Assessment and Care Planning

(A) Assessment. (1) A Program shall conduct and document in writing a participant-specific, inter- disciplinary, accurate, comprehensive assessment, as specified in 105 CMR 158.037 and in guidelines of the Department. (2) A Program shall: (a) Complete an initial comprehensive assessment within 14 days of enrollment. (b) Complete a revised comprehensive assessment within 14 days of any significant change. (c) Review and revise, as necessary, the comprehensive assessment at least once every six months. (d) Complete a new comprehensive assessment within 365 days of the completion of the most recent comprehensive assessment. (e) Assess participants' health status and evolving needs on an ongoing basis. (3) The comprehensive assessment shall include an assessment of the participant's health status and care requirements, as well as the participant's and his or her family's goals and desires, and shall be conducted in conformance with guidelines of the Department and 105 CMR 158.037. The comprehensive assessment shall include, at minimum, the following areas: (a) Identification and demographic information; (b) Customary routine and support services; (c) Cognitive patterns; (d) Communication; (e) Vision; (f) Mood and behavior patterns; (g) Psychological well-being; (h) Physical functioning and structural problems; (i) Continence; (j) Disease diagnoses and health conditions; (k) Dental and nutritional status; (l) Skin conditions; (m) Activity pursuits; (n) Medications, including a review of all of the participant's prescription and over-the- counter drugs, herbal remedies, and other alternative treatments that could affect drug therapy; (o) Special treatments and procedures; (p) The need for referrals and further evaluation by appropriate health professionals; (q) Discharge potential; (r) Complications and risk factors that affect care planning; (s) A comprehensive summary of the participant's health status; and (t) Name and credentials of those who participated in the comprehensive assessment. (B) Interim Plan of Care. An interim plan of care shall be developed upon enrollment in order to meet a participant's immediate care needs until the comprehensive plan of care is developed. (C) Comprehensive Plan of Care. (1) The comprehensive plan of care shall be based on the comprehensive assessment and shall specify the type, amount, frequency, and duration of' services to be provided to each participant and shall include the following: (a) Required medical services; (b) Required nursing services; (c) Required service coordination; (d) Required dietary services; (e) Required rehabilitation services; (f) Required therapeutic activity services; (g) Any other service required to meet the participant's needs; (h) Information regarding the coordination of the participant's care with primary care providers, caregivers, and community services (including homemaker, home health, personal care, or therapy services) that the participant is receiving outside the Program; and (i) Measurable goals, objectives, and timetables to meet a participant's needs as identified in the comprehensive assessment. (2) A Program shall complete the comprehensive plan of care within seven days of completion of the comprehensive assessment. (3) A Program shall review and revise each participant's comprehensive plan of care after each comprehensive assessment and at least once every six months or more often as necessary. (4) Each participant's comprehensive plan of care shall be developed by the registered nurse in conjunction with other care team members and the participant or his or her legally authorized representative. (5) The registered nurse shall consult with and shall notify the primary care provider of the participant's plan of care after each assessment and at least once every six months, or more often in the event of a significant change.