Monitoring Visit - 90 Days

Purpose: 

To meet regulatory requirements and ensure accurate client care.

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

Measurement:

  1. 100% of clients have a monitoring visit at least every 90 days (starting from the Monitoring Visit - 14 Days

Process:

  1. 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.
  2. 90-day monitoring visit is scheduled in Clear Care 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, "90 Day Supervisory Visit"  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 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:

  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, a service plan addendum must be completed and signed by the client/responsible party.  

6. No additional documentation is needed/required.