(1) In accordance with federal regulations at 42 CFR § 483.20, the medicaid certified nursing facilities shall provide resident care based on a systematic, comprehensive, interdisciplinary assessment, and care planning process in which the resident actively participates.
(2) The medicaid certified nursing facility shall:
(a) Conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity;
(b) At the time each resident is admitted, have physician orders for the resident's immediate care; and
(c) Ensure that the comprehensive assessment of a resident's needs describes the resident's capability to perform daily life functions and significant impairments in the functional capacity.
(3) The comprehensive assessment shall include at least the following information:
(a) Medically defined conditions and prior medical history;
(b) Medical status measurement;
(c) Physical and mental functional status;
(d) Sensory and physical impairments;
(e) Nutritional status and requirements;
(f) Special treatments or procedures;
(g) Mental and psychosocial status;
(h) Discharge potential;
(i) Dental condition;
(j) Activities potential;
(k) Rehabilitation potential;
(l) Cognitive status; and
(m) Drug therapy.
(4) The medicaid certified nursing facility shall conduct comprehensive assessments:
(a) No later than fourteen days after the date of admission;
(b) Promptly after any significant change in the resident's physical or mental condition; and
(c) In no case less often than once every twelve months.
(5) The medicaid certified nursing facility shall ensure:
(a) Each resident is examined no less than once every three months, and as appropriate, the resident's assessment is revised to assure the continued accuracy of the assessment; and
(b) The results of the assessment are used to develop, review and revise the resident's comprehensive plan or care under subsection (6) of this section.
(6) Comprehensive care planning. The medicaid certified nursing facility in compliance with federal regulations at 42 CFR § 483.20 shall develop a comprehensive care plan for each resident that includes measurable objective and timetables to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan shall:
(a) Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;
(b) Describe any services that would otherwise be required, but are not provided due to the resident's exercise of rights, including the right to refuse treatment;
(c) Be developed within seven days after completion of the comprehensive assessment;
(d) Be prepared by an interdisciplinary team that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs; and
(e) Include the participation of the resident, the resident's family or the resident's legal representative.
(7) The medicaid certified nursing facility shall follow the informed consent process as specified in WAC
388-97-060 regarding the interdisciplinary team's care plan recommendations. The resident care plan shall contain the resident's statement of consent to or refusal of care and service goals. Consent or refusal may be provided by the resident's legal representative when allowed by state law.
[Statutory Authority: RCW 43.60A.070 and chapter 72.36 RCW. 94-22-050, § 484-20-061, filed 10/31/94, effective 12/1/94.]