RESIDENT ASSESSMENTS

POLICY STATEMENT.

The Division of Veterans Healthcare Services (DVHS) requires that each of the New Jersey Veterans Memorial Homes (VMH) complete an initial assessment for each resident beginning on the day of admission, which shall address all immediate needs including but not limited to personal hygiene, dietary needs, medications and ambulation. A comprehensive assessment shall be completed for each resident within 14 days of admission, utilizing the standardized Resident Assessment Instrument - RAI (Minimum Data Set – MDS - 2.0, or version at the time of assessment) and based upon oral or written communication and assessments provided by nursing, dietary, activities, and social work staff. When ordered by the physician or the advanced practice nurse, assessments shall also be provided by other health professionals.

PURPOSE.

This policy and procedure shall ensure that VMH staff consistently and accurately gathers information regarding resident needs and strengths, which provides the foundation for an individualized plan of care for each resident, developed by the Interdisciplinary Team.

DEFINITIONS.

MINIMUM DATA SET (MDS) – The Minimum Data Set is one of several patient assessment tools, the use of which is required by the Federal Government as part of reimbursement and regulation. The MDS captures screening and assessment elements (which includes common definitions and coding categories) needed to comprehensively assess an individual nursing home resident’s functional capabilities, and helps VMH staff identify health problems. The MDS contains items that measure physical, psychological and psychosocial functioning.

COMMON DEFINITIONS – are standardized explanations of each category specified in the MDS.

CODING CATEGORIES – are the levels of measurement for each category included in the MDS.

TRIGGERS – are levels of measurement (coding categories) of the MDS that serve to identify residents who may require further evaluation using the Resident Assessment Protocols (RAPs).

RESIDENT ASSESSMENT PROTOCOLS (RAPs) – the RAPs are problem-oriented frameworks for additional assessment based on problem identification items (triggered conditions). They form a critical link to decisions about care planning. The RAP Guidelines provide guidance on how to synthesize assessment information within a comprehensive assessment.

RESIDENT ASSESSMENT INSTRUMENT (RAI) – the RAI helps VMH staff to gather definitive information on a resident’s strengths and needs, which must be addressed in an individualized care plan. It also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the VMH to track changes in the resident’s status. As the process of problem identification is integrated with sound clinical interventions, the care plan becomes each resident’s unique path toward achieving or maintaining his or her highest practicable level of well-being.

INTERDISCIPLIANRY TEAM (IDT) - a group of staff members, both professional and ancillary, representative of each service, coordinated by a Registered Nurse (RN), and responsible for the development of individual resident care and treatment plans, in accordance with the New Jersey Department of Health and Senior Services’ licensing standards. 

PROCEDURE

  1. New Jersey Veterans Memorial Homes
    1. The New Jersey Veterans Memorial Homes will develop and implement procedures governing the practice of completing timely resident assessments and coordination of individualized Interdisciplinary Team care plans.
      1. A registered professional nurse (RN) shall assess the nursing needs of each resident, coordinate the written interdisciplinary care plan, sign and date the assessment to certify that it is complete, and ensure the timeliness of all services.
      2. A physician or advanced practice nurse shall provide orders for each resident’s care beginning on the day of admission.
      3. Each physician’s or advanced practice nurse’s orders shall be executed by the nursing, dietary, social work, activities, rehabilitation and pharmacy services as appropriate, in accordance with professional standards of practice.
      4. Each resident shall be examined by a physician or advanced practice nurse within five (5) days before, or 48 hours after, admission.
      5. An initial assessment and care plan shall be developed on the day of admission and shall address all immediate needs, including but not limited to personal hygiene, dietary needs, medications and ambulation.
      6. A comprehensive assessment shall be completed for each resident within 14 days of admission, utilizing the standardized Resident Assessment Instrument–RAI (Minimum Data Set – MDS- 2.0 or version current at the time of the assessment).
      7. The complete assessment and care plan shall be based on oral or written communication and assessments provided by nursing, dietary, resident activities and social work staff; and when ordered by the physician or advanced practice nurse, assessments shall also be provided by other health professionals.
      8. The care plan shall include measurable objectives with interventions based on the resident’s care needs and means of achieving each goal.
      9. Each facility shall have the equipment and software necessary to enter, store, and transmit each resident’s standardized Resident Assessment Instrument-RAI (MDS 2.0 or most current version) electronically to the New Jersey Department of Health and Senior Services (DOHSS) and shall transmit such data to the DOHSS.  The facility shall use software which meets technical specifications for the MDS 2.0 (or the version current at the time of the assessment) as required by the U.S. Health Care Financing Administration at 42 CFR 483.20(b), and published in the Federal Register at 63 FR 2896.
      10. The complete care plan shall be established and implementation shall begin within 21 days, and shall include, if appropriate, rehabilitative and/or restorative measures, preventive intervention, and training and teaching of self-care.
      11. If a resident is discharged to a hospital and returns to the facility within 30 days of discharge, reassessment shall be conducted in those areas where the resident’s needs have changed substantially.  A complete reassessment shall be performed if the resident was discharged for more than 30 days.
      12. There shall be a scheduled comprehensive reassessment in each service involved in the initial assessment, plus other areas which the physician, advanced practice nurse, or Interdisciplinary Team indicates are necessary.  Reassessments shall be performed according to time frames established in the previous care plan.
      13. Each quarterly assessment is due for completion no later than 92 days after the previous assessment’s date of completion. The Centers for Medicare and Medicaid (CMS) require an MDS assessment every 92 days.
      14. Annual assessments must be completed no later than 366 days after the completion date of the previous comprehensive assessment.
      15. A reassessment shall be performed in response to all substantial changes in the resident’s condition, such as fractures, onset of debilitating chronic diseases, loss of a loved one, or recovery from depression.
      16. The VMH shall have a written transfer agreement with one or more hospitals for emergency care, and inpatient and outpatient services.

 

 

 

11-02-001

Revised:  June 2007

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