N.J. Admin. Code § 5:27A-9.2

Current through Register Vol. 56, No. 23, December 2, 2024

Section 5:27A-9.2 - Provision of health services

(a) The facility shall arrange for health services to be provided to residents as needed.

(b) At the time of admission, arrangements shall be made between the administrator and the resident, guardian, or designated community agency regarding the physician, advanced practice nurse, or physician assistant, and dentist to be called in case of illness, or the person to be called for a resident who because of religious affiliation is opposed to medical treatment.

(c) The registered professional nurse shall notify the resident's physician, advanced practice nurse, or physician assistant of any significant change in the resident's physical or psychological condition.

(d) Each resident shall receive an initial nursing assessment from the registered professional nurse. Thereafter, each resident shall be reassessed annually or whenever there is a significant change in the resident's condition. The nursing assessment shall include, at a minimum, evaluation of the following:

1. Cognitive patterns;

2. Communication/hearing patterns;

3. Vision patterns;

4. Physical functioning and structural problems;

5. Continence;

6. Psychosocial well-being;

7. Mood and behavior patterns;

8. Activity pursuit patterns;

9. Disease diagnoses;

10. Health conditions;

11. Oral/nutritional status;

12. Oral/dental status;

13. Skin condition;

14. Medication use; and

15. Special treatment and procedures.

(e) The nursing assessment required by (d) above shall be documented on the Minimum Data Set for resident assessment and care screening (MDS 2.0, 3.0, or the latest version required by the Center for Medicare and Medicaid Services), or an equivalent assessment instrument, which has been developed by the facility and approved by the Department of Health prior to its use. Copies of the MDS may be obtained by contacting the Department of Health.

(f) Nurses' monitoring notes shall be written on an ongoing basis and shall reflect the current health status of the resident. Events and/or situations to be addressed in the nurse's monitoring notes shall be as follows, where appropriate:

1. Admission/discharge from the hospital;

2. Injuries/illness in the facility that did not require hospitalization;

3. Inappropriate/unusual behaviors with notification of physician, advanced practice nurse, or physician assistant;

4. Response to new medications;

5. Follow-up to physicians', advanced practice nurses', or physician assistants' referrals;

6. Follow-up to visits from the visiting nurse;

7. Follow-up on abnormal labs or other diagnostic studies;

8. Compliance/noncompliance with diet order;

9. Pattern of weight loss/gain over a continuous period;

10. Change in status of incontinency problem;

11. Change in status of ostomy care;

12. Status of wound care;

13. Attendance at or need for referral to a partial care program;

14. Change in personal hygiene;

15. Progression of level of confusion;

16. Change in interactions with other residents;

17. Leaving the facility for extended periods without the knowledge of staff;

18. Status of an identified medical problem (skin rash, hypertension, UTI, URI, elevated blood sugar);

19. Change in family involvement and concerns;

20. Status of the condition of a resident awaiting transfer to a higher level of care; and

21. Nursing interventions and resident response to interventions.

(g) The registered professional nurse or a physician, advanced practice nurse, or physician assistant shall be called at the onset of illness of any resident to arrange for an evaluation of the resident's nursing care needs or medical needs and for needed nursing care intervention or medical care.

(h) A resident with a temporary illness may be cared for in a residential health care facility for a period not to exceed 14 days. If a resident needs bed care for a more extended period, arrangements shall be made for his or her prompt transfer to an appropriate health care facility.

(i) Each resident shall have an annual physical examination by a physician, advanced practice nurse, or physician assistant, which shall be documented in the resident's record. The physician, advanced practice nurse, or physician assistant shall certify annually that the resident does not have needs which exceed the care provided by the residential health care facility.

(j) Residents shall be permitted free choice of a physician, advanced practice nurse, or physician assistant.

(k) The administrator shall arrange for a physician, advanced practice nurse, or physician assistant to be available for emergencies, including injuries or accidents to residents, or when required by a resident's condition.

(l) If the physician, advanced practice nurse, or physician assistant determines the need for a transfer to another health care facility because the residential health care facility cannot meet the resident's needs, such transfers shall be initiated promptly. The registered professional nurse shall be notified to ensure that the resident is receiving appropriate care during the transfer period.

(m) Upon completion of the annual physical required in (i) above, or more often, as determined by the physician, advanced practice nurse, or physician assistant, a licensed physician, advanced practice nurse or physician assistant shall certify that the resident does not have medical or personal care needs which exceed the level of services provided in a residential health care facility, is free from communicable diseases (that is, does not have a reportable, communicable disease which is not controlled through prophylaxis or medication), and does not require skilled nursing care.

N.J. Admin. Code § 5:27A-9.2

Amended by 49 N.J.R. 3821(a), effective 12/18/2017