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4.the name, address and telephone number of the participant's physician and/or medical center as well as the date of participant's last physical exam;
5.a nursing assessment summary performed by the center’s staff nurse at the time of the participant's admission to the center which includes:
a.special dietary needs;
b.prescribed medication;
c.allergies;
d.any limitations on activity;
e.the degree to which the participant is ambulant;
f.visual or hearing limitations and/or other physical impairments;
g.apparent mental state or degree of confusion or alertness;
h.the ability to control bowel or bladder;
i.the ability to feed self;
j.the ability to dress self; and
k.the ability to self-administer medication.

NOTE: The Minimum Data Set Home Care (MDS/HC) can be used in place of the nursing assessment summary.

B.The center shall not refuse admission to any participant on the grounds of race, sex or ethnic origin.

C.The center shall not knowingly admit any participant into care whose presence would be seriously damaging to the ongoing functioning of the center or to participants already receiving services.

AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and 40:2120.41-46.

HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:2189 (October 2008).

§4275.Discharge

A.The center shall have written policies and procedures governing voluntary discharges (the participant withdraws from the program on his/her own) and non-voluntary discharges (center initiated discharges).

1.The policy may include the procedures for non-voluntary discharges due to the health and safety of the participant or that of other participants if they would be endangered by the further stay of a particular participant in the center.

B.There shall be a written report detailing the circumstances leading to any discharge.

C.Prior to a planned discharge, the center's ID Team shall formulate an aftercare plan specifying needed supports and the resources available to the participant.

D.When the participant is going to another home and community-based program or institutional center, discharge planning shall include the participant's needs, medication history, social data and any other information that will assist in his/her care in the new program or center.

1.A center member of the ID Team shall confer with the representatives of the new program regarding the individual needs and problems of the participant, if at all possible.
2.Upon discharge, the center shall provide a summary of the participant's health record to the person or agency responsible for the future planning and care of the participant. The discharge summary shall include:
a.medical diagnoses;
b.medication regimen (current physicians orders);
c.treatment regimen (current physicians orders);
d.functional needs (inabilities);
e.any special equipment utilized (dentures, ambulatory aids, eye glasses, etc.);
f.social needs;
g.financial resources; and
h.any other information which will enable the receiving center/caregivers to provide the continued necessary care without interruption.

AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and 40:2120.41-46.

HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:2190 (October 2008).

§4277.Interdisciplinary Team Responsibilities

A.It shall be the responsibility of the ID team to assess and develop an individualized service plan for each participant prior to or within 20 days of admission of a participant.

B.Prior to the individual staffing of a participant by the ID team, each team member shall complete an assessment to be used at the team meeting. This assessment shall, at a minimum, include a medical evaluation and a social evaluation.

C.The ID team shall meet, reassess, and reevaluate each participant at least annually, but will meet at the end of each quarter to review the current individualized service plan and ensure that it is adequate for each participant.

D.The ID team shall make referrals, as indicated, to other disciplines and for any service which would enhance the functional capacity of a participant.

AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and 40:2120.41-46.

HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:2190 (October 2008).

§4279.Interdisciplinary Team-Composition

A. The ID team may be composed of either full-time staff members, contractual consultants or a combination of both.

B.The ID team shall be composed of:

1.a registered nurse licensed to practice in the state of Louisiana;
2.a social service designee/social worker; and
3.at least one direct care staff person from the center.

C.In addition, dietitians, physical therapists, occupational therapists, recreational therapists, physicians and others may sit on the team to staff an individual participant on an as needed basis.

D.The participant, and/or family members or legal or personal representative if appropriate, shall be involved in the ID team staffing and any other meeting involving the care needed by the participant while receiving services at the ADHC center.

AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and 40:2120.41-46.

HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:2190 (October 2008).

§4281.Individualized Service Plan

A.The participant's ADHC individualized service plan shall:

1.be developed from the staffing performed by the ID team of each participant;

Louisiana Register   Vol. 34, No. 10   October 20, 2008

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