CLINICAL & DIAGNOSTICS INFORMATION
Policy 2: Holy Trinity Center director of nursing shall ensure that plan of care is developed for each individual served; specific to the medical necessity and severity of needs of the individual served that is supervised or completed by the registered nurse.
Procedures 2: Holy Trinity Center’s registered nurse as stipulated in the policy 2 above shall also ensure that all the needed tasks, duties, responsibilities, and training is provided as:
a) An individual’s plan of care shall be based on assessments of the client’s health, function, and psychosocial condition performed by a registered nurse.
b) An assessment of an individual served shall be completed when the individual is requesting or requiring services regulated by this chapter;
c) An assessment of an individual served shall be completed before the individual receives services from the agency unless.
i. The client does not request skilled care or skilled services; and
ii. There is no reason to believe that the individual requires skilled care or skilled services, such as discharge instructions requiring skilled care;
d) An assessment of an individual served shall be completed within 48 hours of when the individual begins services; when the individual requires, including but not limited to:
(i) Wound and catheter care;
(ii) Treatment of stage three or stage four skin ulcers;
(iii) Ventilator services;
(iv) Skilled monitoring, testing, and aggressive adjustment of medications and treatments where there is the presence of, or risk for, a fluctuating acute condition;
(v) Monitoring of a chronic medical condition that is not readily controllable through available medications and treatments;
(vi) Infusion therapy;
(vii) Specialized intravenous therapies or nutrition support;
(viii) Monitoring for being at high risk for health or safety complications which cannot be adequately managed; or
(ix) A different level of care after notification of a significant change of condition;
e) An assessment of an individual served shall be completed at the request of the individual or the individual’s representative;