Section 1418.81 Of Chapter 2.4. Quality Of Long-term Health Facilities From California Health And Safety Code >> Division 2. >> Chapter 2.4.
1418.81
. (a) In order to assure the provision of quality patient
care and as part of the planning for that quality patient care,
commencing at the time of admission, a skilled nursing facility, as
defined in subdivision (c) of Section 1250, shall include in a
resident's care assessment the resident's projected length of stay
and the resident's discharge potential. The assessment shall include
whether the resident has expressed or indicated a preference to
return to the community and whether the resident has social support,
such as family, that may help to facilitate and sustain return to the
community. The assessment shall be recorded with the relevant
portions of the minimum data set, as described in Section 14110.15 of
the Welfare and Institutions Code. The plan of care shall reflect,
if applicable, the care ordered by the attending physician needed to
assist the resident in achieving the resident's preference of return
to the community.
(b) The skilled nursing facility shall evaluate the resident's
discharge potential at least quarterly or upon a significant change
in the resident's medical condition.
(c) The interdisciplinary team shall oversee the care of the
resident utilizing a team approach to assessment and care planning
and shall include the resident's attending physician, a registered
professional nurse with responsibility for the resident, other
appropriate staff in disciplines as determined by the resident's
needs, and, where practicable, a resident's representative, in
accordance with applicable federal and state requirements.
(d) If return to the community is part of the care plan, the
facility shall provide to the resident or responsible party and
document in the care plan the information concerning services and
resources in the community. That information may include information
concerning:
(1) In-home supportive services provided by a public authority or
other legally recognized entity, if any.
(2) Services provided by the Area Agency on Aging, if any.
(3) Resources available through an independent living center.
(4) Other resources or services in the community available to
support return to the community.
(e) If the resident is otherwise eligible, a skilled nursing
facility shall make, to the extent services are available in the
community, a reasonable attempt to assist a resident who has a
preference for return to the community and who has been determined to
be able to do so by the attending physician, to obtain assistance
within existing programs, including appropriate case management
services, in order to facilitate return to the community. The
targeted case management services provided by entities other than the
skilled nursing facility shall be intended to facilitate and sustain
return to the community.
(f) Costs to skilled nursing facilities to comply with this
section shall be allowable for Medi-Cal reimbursement purposes
pursuant to Section 1324.25, but shall not be considered a new state
mandate under Section 14126.023 of the Welfare and Institutions Code.