N.H. Admin. Code § He-P 813.15

Current through Register No. 50, December 12, 2024

Section He-P 813.15 - Resident Admission and Person-Centered Plan Development

(a) Prior to admission, family provider shall provide the resident and/or his or her authorized representative with a written copy of the resident admissions contract pursuant to RSA 161- J:4, which includes the following information:

(1) The basic daily, weekly and monthly rate paid to the family provider;

(2) A list of the services required by He-P 813 that are covered by the basic rate;

(3) The time period covered by the admissions contract;

(4) The AFCR's house rules;

(5) The grounds for immediate termination of the agreement, pursuant to RSA 151:26, II(b) ;6

(6) The AFCR's responsibility for resident discharge planning;

(7) Information regarding services not provided by the AFCR, to include:

a. Contact and other information regarding nursing and other health care services;

b. The AFCR's responsibility for arranging services;

c. The rate and payment for services;

(8) The AFCR's policies and procedures regarding:

a. Providing transportation;

b. Arranging for the provision of third party services, such as cable television;

c. Third party services contracted directly by the resident and provided on the AFCR premises;

d. Storage and loss of the resident's personal property;

e. Filing complaints; and

f. When a residents temporarily leaves the AFCR, the policy for holding a bed open, in compliance with RSA 151:25;

(9) The AFCR's medication management services;

(10) A copy of the current version of the patients' bill of rights under RSA 151: 21 and the AFCR's policies and procedures for implementation of the patient's bill of rights pursuant to RSA 151:20, II;

(11) A copy of the resident's right to appeal an involuntary transfer or discharge under RSA 151:26, II(5) , and the AFCR 's policy and procedure for assisting with the appeals process; and

(12) The AFCR's policy and procedure for handling reports of abuse, neglect or exploitation.

(b) The family provider shall develop a person-centered plan, reviewed every 6 months, and revised based on the resident's needs.

(c) The person-centered plan shall include the following:

(1) A description of the resident's needs;

(2) The date the need was identified;

(3) The goals or objectives of the plan;

(4) The actions or approaches to be taken;

(5) A statement about whether or not the resident may safely be left alone in the home and if so, the time frame and duration that he or she may be left alone;

(6) The name of the individual responsible for carrying out the plan; and

(7) The date(s) of re-evaluation, review, or resolution for any identified issues.

(d) The person-centered plan shall be a written guide:

(1) Developed by the case manager, the resident and/or his or her representative, the family provider and the oversight agency that outlines the resident's needs and process for the provision of services which shall address the resident's:

a. Ability to manage his or her ADL's;

b. Physical health, including impairments of mobility, sight, hearing and speech;

c. Intellectual functioning and mental health;

d. Need for supervision;

e. Need for medication assistance;

f. Need for family and community involvement; and

g. Need for community and social health services; and

(2) Reviewed and updated whenever there is a change in the resident's condition and at the time of annual eligibility redetermination.

(e) Monthly progress notes for every resident shall be recorded by the family provider including, at a minimum:

(1) A brief description of the care, including assistance with ADLs, that has been provided;

(2) Observations regarding changes in the resident's physical, functional and cognitive abilities; and

(3) Observations regarding changes in behavior, such as eating habits, sleeping patterns, and relationships.

(f) The family provider, case manager and oversight agency shall meet or confer quarterly to review the progress notes required in (e) above.

(g) At the time of admission the family provider, with the assistance of the oversight agency, if necessary, shall obtain orders from a licensed practitioner for medications if applicable.

(h) Each resident shall have a health examination not more than 6 months prior to admission and at least one health examination every 12 months.

(i) If a resident refuses care or services, the family provider shall notify the case manager and oversight agency.

(j) The family provider shall maintain an emergency data sheet in the resident's record and promptly give a copy to emergency medical personnel in the event of an emergency transfer to another medical facility, which includes:

(1) The resident's full name and the name the resident prefers to be called by, if different;

(2) The name, address and telephone number of the resident's next of kin or representative;

(3) The resident's diagnoses;

(4) The resident's allergies, if any;

(5) The resident's functional limitations, if any;

(6) The resident's date of birth;

(7) The resident's advanced directives; and

(8) Any other pertinent information not specified in (1) -(7) above.

N.H. Admin. Code § He-P 813.15

#8595, eff 4-1-06; ss by #9899-A, eff 3-29-11

Amended by Volume XXXIX Number 16, Filed April 18, 2019, Proposed by #12740, Effective 3/20/2019, Expires 9/16/2019.