Monitoring Visit - Annual Assessment

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 comprehensive annual reassessment 

Process:

  1. Annual Reassessment and medication monitoring visit is to be made at least every 12 months. It should be conducted face to face at the client’s home.
  2. Annual Reassessment is scheduled ClearCare 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, "Community Nurse 15 (or 30) Minute"  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: Annual Assessment". All charting can be entered here and should be completed in the home:

 5. Annual Assessment Charting must include:

  1. Reassessment of client’s health status,
  2. Completion of medication assessment
  3. Renewal of medication orders
  4. Review of IMMP and ITP
  5. Reassessment of Plan of care
  6. Reassessment of client’s vulnerabilities.

6. 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.  

7. No additional documentation is needed/required.