Service Plans
Diets should be documented on the ISP no later than how many days after admission?
30 days
(The day of admission is day 1)
Controlled PRN medications should be documented on the _______ and ______.
Proof-of-use record (narc book), MAR
If a resdient has a COC, what evaluations MUST be done?
Comprehensive evaluation, Evacuation Evaluation
The ED and WD (or designees) should REVIEW & SIGN off on fall/incident reports within how many days of occurence?
7 days.
7 CALENDAR days, not business days.
The date of the incident or fall is day 1.
How often should Outside Agency notes be scanned in to PCC?
At least monthly
How often should a service plan be reviewed/updated?
A New Review should be done every 6 months at a minimum. If there is a Change of Condition, a new review must be completed. The service plan should be updated whenever there is a change to interventions or tasks, for instance, after an incident or fall when a new intervention is added, or when therapy starts or ends. A new review is not necessary in these cases
A resident has refused a medication for 2 days in a row, what do you need to do?
Notify the provider of the refusal, DOCUMENT the notification and the provider response in the progress notes. You may want to request a discontinue or hold order, depending on the circumstances.
(Wisconsin regulations require that we notify the provider if the resident refuses medication for 2 consecutive days).
If a resident has a change of condition, what must be done with the ISP?
A new review reflecting the COC within a reasonable amount of time
How many days after a fall or incident should follow up be done and documented?
Within 5 business days.
The date of the fall or incident is day 1.
True or False: A resident's condition upon return from the hospital, ER, or extended pass/leave should be documented in a progress note within 10 business days of return.
FALSE!
It should be documented in a progress note within 5 business days of return.
Devices such as Ubars, bed rails, bed cane would have a written order in the chart and would be listed under which section of the ISP?
Assistive Devices and/or Mobility
If a resident is on scheduled psychotropic medications, how often should this resident be assessed for desired responses and possible side effects of the medication?
Quarterly
A resident has had multiple unwitnessed falls over the last month due to increased confusion and not remembering to call for help, none resulting in injury.
Is this a change of condition?
Yes
An Initial Action Note should be put in within how many days of a fall/incident?
3 business days. (The date of the fall or incident is day ???)
If a resident passes away, a progress note should be put into PCC within 5 business days and should include what?
Date, Time, circumstances of the resdient's death, and to whom the body was released
A resident is incontinent of bowel and bladder, is a standby assist for transfers, requires 1 assist for bathing and dressing. What POC tasks would need to be implemented?
Routine toileting/incontinence checks
Assist needed with toileting and cares
Routine bath w/assist level
Stand-by transfer
If a resident has a PRN psychotropic medication that is administered by the community staff, what should be on the ISP?
The rationale for use and a detailed description of the behaviors indicating the need for the PRN admin.
A resident has a syncopal episode and is sent out to the ER. The resident returns to the community with no new orders or changes to their care.
Is this a change of condition?
No
Who should be notified of a fall/incident within 24 hours?
Family/responsible party,
PCP (even if on hospice, if PCP is different than hospice MD), and
other outside agencies as applicable (MCO, i.e. Community Care, Lakeland, etc.)
Service plans should be signed and dated by the resident/responsible party within how many days of move in date?
30 days
For every intervention on the ISP there should be a _____________ (what?).
POC task
If a resident missed doses (med unavailable, med held, other), what documentation needs to be done?
The reason for the missed dose(s), provider notification of the missed dose(s), specific actions taken to obtain medication-DOCUMENT IT
You are doing your monthly weight reviews and you find a resident has gained 15 pounds in the last month. You have the weight rechecked for accuracy and it is a true weight gain. Who do you notify?
PCP, POA, and/or responsible party as applicable-DOCUMENT NOTIFICATIONS
A resident has had a pattern of multiple falls, what is something that needs to be done?
Update ISP with NEW intervention.
POC documentation compliance should be at or above what percent?
99%
If a resident is receiving care from an outside agency, and their note includes new orders/instructions, they should be documented on the ISP, PCC orders, POC tasks as applicable, how soon after receiving them?
As soon as possible but weekly at a minimum
What evaluation needs to be done prior to a resident being able to administer ANY of their own medications?
Self-Administration of Medication Assessment
A resident is admitted to hospice and they were not receiving hospice services upon moving into the community.
Is this a Change of Condition?
Yes
Every Initial Action Note must include what information?
1. Date & time of the incident,
2. Summary of what happened,
3. Immediate action taken, and
4. The date and time all required parties were contacted.
Vitals (BP, Temp, pulse, weight) should be obtained how often, be reviewed for _________, and be __________ in PCC.
Monthly
Accuracy
Documented