Or. Admin. Code § 411-086-0060 - Comprehensive Assessment and Care Plan
(1) Comprehensive Assessment:
(a) An RN shall ensure completion and
documentation of a comprehensive assessment of the resident's capabilities and
needs for nursing services within 14 days of admission. Comprehensive
assessments shall be updated promptly after any significant change of condition
and reviewed no less often than quarterly. This assessment shall be on a form
specified by the Division. The assessment shall include the following:
(A) Medically defined conditions and medical
history;
(B) Medical status
measurement;
(C) Functional
status;
(D) Sensory and physical
impairments;
(E) Nutritional status
and requirements;
(F) Treatments
and procedures;
(G) Psychosocial
status (see OAR 411-086-0240);
(H) Discharge potential (see OAR
411-086-0160);
(I) Dental condition;
(J) Activities potential (see OAR
411-086-0230);
(L) Cognitive status; and
(M) Drug therapy.
(b) Social services, activities and dietary
personnel shall complete an assessment within 14 days of admission.
(2) Care Plan Preparation and
Implementation. The facility, through the nursing services department and the
interdisciplinary staff, shall provide services to attain or maintain the
highest practicable physical, mental and psychosocial well-being of each
resident in accordance with a written, dated, care plan:
(a) The plan shall be completed within seven
days after completion of the comprehensive assessment. The care plan shall be
reviewed and updated whenever the resident's needs change, but no less often
than quarterly;
(b) The care plan
shall describe the medical, nursing, and psychosocial needs of the resident and
how the facility will actively meet those needs. This description of needs
shall include measurable objectives and time frames in which the objectives
will be met;
(c) The plan shall
provide for and promote personal choice and independence of the
resident;
(d) The resident care
plan must address the following, if indicated by the resident,
(A) Name.
(B) Pronouns.
(C) Gender identity.
(e) The plan shall be reviewed and completed
at an interdisciplinary care planning conference with participation from the
resident's RN care manager and personnel from dietary, activities and social
services. The resident's attending physician will participate in the
development and any revision of the care plan. Physician participation may be
in person, through communication with the DNS or RN Care Manager, or via
telephone conference;
(f) The
resident, the resident's legal representative, and anyone designated by the
resident shall be requested to participate. The request shall be documented in
the resident's clinical record;
(g)
The plan shall be prepared and implemented with participation of the resident
and in accordance with the resident's wishes;
(h) Unless required or allowed by state or
federal law, a facility shall not disclose any personally identifiable
information regarding:
(A) A resident's sexual
orientation;
(B) Whether a resident
is LGBTQIA2S+;
(C) A resident's
gender transition status; or
(D) A
resident's human immunodeficiency virus status.
(i) The facility shall take appropriate steps
to minimize the likelihood of inadvertent or accidental disclosure of
information described in subsection (h) of this section to other residents,
visitors or facility staff, except to the minimum extent necessary for facility
staff to perform their duties.
(j)
Facilities must notify the resident or resident's representative if the
facility inadvertently or accidentally discloses such information to
unauthorized persons.
(k) The plan
shall include an assessment of the resident's potential for discharge and the
facility's efforts to work toward discharge;
(l) The plan shall be available to and
followed by all staff involved with care of the resident.
(3) Documentation:
(a) The care plan shall be written in ink and
made a part of the resident's clinical record;
(b) Participation in development of the care
plan by interdisciplinary staff will be clearly documented.
Notes
Statutory/Other Authority: ORS 410.070, 410.090, 441.055 & 441.122
Statutes/Other Implemented: ORS 441.055, 441.111, 441.114 & 441.615
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