{"ref":"NC-HC-ADM-02","title":"Initial Assessment, Admission, and Service Agreement","category":"Service delivery","summary":"Requires a registered nurse to assess every in-home aide client in the client's home before the plan of care is written, covering the functional areas 10A NCAC 13J .1107(d) lists; sets how companion, sitter and respite clients are assessed; and sets the admission visit at which the client receives the required notices, signs the service agreement and approves the services before any service starts.","inShort":["A registered nurse assesses every in-home aide client at home before the plan of care is written.","An LPN or an aide never does the initial assessment.","The client receives the admission packet and signs the plan of care before the first visit.","No visit starts until the signed papers are in the client record.","A companion client who needs hands-on care must be assessed by the nurse first."],"primaryCitation":"10A NCAC 13J .1107(d)","citations":["10A NCAC 13J .1107(b), (d), (e)","10A NCAC 13J .1402(a)(1), (a)(2)(A), (B)","10A NCAC 13J .1502(b)","10A NCAC 13J .1501(2)","10A NCAC 13J .0901(7), (10), (18)","10A NCAC 13J .1007(a)","G.S. 131E-144.4","G.S. 131E-144.3(7)","DHSR Home Care Frequently Asked Questions, Q44, Q47, Q48, Q50, Q51","NC Medicaid Clinical Coverage Policy 3L, §6.1.4(l)"],"federalCitations":[],"surveyorAsks":["Who did the initial assessment for this in-home aide client, where, and on what date? Was it before the plan of care?","Does the assessment cover social, mental, physical health, environmental, economic, ADL and IADL status, and is it signed and dated?"],"forms":[{"ref":"NC-HC-ADM-02-A","title":"Initial Assessment"},{"ref":"NC-HC-ADM-02-B","title":"Client Service Agreement"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (10A NCAC 13J .1107(d))","5. Who Assesses the Client","6. Preparing for the Visit","7. The Initial Assessment","8. Conclusions of the Assessment","9. Admission","10. Starting Services","11. Readmission and Added Services","12. Responsibilities","13. Records and Compliance Monitoring","14. Staff Training","15. References","16. Related Policies and Forms","17. Approval","18. Revision History"],"version":"1.0","sample":false,"pack":"nc-hca","state":"North Carolina","service":"Home care","guides":[{"path":"/guides/home-care-agency-policies/","h1":"What policies does a home care agency need?"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}