Section 131.20. Assessment.

 

(1)   Initial assessment.

(a) If the hospice determines that it has the general capability to meet the prospective patient's described needs, then before services are provided, a registered nurse shall perform an initial assessment of the person's condition and needs and shall describe in writing the person's current status, including physical condition, present pain status, emotional status, pertinent psychosocial and spiritual concerns and coping ability of the prospective patient and family support system, and shall determine the appropriateness or inappropriateness of admission to the hospice based on the assessment.

(b) The designated hospice employee shall confer with at least one other core team member and receive that person's views in order to start the initial plan of care.

(2)   Time frame for completion of the comprehensive assessment. The hospice interdisciplinary group, in consultation with the individual's attending physician, if any, shall complete the comprehensive assessment no later than 5 calendar days after the election of hospice care.

(3)   Content of the comprehensive assessment. The comprehensive assessment shall identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that shall be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. The comprehensive assessment shall take into consideration all of the following factors:

(a) The nature and condition causing admission including the presence or lack of objective data and subjective complaints.

(b) Complications and risk factors that affect care planning.

(c) Functional status, including the patient's ability to understand and participate in his or her own care.

(d) Imminence of death.

(e) Severity of symptoms.

(f) Drug profile. A review of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following:

1. Effectiveness of drug therapy.

2. Drug side effects.

3. Actual or potential drug interactions.

4. Duplicate drug therapy.

5. Drug therapy currently associated with laboratory monitoring.

(g) Bereavement. An initial bereavement assessment of the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment shall be incorporated into the plan of care and considered in the bereavement plan of care.

(h) The need for referrals and further evaluation by appropriate health professionals.

(4)   Update of the comprehensive assessment. The update of the comprehensive assessment shall be accomplished by the hospice interdisciplinary group in collaboration with the individual's attending physician, if any, and shall consider changes that have taken place since the initial assessment. The comprehensive assessment shall include information on the patient's progress toward desired outcomes, as well as a reassessment of the patient's response to care. The assessment update shall be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days. The hospice interdisciplinary group shall primarily meet in person to conduct the update of the comprehensive assessment.

(5)   Patient outcome measures .

(a) The comprehensive assessment shall include data elements that allow for measurement of outcomes. The hospice shall measure and document data in the same way for all patients.

(b) The data elements shall do all of the following:

1. Take into consideration aspects of care related to hospice and palliation.

2. Be an integral part of the comprehensive assessment.

3. Be documented in a systematic and retrievable way for each patient.

(c) The data elements for each patient shall be used in individual patient care planning and in the coordination of services, and shall be used in the aggregate for the hospice's quality assessment and performance improvement program.

History: CR 10-034 : cr. Register September 2010 No. 657 , eff. 10-1-10.