W. Va. Code R. § 69-9-11

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 69-9-11 - PLAN OF CARE

11.1. Preventive health examinations shall occur at two to four week intervals up to 24 weeks.

11.2. Thorough medical supervision and testing shall be done by an appropriately licensed health care professional with a specialization in neonatal abstinence syndrome.

11.3. Standing medical orders for conditions other than neonatal abstinence syndrome shall be carefully evaluated and shall take into consideration cautions necessary for neonatal abstinence syndrome.

11.4. The center shall have policies and procedures to assess and treat patients who show signs of illness, which include but are not limited to diarrhea, vomiting, and fever.

11.5. Each patient shall have an initial comprehensive assessment within 24 hours of admission that will result in the development of the initial plan of care. The initial plan of care will include a comprehensive summary of findings. The initial plan of care and implementation of services must begin at the earliest opportunity immediately after the initial assessment.

11.6. Comprehensive Assessment. The assessment will result in the development of the summary of findings and the plan of care.

11.6.a. The comprehensive assessment shall include:

11.6.a.1. Physical and medical assessment;

11.6.a.2. Demographic information and custody status;

11.6.a.3. Presenting problems and reason for referral;

11.6.a.4. Medical history;

11.6.a.5. Social history;

11.6.a.6. Developmental history;

11.6.a.7. Exposure history;

11.6.a.8. Summary of family strengths and weaknesses;

11.6.a.9. Treatment and medication orders;

11.6.a.10. Nutritional and dietary needs;

11.6.a.11. Summary of presenting problems and focus for treatment;

11.6.a.12. Behavioral status and needs; and

11.6.a.13. Any other special needs or accommodations.

11.6.b. When appropriate to the needs of the patient, the assessment should include:

11.6.b.1. Review of adaptive behavior;

11.6.b.2. Review of need for special accommodations or adaptive technology; and

11.6.b.3. Special or unique behavioral issues.

11.6.c. Each assessment will consider any unique aspects of the patient's racial, ethnic and cultural backgrounds and the need for any special service approaches resulting from the assessment.

11.6.d. The results of the initial assessment will be included in a written summary included in the patient's chart. This summary must include:

11.6.d.1. Recommendations for health screenings or treatment;

11.6.d.2. A diagnosis;

11.6.d.3. Recommendations for further assessment;

11.6.d.4. Recommendations for clinical behavioral health treatment;

11.6.d.5. Recommendations for interventions to be made in the home environment;

11.6.d.6. Recommendations for placement and aftercare upon discharge; and

11.6.d.7. Recommendations for family visitation unless contraindicated clinically or legally.

11.6.e. Medical and Physical Assessments.

11.6.e.1. Medical and physical assessments must occur upon admission and ongoing assessment must occur at various times throughout the day, week and month.

11.6.e.2. Medical and physical assessments must include, at a minimum, the following:

11.6.e.2.A. A head-to-toe physical assessment must be completed upon admission;

11.6.e.2.B. Vital signs and temperature must be completed upon admission and daily once per shift;

11.6.e.2.C. Scoring of neonatal abstinence syndrome symptoms, while the infant is on medication and during the observation period, is to be completed upon admission and every three to four hours thereafter;

11.6.e.2.D. Skin integrity for mottling or breakdown;

11.6.e.2.E. Respiratory status;

11.6.e.2.F. Breathing sounds;

11.6.e.2.G. Cardiovascular system;

11.6.e.2.H. Brief neurological exam; and

11.6.e.2.I. Weight and length of infant, and circumference of head.

11.6.e.3. Twice Daily Assessment.

11.6.e.3.A. Each patient will undergo a comprehensive head-to-toe assessment by a registered professional nurse every 12 hours. A patient care assistant may assist the nurse and observe the assessment.

11.6.e.3.B. Coordination of at least one of the twice daily assessments should take place during visitation hours, when possible, to provide an opportunity for parental participation.

11.7. Comprehensive Summary of Findings. The comprehensive summary of findings shall be developed as a result of the comprehensive assessment, and shall include:

11.7.a. A diagnosis;

11.7.b. A prognosis;

11.7.c. Recommendations for health screenings, pharmacological interventions, and non-pharmacological interventions;

11.7.d. Recommendations for continued assessment;

11.7.e. Recommendations for behavioral health treatment;

11.7.f. Recommendations for interventions needed in the home environment;

11.7.g. Recommendations for placement and aftercare upon discharge;

11.7.h. Recommendations for family visitation unless contraindicated clinically or legally; and

11.7.i. Recommendations for rights restrictions.

11.8. Plan of Care.

11.8.a. The Plan of Care will be developed based on the Comprehensive Summary of Findings.

11.8.b. The Plan of Care shall include the type, frequency, responsible party and justification or rationale for the following:

11.8.b.1. Treatment to be provided for health screenings, pharmacological interventions, and non-pharmacological interventions;

11.8.b.2. Nutritional interventions;

11.8.b.3. Continued assessment needs and schedule;

11.8.b.4. Behavioral health treatment and interventions;

11.8.b.5. Interventions for in the home environment;

11.8.b.6. Interventions for any other underlying medical problems;

11.8.b.7. Description of all services to be provided;

11.8.b.8. Family visitation schedule unless contraindicated clinically or legally; and

11.8.b.9. Consent and approval of the parent or legal representative, as appropriate.

11.8.c. The Plan of Care shall be developed by a team consisting of, at a minimum, the Medical Director, Director of Nursing, the patient's nurse, and the parents or legal representative of the patient.

11.8.d. A weekly review and update to the Plan of Care shall be conducted for the initial 30 days. All data from the weekly reviews shall be compiled to develop the Comprehensive Care Plan.

11.8.e. Development of the Plan of Care. The Plan of Care shall include, at a minimum, the following:

11.8.e.1. Plan to strengthen the relationship between patient and family, if clinically and legally appropriate;

11.8.e.2. Identify the goals of each service to be provided;

11.8.e.3. Identify the services to be provided to achieve all identified goals;

11.8.e.4. Identify pharmacological and non-pharmacological treatments and interventions prescribed by the physician;

11.8.e.5. Identify therapeutic and other behavioral health interventions to be provided;

11.8.e.6. Identify dietary and other health services to be provided;

11.8.e.7. Identify services provided by outside providers or entities;

11.8.e.8. Discharge and permanency plan;

11.8.e.9. Identify the person(s) responsible for all services and interventions provided; and

11.8.e.10. Identify the frequency for all services and interventions provided.

11.8.f. Review of the Plan of Care. The Plan of Care will be reviewed and updated on a weekly basis and at all critical junctures. The review shall be conducted by Medical Director, Director of Nursing, patient's family and/or legal representative. The review shall include, at a minimum, the following:

11.8.f.1. Review of each goal and its current status;

11.8.f.2. Identification of problems preventing progress and strategies to address these problems;

11.8.f.3. Modifications to the made to the plan;

11.8.f.4. Summary of interventions provided to date; and

11.8.f.5. Review of discharge plan.

W. Va. Code R. § 69-9-11