N.J. Admin. Code § 10:37A-4.4 - Nursing assessments, reassessments, and 90-day visits in supervised residences

(a) Initial comprehensive nursing assessment. Within the 14th day of a consumer's admission to a supervised residence, a registered nurse, or higher level nursing professional, shall provide, in a face-to-face setting, an initial comprehensive nursing assessment.

(b) Comprehensive nursing reassessments shall be performed annually, at a minimum. These reassessments may be performed on a more frequent basis than annually, where clinically necessary, shall cover the same information as the annual reassessment, and shall include a justification for the level of care received by the consumer.

(c) The initial nursing assessment and annual reassessments shall include:

1. An evaluation of the current status of diagnosed medical conditions, as well as identification of risk factors for medical conditions;

2. Allergies;

3. Adverse medication reactions;

4. An indication of whether the consumer possesses the ability to take medications as prescribed;

5. An indication of whether the consumer possesses an understanding of the risks and benefits of the medications prescribed;

6. An indication of whether the consumer possesses the ability to manage healthcare problems and healthcare appointments;

7. An indication of whether the consumer possesses the ability to manage mental illness and crises;

8. A physical wellness assessment (exercise, tobacco use, alcohol intake, sleep habits, coping mechanisms to deal with stress, dates of physicals/dental exams, height, weight, and vital signs);

9. Whether there are any barriers to wellness and recovery;

10. The consumer's dietary needs and current status;

11. An indication of whether the consumer possesses the ability to complete daily living tasks to meet safety, nutritional, food preparation, hygiene, household cleanliness, and clothing needs; and

12. Documentation of the justification for the continuation of services and a recommendation for the appropriate level of care (Level A+, A, or B housing, and family care homes).

(d) In addition to (c) above, the initial comprehensive nursing assessment shall:

1. Determine the appropriate level of service required;

2. Justify the need for continued mental health services; and

3. Be used in conjunction with the comprehensive rehabilitation needs assessment required by N.J.A.C. 10:37A-5.2.

(e) A registered nurse or higher level nursing professional shall provide face-to-face nursing visits every 90 days following the initial comprehensive nursing assessment while the consumer resides in a supervised residence and shall document such visits in the consumer's progress notes. In addition, where necessitated by the consumer's needs, a registered nurse or higher level nursing professional shall visit the consumer to periodically evaluate the consumer's condition and the appropriateness of care provided by staff. These 90-day visits shall include an assessment and review of the consumer's clinical condition, which shall assure that services are being provided consistent with the consumer's individualized rehabilitation plan. During each 90-day visit, the nursing professional shall:

1. Review the individualized rehabilitation plan;

2. Review the observations and progress notes made by the direct care staff;

3. Assess the consumer's health; and

4. Indicate any changes needed in treatment approaches in the individualized rehabilitation plan.

Notes

N.J. Admin. Code § 10:37A-4.4

Adopted by 48 N.J.R. 1636(a), effective 8/15/2016