Initial Nursing Assessment, Start of Care, and Comprehensive Assessment
Sets out how care starts: the Agency’s own start-of-care time frame; the registered nurse’s initial nursing assessment before any care (22 CCR §74707(a)(2)), including the initial assessment of the patient and the care environment for aide cases (§74709(a)(1)); consulting the practitioner when the initial plan does not meet the patient’s needs (§74697(c)); and, if the Agency is Medicare-certified, the initial assessment visit within 48 hours, the comprehensive assessment within 5 calendar days after the start of care with its required content, and its updates (42 CFR §484.55).
- Policy number
- CA-HH-ADM-02
- Version
- 1.0
- Main rule
- 22 CCR §74707(a)(2)
- Library
- California home health · 58 policies
- Category
- Service delivery
- Sections
- 18
In short
- A registered nurse sees the patient and the home before any care starts. An LVN or aide never does the first assessment.
- For a therapy-only patient, the therapist may do the first assessment.
- At the first visit, give the rights, advance directive, and consent forms before any treatment.
- Check every medication the patient uses and record allergies where everyone can see them.
- If the orders do not meet the patient’s needs, call the doctor for new orders.
- Update the assessment when the patient’s condition changes or they come home from the hospital.
What's inside
18 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (22 CCR §74707(a)(2))
- 5. Scheduling the First Visit
- 6. Who Does the First Assessment
- 7. The First Visit
- 8. The Comprehensive Assessment
- 9. From Assessment to Plan of Treatment
- 10. Updating the Assessment
- 11. Responsibilities
- 12. Records and Compliance Monitoring
- 13. Staff Training
- 14. References
- 15. Related Policies and Forms
- 16. Approval
- 17. Revision History
An inspector may ask
- Who did the initial nursing assessment for this patient, and was it done before any care was given?
- What is your start-of-care time frame, and did you meet it for this patient?
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