To meet regulatory requirements and ensure accurate client care.
- 100% of clients have a monitoring visit at least every 90 days (starting from the Monitoring Visit - 14 Days)
- 90 day Monitoring visit is to be completed at least every 90 days. Use the Activity tab in client’s Clear care record to schedule by adding a New Task to reoccur 10 weeks after 14 day visit was completed or last assessment. May be completed by LPN or RN, any changes in condition or needs of a client must be reported to a RN. May be completed at the client’s home or through use of telecommunication methods if this meets client’s needs.
- 90-day monitoring visit is scheduled in Clear Care on the client’s Shift Calendar, assigned to the assigned RN Case Manager
- RCH - shift is scheduled as an hourly RN service, using the service: "Nursing Supervision"
- RCC - shift is scheduled as a visit, assigned to the appropriate RN Case Manager" using service, "90 Day Supervisory Visit" Documentation is done in the note section of the visit schedule.
- To document note, RN must click on the assigned visit and select the note field and choose the Activity Note, "Monitoring Visit: 90 Day Assessment". All charting can be entered here and should be completed in the home:
4. Monitoring Visit Charting must include:
- Location where monitoring visit was completed, (i.e. client’s home)
- Who was present at monitoring visit?
- Client’s current health status
- Observations made of the home environment
- Review of plan of care. Indicate if any changes made.
- Review of Vulnerability assessment. Indicate if any changes made.
- Review current service provided and if meeting client’s needs.
- Monitor the client’s medication management services and if any concerns.
- If caregiver is present: Observe administration of medication
- If caregiver is present: Observe infection control practice
- Document if pleased with services
- Plan for next visit.
5. If any significant changes need to be made to the client's care, a service plan addendum must be completed and signed by the client/responsible party.
6. No additional documentation is needed/required.