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Initial Assessment, Admission, and Service Agreement

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.

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About this policy
Policy number
NC-HC-ADM-02
Version
1.0
Main rule
10A NCAC 13J .1107(d)
Library
North Carolina home care · 50 policies
Category
Service delivery
Sections
19

In short

  • 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.

What's inside

19 sections. The full text comes with the One-time Policy Pack.

Full text with a package
  • 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

An inspector may ask

  • 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?

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