Rule 3701-17-14 | Plan of care; treatment and care: discharge planning, bathing.
(A) The nursing home shall assure that development of a plan of care is initiated upon admission and completed and implemented for each resident within seven days of completion of the initial comprehensive assessment, required by rule 3701-17-10 of the Administrative Code. The plan shall be resident-focused and goal driven, and prepared by an interdisciplinary team that includes the attending physician or other licensed health professional acting within the applicable scope of practice, or both, a registered nurse with responsibility for the resident and other appropriate staff in disciplines as determined by the needs of the resident including, but not limited to dietary, recreation, and social work staff. The home shall offer opportunities for the resident, the residents sponsor, and those of the resident's choice to participate in the care planning process and will provide necessary information, support, and options for engaging in the process to ensure that the resident/sponsor directs the process to the maximum extent possible and is enabled to make informed choices and decisions.
(1) The plan of care shall be consistent with the comprehensive assessment with recognition of the capabilities, preferences and goals of the resident, and shall contain a written description of what services, supplies and equipment, are needed, when, how often, and by whom services, supplies and equipment will be provided and the measurable goals or outcomes.
(2) The plan of care shall be reviewed whenever there is a change in the resident's condition, needs, or preferences that warrant a change in the services, supplies or equipment to be provided, and at least quarterly, by the nursing home and the resident, or sponsor, or both, and shall be updated, as appropriate.
(3) Each resident shall have access to his or her assessment and plan of care at any time upon request.
(B) All skilled nursing care shall be provided by a nurse except a nurse may delegate certain tasks as authorized by Chapter 4723. of the Revised Code in accordance with the applicable rules adopted under that chapter.
(C) The nursing home shall provide all residents who cannot give themselves adequate personal care with such care as is necessary to keep them clean and comfortable.
(D) Each nursing home shall provide adequate supervision of residents who are assessed for risk of falls, or elopement, or both.
(E) All services, supplies and equipment provided or arranged for by the nursing home shall be provided, in accordance with acceptable standards of practice and the written plans of care, by individuals who meet the applicable qualifications of this chapter.
(F) The nursing home shall assure that all residents receive adequate, kind, and considerate care and treatment at all times.
(G) The nursing home shall transfer and discharge a resident in an orderly, dignified, and safe manner in accordance with Chapter 3701-61 of the Administrative Code. In anticipation of a discharge, the nursing home shall:
(1) Prepare the following information to be shared with appropriate persons and agencies upon consent of the resident, except the resident's right to refuse release of such information does not apply in the case of transfer to another home, hospital, or health care system, if the release is required by law or rule or by a third-party payment contract;
(a) An updated assessment that addresses the criteria outlined in paragraph (E) of rule 3701-17-10 of the Administrative Code and accurately identifies the resident's condition and continuing care need at the time of transfer and discharge;
(b) A plan that is developed with the resident and those persons of the resident's choice, that indicates where the individual plans to reside, and any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services. The plan shall also identify need for the resident and care givers' education, including resident and care giver instruction on the proper use of grab rails and other safety devices, and any accommodations to the physical environment to meet the needs of the resident;
(2) Provide for drugs to be sent with or arranged for the resident pursuant to paragraph (F)(2) of rule 3701-17-17 of the Administrative Code.
(3) With the consent of the resident, arrange and confirm the services, equipment and supplies in advance of discharge or transfer of the resident.
(H) If the nursing home resident is also a patient of a hospice care program, the nursing home shall communicate and work with the hospice in development and implementation of a coordinated plan of care between the nursing home and hospice. The nursing home shall allow the hospice care program to retain professional management responsibility for directing the implementation of the resident's plan of care related to the resident's terminal illness pursuant and related conditions to Chapter 3701-19 of the Administrative Code as long as the resident is receiving hospice care. The coordinated plan of care shall:
(1) Reflect the hospice philosophy;
(2) Be based on the assessment of the resident and the unique living situation in the nursing home; and
(3) Identify the services, supplies, and equipment to be provided by the nursing home and those to be provided by the hospice care program.
(I) The nursing shall ensure that the privacy and dignity of residents is protected when residents are transported to and from bathing facilities, when residents are preparing for bathing, and during resident bathing.
(J) Upon a resident's transfer, discharge, or death, the nursing home shall make an accounting of all that resident's monies held by the facility. The nursing home shall convey any remaining funds immediately to the resident or within thirty days to the resident's estate unless otherwise directed by law.