Ohio Admin. Code 3701-17-14 - Plan of care; treatment and care: discharge planning, bathing
(A) The nursing
home shall assure that development of a plan of care is initiated upon
admission and completed and implemented for each resident within seven days of
completion of the initial comprehensive assessment, required by rule
3701-17-10 of the Administrative
Code. The plan shall be resident-focused and goal
driven, and prepared by an interdisciplinary team that includes the
attending physician or other licensed health professional acting within the
applicable scope of practice, or both, a registered nurse with responsibility
for the resident and other appropriate staff in disciplines as determined by
the needs of the resident including, but not limited to dietary, recreation,
and social work staff, and, to the extent
practicable, the resident and the family or sponsor of the resident unless the
resident does not wish them to be involved. The home shall offer opportunities for the resident, the
resident's sponsor, and those of the resident's choice to participate in the
care planning process and will provide necessary information, support, and
options for engaging in the process to ensure that the resident/sponsor directs
the process to the maximum extent possible and is enabled to make informed
choices and decisions.
(1) The plan of
care shall be consistent with the comprehensive assessment with recognition of
the capabilities,
and preferences and
goals of the resident, and shall contain a written description of what
services, supplies and equipment, are needed, when, how often, and by whom
services, supplies and equipment will be provided and the measurable goals or
outcomes.
(2) The plan of care
shall be reviewed whenever there is a change in the resident's condition, needs, or preferences
and
the needs of the resident
that warrants
warrant a
change in the services, supplies or equipment to be provided, and at least
quarterly, by the nursing home and the resident, or sponsor, or both, and shall
be updated, as appropriate.
(3)
Each resident shall have access to his or her assessment and plan of care at
any time upon request.
(B) All skilled nursing care shall be
provided by a nurse except a nurse may delegate certain tasks as authorized by
Chapter 4723. of the Revised Code in accordance with the applicable rules
adopted under that chapter.
(C) The
nursing home shall provide all residents who cannot give themselves adequate
personal care with such care as is necessary to keep them clean and
comfortable.
(D) Each nursing home
shall provide adequate supervision of residents who are assessed for risk of
falls, or elopement, or both.
(E)
All services, supplies and equipment provided or arranged for by the nursing
home shall be provided, in accordance with acceptable standards of practice and
the written plans of care, by individuals who meet the applicable
qualifications of this chapter.
(F)
The nursing home shall assure that all residents receive adequate, kind, and
considerate care and treatment at all times.
(G) The nursing home shall transfer and
discharge a resident in an orderly, dignified, and safe manner in accordance
with Chapter 3701-61 of the Administrative Code. In anticipation of a
discharge, the nursing home shall:
(1) Prepare
the following information to be shared with appropriate persons and agencies
upon consent of the resident, except the resident's right to refuse release of
such information does not apply in the case of transfer to another home,
hospital, or health care system, if the release is required by law or rule or
by a third-party payment contract;
(a) An
updated assessment that addresses the criteria outlined in paragraph (E) of
rule 3701-17-10 of the Administrative
Code and accurately identifies the resident's condition and continuing care
need at the time of transfer and discharge;
(b) A plan that is developed with the
resident and family members
those persons of the resident's choice, with the consent of the resident, that
indicates where the individual plans to reside, and any
arrangements that have been made for the resident's follow up care and any
post-discharge medical and non-medical services.describes what services, supplies and equipment are needed,
how needed services, supplies and equipment can be accessed, and how to
coordinate care if multiple care givers are involved. The plan shall
also identify need for the resident and care givers' education, including
resident and care giver instruction on the proper use of grab rails and other
safety devices, and any accommodations to the physical environment to meet the
needs of the resident;
(2) Provide for drugs to be sent with or
arranged for the resident pursuant to paragraph(F)(2) of rule
3701-17-17 of the Administrative
Code.
(3) With the consent of the
resident, arrange and confirm the services, equipment and supplies in advance
of discharge or transfer of the resident.
(H) If the nursing home resident is also a
patient of a hospice care program, the nursing home shall communicate and work
with the hospice in development and implementation of a coordinated plan of
care between the nursing home and hospice.
The nursing home shall allow the hospice care program to retain professional management responsibility for directing the implementation of the resident's plan of care related to the resident's terminal illness pursuant and related conditions to Chapter 3701-19 of the Administrative Code as long as the resident is receiving hospice care. The coordinated plan of care shall:
(1) Reflect the hospice philosophy;
(2) Be based on the assessment of the
resident and the unique living situation in the nursing home; and
(3) Identify the services, supplies, and
equipment to be provided by the nursing home and those to be provided by the
hospice care program.
(I) The nursing shall ensure that the privacy
and dignity of residents is protected when residents are transported to and
from bathing facilities, when residents are preparing for bathing, and during
resident bathing.
(J)
Upon a resident's transfer, discharge, or death, the
nursing home shall make an accounting of all that resident's monies held by the
facility. The nursing home shall convey any remaining funds immediately to the
resident or within thirty days to the resident's estate unless otherwise
directed by law.
Notes
Promulgated Under: 119.03
Statutory Authority: 3721.04
Rule Amplifies: 3721.04
Prior Effective Dates: 5/2/1966, 3/8/93, 10/20/01, 4/1/12
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