Initial Evaluation Visit and Comprehensive Assessment
Sets out what the registered nurse does at the initial evaluation visit, what the comprehensive assessment covers and when it is completed and updated, how medicines are reviewed, who may assess (registered nurses and, for therapy-only patients, therapists; licensed practical nurses contribute focused assessments only), and how each patient’s individual emergency plan is built into the assessment. The federal content and time frames in 42 CFR §484.55 are the Agency’s standard for every patient and are binding if the Agency is Medicare-certified.
- Policy number
- PA-HH-ASM-01
- Version
- 1.0
- Main rule
- 42 CFR §484.55
- Library
- Pennsylvania home health · 56 policies
- Category
- Patient care
- Sections
- 20
In short
- Only a registered nurse makes the initial evaluation visit; LPNs do focused assessments and report to the RN.
- Finish the comprehensive assessment no later than 5 calendar days after the start of care.
- Look at every medicine in the home and report any problem to the doctor promptly.
- Update the assessment in the last 5 days of every 60 days, within 48 hours after a hospital stay, at discharge, and after any major change.
- Build the patient’s individual emergency plan into the assessment and leave a copy in the home.
What's inside
20 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 Assesses
- 6. The Initial Evaluation Visit
- 7. Content of the Comprehensive Assessment
- 8. Medication Review
- 9. Individual Emergency Plan
- 10. Updates of the Comprehensive Assessment
- 11. Reevaluation at Each Visit
- 12. Timeliness and Completeness Checks
- 13. Responsibilities
- 14. Records and Compliance Monitoring
- 15. Staff Training
- 16. References
- 17. Related Policies and Forms
- 18. Approval
- 19. Revision History
An inspector may ask
- Show me this patient’s initial evaluation visit and comprehensive assessment. When was each done?
- Where in the assessment is the review of all the medicines the patient is taking?
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