Monitoring Visit - 14 Days

Purpose: 

To meet regulatory requirements and ensure accurate client care.

Regulation: 144A.4791(8)(b)
Policy: RC-C7

Measurement:

  1. 100% of clients have a monitoring visit within 14 days of client's SOC

Process:

  1. A 14-day Monitoring visit is to be completed within 14 days after initiation of home care services. It must be completed by an RN and in person in the client’s home.  
  2. 14 day visit is scheduled in Clear Care at SOC on the client’s shift Calendar, assigned to the assigned RN Case Manager
    1. RCH - shift is scheduled as an hourly RN service, using the service: "Nursing Supervision"
    2. RCC - shift is scheduled as a visit, assigned to the appropriate RN Case Manager" using service, "14-Day Reassessment"  Documentation is done in the note section of the visit schedule.
  3. To document note, RN must click on the assigned visit and select the note field. All charting can be entered here and should be completed in the home:

4. Monitoring Visit Charting must include:

  1. Location where monitoring visit was completed, (i.e. client’s home)
  2. Who was present at monitoring visit?
  3. Client’s current health status
  4. Observations made of the home environment
  5. Review of plan of care. Indicate if any changes made.
  6. Review of Vulnerability assessment. Indicate if any changes made.
  7. Review current service provided and if meeting client’s needs.
  8. Monitor the client’s medication management services and if any concerns.
  9. If caregiver is present: Observe administration of medication
  10. If caregiver is present: Observe infection control practice
  11. Document if pleased with services
  12. Plan for next visit.

5. If any significant changes need to be made to the client's care, the service plan must be updated. This can be updated on the original service plan within 14 days of start of care.

6. No additional documentation is needed/required.