N.H. Admin. Code § He-P 818.16

Current through Register No. 50, December 12, 2024

Section He-P 818.16 - Care Requirements

(a) At the time of admission, personnel of the ADP shall:

(1) Provide, both verbally and in writing, to the participant, guardian, agent, and personal representative, as applicable:

a. The ADP's policies on participant rights and responsibilities;

b. The scope and type of services to be provided by the ADP;

c. The ADP's complaint procedure and rules; and

d. Obtain written confirmation acknowledging receipt of these policies and rules;

(2) Collect and record in the participant record the following information:

a. Participant's name, home address, home telephone number, and date of birth;

b. Name, address, and telephone number of an emergency contact;

c. Participant's primary licensed practitioner's name, address, and phone number;

d. Copies of any executed legal directives such as guardianship orders for health care issues under RSA 464-A, durable power of attorney, or a living will; and

e. The name of the participant's guardian, agent, or personal representative, if any;

(3) Require the participant to have a physical examination by a licensed practitioner that has been completed no more than one year prior to admission or within 72 hours after admission and includes:

a. Diagnoses, if any;

b. The medical history;

c. Medical findings, including the presence of communicable disease;

d. Vital signs;

e. Prescribed and over-the-counter medications;

f. Allergies, if any;

g. Dietary needs, if any; and

h. Functional abilities and limitations;

(4) Have the RN, or LPN who is directly or indirectly supervised by an RN, complete a nursing assessment within 7 days of attendance to determine the level of services required by the participant;

(5) Have the administrator, licensed nurse, or activities coordinator complete a recreational assessment;

(6) Have the administrator, licensed nurse, or social worker complete a social history;

(7) Complete an emergency data sheet that, at a minimum, lists the following information:

a. The participant's full name, address, telephone number, and date of birth;

b. The name, address, and telephone number of the participant's family or the person legally responsible for the participant;

c. The participant's diagnosis;

d. Medications administered to or by the participant at the ADP, including the last dose taken and when;

e. Any known allergies;

f. The participant's functional level and needs requirements as assessed by the ADP staff;

g. Copies of any advanced directives, guardianship, or durable powers of attorney, if applicable;

h. The participant's health insurance information; and

i. Any other pertinent information not specified in a.-h. above; and

(8) Obtain orders from a licensed practitioner for medications, prescriptions, and diets.

(b) A written daily medication record shall be utilized for all medication taken by participants at the ADP.

(c) A care plan shall be completed within the first 30 days of attendance based upon the results of all of the participant's assessments listed above and shall include:

(1) The date any specific problem or need was identified;

(2) A description of services to let caregivers and personnel know what problem(s) or need(s) was identified as a result of the assessments;

(3) The goals for the participant;

(4) The action or approach to be taken by the ADP to meet needs identified by the assessment(s);

(5) The party responsible for implementing the action or approach to be taken;

(6) The date the next re-evaluation is to occur; and

(7) Written documentation to verify that the participant, family, or caregiver was offered the opportunity to be involved in the development of the care plan and any revisions made thereafter.

(d) The licensed nurse and other personnel as deemed necessary by the licensed nurse shall review the care plan at least every 6 months and revise it whenever necessary.

(e) The care plan referenced in (c) above shall be:

(1) Reviewed and updated within 5 business days following the completion of each future assessment; and

(2) Made available to personnel who assist participants in the implementation of the plan.

(f) If the nursing assessment, developed in accordance with (a) (4) above, or the care plan, developed in accordance with (c) above, is completed by an LPN, the assessment and care plan shall be reviewed and co-signed by an RN or physician that is supervising the LPN prior to the implementation of the participant's care plan.

(g) The direct care personnel of the ADP shall implement the care plan.

(h) The participant record shall contain written notes as follows:

(1) Notes on all medical, nursing, rehabilitative, or therapeutic care and services provided at the ADP shall include the:

a. Date and time that the care or services were provided;

b. Description of the care or services provided;

c. Participant's response to the care or services provided; and

d. Signature and title of the person providing the care or service;

(2) Progress notes shall include at a minimum:

a. Care plan outcomes;

b. Changes in the participant's physical, functional, and mental abilities;

c. Changes in behavior;

d. Summary of protective care that has been provided; and

e. Summary of assistance provided with ADLs; and

(3) Progress notes in (2) above shall be written at least every 30 days for the first 90 days and then quarterly thereafter.

(i) The use of chemical or physical restraints shall be prohibited except as allowed by RSA 151:21, IX.

(j) Immediately after the use of a physical or chemical restraint, the participant's guardian or agent, if any, and the department shall be notified of the use of such restraints.

(k) The ADP shall:

(1) Have policies and procedures on the use of restraints in an emergency:

a. What type of restraints may be used;

b. When restraints may be used; and

c. What personnel may authorize the use of restraints, which shall be limited to the administrator, medical director, director of nursing, and other licensed personnel; and

(2) Provide personnel with education and training on the limitations and the correct use of restraints.

(l) The use of mechanical restraints shall be allowed.

(m) The participant shall be discharged, as defined under RSA 151:19, I-a, in accordance with RSA 151:26 and RSA 151:21, V.

(n) The licensee shall develop a discharge plan for each participant with the input of the participant and the guardian or agent, if any.

(o) Transfers to a medical facility for emergency medical treatment may occur without prior notification to the guardian, agent pursuant to an activated POA, or the licensed practitioner, when the participant is in need of immediate emergency care.

(p) For each participant accepted for care and services at the ADP, a current and accurate record shall be maintained and include, at a minimum:

(1) The written confirmation required by He-P 818.16(a) (1);

(2) The identification data required by He-P 818.16(a) (2);

(3) Consent and medical release forms, as applicable;

(4) The record of a physical examination as required by He-P 818.16(a) (3);

(5) All orders from a licensed practitioner, including the date and signature of the licensed practitioner;

(6) All assessments;

(7) All care plans, including documentation that the participant or person legally responsible participated in the development of the care plan if they chose to;

(8) All written notes required by He-P 818.16(h);

(9) All daily medication records;

(10) A discharge plan as required by He-P 818.16(n);

(11) The emergency data sheet required by He-P 818.16(a) (7);

(12) Documentation of reportable incidents involving the participant, including the information required by He-P 818.14(s) ; and

(13) Documentation of the refusal of a participant to follow the prescribed orders of the licensed practitioner including the date and time the licensed practitioner was notified of the refusal.

(q) Participant records shall be safeguarded against loss, damage, or unauthorized use by being stored in locked containers, cabinets, rooms, or closets except when being used by the ADP's personnel.

(r) Participant records shall be retained for a minimum of 4 years after discharge.

(s) Prior to the ADP cessation of operations, it shall arrange for the storage of and access to participant records for 4 years after the date of closure, which shall be made available to the department and past participants, their designees, or both upon request.

N.H. Admin. Code § He-P 818.16

#9106, eff 3-18-08

Amended by Volume XXXVI Number 45, Filed November 10, 2016, Proposed by #12006, Effective 10/15/2016, Expires 4/13/2017.

Amended by Volume XXXVII Number 23, Filed June 8, 2017, Proposed by #12198, Effective 6/2/2017, Expires 6/2/2027.