W. Va. Code R. § 64-85-6 - Assessments and Plans of Care
6.1. Within three (3) days of admission, the unit coordinator, with input from at least the resident and/or the resident's legal representative, shall review the immediate care needs of the resident and establish a preliminary care plan.
6.2. Within seven (7) days of admission, an interdisciplinary team including the unit coordinator, a social worker, the activities director, direct care staff and a registered nurse and other professional disciplines as appropriate, shall complete an initial assessment of a new resident which includes at a minimum: a social history; family supports; level of activities of daily living functioning; cognitive level; behavioral impairment; and nutritional status, including weight and nutritional requirements.
6.3. Within twenty-one (21) days of admission the interdisciplinary team and the resident and/or the resident's legal representative, shall develop a written individualized care plan, signed by each member of the alzheimer's/dementia special care unit or program staff, the resident and/or the resident's legal representative which shall:
6.3.a. Reflect the resident as a person, with family history and interests;
6.3.b. Accurately describe specific needs, choices, problems and any inappropriate behaviors;
6.3.c. Describe specific desired outcomes and specific interventions to be used to achieve the desired outcomes;
6.3.d. Support the individual toward as much independence as possible;
6.3.e. Include opportunities for resident choice and self management; and
6.3.f. Contain the job titles of staff who are to be primarily responsible for implementing the care plan.
6.4. The facility shall make a copy of the care plan available to all staff to ensure consistent implementation.
6.5. The facility shall provide resident care in accordance with the care plan.
6.6. The interdisciplinary team shall review, evaluate for effectiveness and revise the resident's assessment and care plan at least quarterly or more frequently as indicated by the changing needs of the resident.
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