Comprehensive Assessment and Reassessment
Requires a patient-specific comprehensive assessment, completed by a registered nurse (or the therapist for a therapy-only patient) no later than 5 calendar days after the start of care, covering the content in 42 CFR §484.55(c) including a drug regimen review, OASIS items, and the patient’s individual emergency plan; updated in the last 5 days of every 60 days, within 48 hours of return home from a hospital stay of 24 hours or more, on a major change, and at discharge; and the 90-day North Carolina review of condition, progress and response by the health care practitioner.
- Policy number
- NC-HH-ASM-01
- Version
- 1.0
- Main rule
- 42 CFR §484.55
- Library
- North Carolina home health · 57 policies
- Category
- Service delivery
- Sections
- 18
In short
- A registered nurse completes the comprehensive assessment no later than 5 calendar days after the start of care (a therapist only for therapy-only patients).
- Review every medicine the patient takes and report problems to the doctor.
- Update the assessment in the last 5 days of every 60 days, within 48 hours after a hospital stay of 24 hours or more, after a big change, and at discharge.
- LPNs and aides do not do assessments; report any change in the patient right away.
- Include the patient’s own emergency plan in the assessment.
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 (42 CFR §484.55)
- 5. Who Completes the Comprehensive Assessment
- 6. Content of the Comprehensive Assessment
- 7. The In-Home Aide Assessment
- 8. Updating the Comprehensive Assessment
- 9. The North Carolina 90-Day Review
- 10. Tracking and Review
- 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
- When did this patient’s comprehensive assessment start and when was it completed?
- Show me the drug regimen review in the comprehensive assessment.
See Cura Core with your agency's name on it.
Choose your state and type of agency, buy your Policy Pack online and get your sign-in by email. Already a customer? Sign in to your portal.