N.J. Admin. Code § 8:36-7.2

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:36-7.2 - Health care assessment and health service plan

(a) Within 30 days prior to admission to the assisted living residence, comprehensive personal care home, or assisted living program, a physician, advanced practice nurse or physician assistant shall specify in writing that the resident is appropriate for this level of care.

(b) At the time of admission, arrangements shall be made between the administrator and the resident, guardian, or responsible person regarding the physician and dentist to be called in case of illness, or the individual to be called for a resident who, because of religious affiliation, is opposed to medical treatment.

(c) If the initial assessment in 8:36-7.1(a) indicates that the resident requires health care services, a health care assessment shall be completed within 14 days of admission by a registered professional nurse using an assessment instrument available from the Department, or an assessment instrument that has been adopted by the facility or program, equivalent to the instrument available from the Department, and which meets the requirements of (d) below.

(d) Each health care assessment by the registered professional nurse shall include, at a minimum, evaluation of the following:

1. Need for assistance with "activities of daily living";

2. Cognitive patterns;

3. Communication/hearing patterns;

4. Vision patterns;

5. Physical functioning and structural problems;

6. Continence;

7. Psychosocial well-being;

8. Mood and behavior problems;

9. Activity pursuit patterns;

10. Disease diagnoses;

11. Health conditions and preventive health measures, including, but not limited to, pain, falls, and lifestyle;

12. Oral/nutritional status;

13. Oral/dental status;

14. Skin conditions;

15. Medication use;

16. Special treatment and procedures;

17. Restraint use; and

18. Outside service utilization.

(e) Based on the health care assessment, a written health service plan shall be developed. The health service plan shall include, but not be limited to, the following:

1. Orders for treatment or services, medications, and diet, if needed;

2. The resident's needs and preferences for himself or herself;

3. The specific goals of treatment or services, if appropriate;

4. The time intervals at which the resident's response to treatment will be reviewed; and

5. The measures to be used to assess the effects of treatment.

(f) The initial health care assessment shall be documented by the registered nurse and shall be updated as required, in accordance with the rules of this chapter and professional standards of practice.

(g) The facility shall make reasonable effort to have documentation of services provided by outside health care professionals entered in the resident record.

N.J. Admin. Code § 8:36-7.2