N.J. Admin. Code § 8:39-11.2

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:39-11.2 - Mandatory policies and procedures for resident assessment and care plans

(a) A physician or advanced practice nurse shall provide orders for each resident's care beginning on the day of admission.

(b) Each physician or advanced practice nurse order shall be executed by the nursing, dietary, social work, activities, rehabilitation or pharmacy service, as appropriate in accordance with professional standards of practice.

(c) Each resident shall be examined by a physician or advanced practice nurse within five days before, or 48 hours after, admission.

(d) An initial assessment and care plan shall be developed on the day of admission and shall address all immediate needs, including, but not limited to, personal hygiene, dietary needs, medications, and ambulation.

(e) A comprehensive assessment shall be completed for each resident within 14 days of admission, utilizing the Standardized Resident Assessment Instrument (Minimum Data Set 3.0, or version current as of time of assessment, incorporated herein by reference).

1. The complete assessment and care plan shall be based on oral or written communication and assessments provided by nursing, dietary, resident activities, and social work staff; and when ordered by the physician or advanced practice nurse, assessments shall also be provided by other health professionals.

2. The care plan shall include measurable objectives with interventions based on the resident's care needs and means of achieving each goal.

3. Each facility shall have the equipment and software necessary to enter, store, and transmit each resident's Standardized Resident Assessment Instrument (MDS 3.0 or most current version) electronically to the Department and shall transmit such data to the Department. The facility shall use software which meets technical specifications for the MDS 3.0 (or the version current at the time of assessment) as required by the United States Centers for Medicare and Medicaid Services at 42 CFR § 483.20(b), as amended and supplemented.

i. Additional information is available from the Centers for Medicare and Medicaid Services, http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html.

(f) The complete care plan shall be established and implementation shall begin within 21 days, and shall include, if appropriate, rehabilitative/restorative measures, preventive intervention, and training and teaching of self-care.

(g) If a resident is discharged to a hospital and returns to the facility within 30 days of discharge, reassessment shall be conducted in those areas where the resident's needs have changed substantially. A complete reassessment shall be performed if the resident was discharged for more than 30 days.

(h) There shall be a scheduled comprehensive reassessment in each service involved in the initial assessment, plus other areas which the physician, advanced practice nurse, or interdisciplinary team indicates are necessary. Reassessments shall be performed according to time frames established in the previous care plan.

(i) A reassessment shall be performed in response to all substantial changes in the resident's condition, such as fractures, onset of debilitating chronic diseases, loss of a loved one, or recovery from depression.

(j) The facility shall have a written transfer agreement with one or more hospitals for emergency care and inpatient and outpatient services.

N.J. Admin. Code § 8:39-11.2

Administrative correction.
See: 33 N.J.R. 4101(b).
Notice of readoption with technical change, effective 12/20/2021.
See: 53 N.J.R. 2199(a).