Upon the completed reassessment of the participant, the plan of care must be re-evaluated and any changes must be discussed by the Interdisciplinary Team (IDT). The changes must be approved by the IDT and the participant or their representative. Once approved, the changes must be provided as quickly as required by the participant's health.

Ala. Admin. Code r. 560-X-53-.07

Emergency rule effective May 1, 1991. Permanent rule effective August 14, 1991. Repealed: Filed April 5, 1999; effective May 10, 1999. New Rule: Filed November 10, 2011; effective December 15, 2011.

Author: Linda Lackey, Medicaid Administrator, LTC Project Development Unit.

Statutory Authority: State Plan, Attachment 2.2-A, Attachment 3.1-A and Supplement 3; 42 CFR 460.104 and 460.106.