59A-4.109. Resident Assessment and Care Plan

(1) Each resident admitted to the nursing home facility shall have a plan of care. The plan of care must consist of:

(a) Physician’s orders, diagnosis, medical history, physical exam and rehabilitative or restorative potential.

(b) A preliminary nursing evaluation with physician’s orders for immediate care, completed upon admission.

(c) A complete, comprehensive, accurate and reproducible assessment of each resident’s functional capacity which is standardized in the facility, and is completed within 14 days of the resident’s admission to the facility and every twelve months, thereafter. The assessment must be:

1. Reviewed no less than once every 3 months;

2. Reviewed promptly after a significant change, which is a need to stop a form of treatment because of adverse consequences (e.g., an adverse drug reaction), or commence a new form of treatment to deal with a problem, in the resident’s physical or mental condition; and,

3. Revised as appropriate to assure the continued accuracy of the assessment.

(2) The nursing home licensee develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental and social well-being. The care plan must be completed within 7 days after completion of the resident assessment.

(3) At the resident’s option, every effort must be made to include the resident and family or responsible party, including private duty nurse or nursing assistant, in the development, implementation, maintenance and evaluation of the resident’s plan of care.

(4) All staff personnel who provide care, and at the resident’s option, private duty nurses or personnel who are not employees of the facility, must be knowledgeable of, and have access to, the resident’s plan of care.

(5) A summary of the resident’s plan of care and a copy of any advanced directives must accompany each resident discharged or transferred to another health care facility, licensed under Chapter 395 or 400, F.S., or must be forwarded to the receiving facility as soon as possible consistent with good medical practice.

Rulemaking Authority 400.23 FS. Law Implemented 400.141, 400.23 FS. History–New 4-1-82, Amended 4-1-84, Formerly 10D-29.109, Amended 4-18-94, 1-10-95, 12-21-15.