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WAC 388-97-1020

Comprehensive plan of care.

(1) The nursing home must develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment.
(2) The comprehensive plan of care must:
(a) Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under WAC 388-97-1060;
(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 (refer to WAC 388-97-0300 and 388-97-0260;
(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 residents needs;
(e) Consist of an ongoing process which includes a meeting if desired by the resident or the resident's representative; and
(f) Include the ongoing participation of the resident to the fullest extent possible, the resident's family or the resident's surrogate decision maker.
(3) The nursing home must implement a plan of care to meet the immediate needs of newly admitted residents, prior to the completion of the comprehensive assessment and plan of care.
(4) The nursing home must:
(a) Follow the informed consent process with the resident as specified in WAC 388-97-0260, regarding the interdisciplinary team's plan of care recommendations;
(b) Respect the resident's right to decide plan of care goals and treatment choices, including acceptance or refusal of plan of care recommendations;
(c) Include in the interdisciplinary plan of care process:
(i) Staff members requested by the resident; and
(ii) Direct care staff who work most closely with the resident.
(d) Respect the resident's wishes regarding which individuals, if any, the resident wants to take part in resident plan of care functions;
(e) Provide reasonable advance notice to and reasonably accommodate the resident family members or other individuals the resident wishes to have attend, when scheduling plan of care meeting times; and
(f) Where for practical reasons any individuals significant to the plan of care process, including the resident, are unable to attend plan of care meetings, provide a method for such individuals to give timely input and recommendations.
(5) The nursing home must ensure that each comprehensive plan of care:
(a) Designates the discipline of the individuals responsible for carrying out the program; and
(b) Is reviewed at least quarterly by qualified staff, as part of the ongoing process of monitoring the resident's needs and preferences.
[Statutory Authority: Chapters 18.51 and 74.42 RCW and 42 C.F.R. 489.52. WSR 08-20-062, ยง 388-97-1020, filed 9/24/08, effective 11/1/08.]
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