HAR §11-100.1-88. spiritual, rehabilitative needs of the resident and any other specific need of the resident

This plan shall identify all services to be provided to the expanded ARCH resident and shall include, but not be limited to, treatment and medication orders of the expanded ARCH resident's physician or APRN, measurable goals and outcomes for the expanded ARCH resident; specific procedures for intervention or services required to meet the expanded ARCH resident's needs; and the names of persons required to perform interventions or services required by the expanded ARCH resident; (3) Review the care plan monthly, or sooner as appropriate; (4) Update the care plan as changes occur in the expanded ARCH resident care needs, services and/or interventions; (5) Promote continuity of care and appropriate integration and utilization of services necessary to implement the care plan; (6) Coordinate care giver training, hospital discharge, respite, home transfers and other services as appropriate. Facilitate, advocate and mediate for expanded ARCH residents, care givers and service providers to ensure linkages and provision of quality care for the optimal function of the expanded ARCH resident; (7) Arrange and participate in the expanded ARCH resident's case conferences. Ensure that the expanded ARCH resident, resident's family or surrogate, expanded ARCH resident's physician and the primary care giver are represented at the case conferences; (8) Have face-to-face contacts with the expanded ARCH resident at least once every thirty days, with more frequent contacts based on the resident's needs and the care giver's capabilities; (9) Provide ongoing evaluation and monitoring of the expanded ARCH resident's status, care giver's skills, competency and quality of services being provided; (10) Conduct comprehensive reassessments of the expanded ARCH resident every six months or sooner as appropriate; 100.1-63 2 §11-100.1-89 (11) Make arrangements with a case manager and/or registered nurse who meets the requirements of this subchapter (a) to provide coverage in the event that the case manager takes leave or is unable to provide services as required in this chapter; and (12) Inform the department of any change in quality of services being provided to the expanded ARCH resident. Case management services shall be subject to all applicable state regulations. (d) The department in collaboration with the expanded ARCH resident family or surrogate may require a change in case management services when it has been determined through review of resident records, care plans and interventions that the case manager is unable to provide adequate services as outlined in this subchapter. (e) When a change in case management services occurs, the new case manager shall perform a comprehensive reassessment of the expanded ARCH resident, review the care plan and make necessary amendments. The expanded ARCH resident, resident's family or surrogate, physician or APRN and primary care giver shall be notified if a change in case management services is contemplated. [Eff SEP 18 2006] (Auth: HRS §§321-1, 321-9, 321-10, 321-11, 321-15.1, 321-15.6, 321-15.61, 321-15.62) (Imp: HRS §§321-1, 321-9, 321-10, 321-11, 321-15.1, 321-15.6, 321-15.61, 321-15.62)