N.J. Admin. Code § 10:77A-2.3

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:77A-2.3 - Nursing assessments

(a) Upon admission to an adult mental health rehabilitation community residence program, all beneficiaries shall receive a comprehensive nursing assessment, completed by a registered nurse, or higher level nursing professional, in addition to any and all assessments required by N.J.A.C. 10:37A.

(b) The initial nursing assessment shall be completed within 14 calendar days of admission, as follows:

1. The initial nursing assessment shall justify the need for continued mental health rehabilitation services and shall include a recommendation for an appropriate level of service; and

2. The initial nursing assessment shall be used in conjunction with the comprehensive intake assessment to develop the comprehensive service plan as required in N.J.A.C. 10:37A.

(c) A registered nurse, or higher level professional, shall conduct a review at least every 90 days for each beneficiary receiving AMHR services. The review conducted shall consist of a face-to-face visit, which shall include an assessment of the beneficiary's clinical condition and a review, which shall assure that services are being provided consistent with the beneficiary's comprehensive service plan. During each visit, the reviewer shall, at a minimum:

1. Review the service plan;

2. Review the observations and progress notes made by the direct care staff;

3. Assess the client's health; and

4. Indicate any changes needed in treatment approaches in the service plan.

(d) Comprehensive nursing reassessments shall be completed on at least an annual basis and shall include a justification for the continuation of services and a recommendation for the appropriate level of care.

1. Nursing reassessments shall be completed upon any significant positive or negative change in the condition of a beneficiary which may warrant a permanent or temporary change in the level of care rendered to the beneficiary.

(e) All nursing assessments, reassessments and supervisory follow up visits shall be performed in the beneficiary's residence and shall be related specifically to mental health rehabilitation services. Nursing reassessments shall indicate progression or regression relative to the beneficiary's condition and treatment goals.

(f) All beneficiaries determined to need community mental health rehabilitation services shall be placed in the least restrictive and most effective level of care that will meet their needs.

(g) If the beneficiary is determined to need a lesser level of care than the group home or supervised apartment he or she is residing in is licensed to provide, the providers shall only bill for the lower level of care needed and provided.

N.J. Admin. Code § 10:77A-2.3

Amended by 49 N.J.R. 201(b), effective 1/17/2017