Post Acute Medical Care
It is the policy of MDCBDSN for those who receive residential habilitation services to be evaluated between twenty four to thirty six hours after being seen by a physician, physician's assistant, or certified nurse practitioner for acute care to determine the status of his/her condition. (If the acute care visit is self-initiated or initiated by a family member(s) without knowledge of the residential provider, this requirement would not apply). "Acute" is defined as treatment sought for a brief and severe condition, as opposed to treatment for chronic long term conditions, routine check-ups, or follow-up visits for previously diagnosed illnesses. Acute visits are not planned in advance but are in response to a sudden change in condition or an accident such as a sinus infection, urinary tract infection, the flu, a broken bone, a laceration, etc. (RH5.3)
Post Acute Care Procedures:
- The nurse who assisted with the acute care visit (unplanned visit/orders) will provide the necessary documentation to implement the post acute medical care follow-up.
- The nurse will complete the top portion of the Post Acute Care Follow-up Report and complete all necessary information in the Post Acute Medical Care Instruction Form. He or she will provide a copy of the written progress note along with the physician's order(s) with date/time of visit. The nurse will forward this information to the Residential Administrator as well as to the designated Service Coordinator. Nurse will date and time when information was forwarded.
- Within 24 hours of the situation, the Nurse will ensure that all orders have been initiated. The nurse will take the necessary items needed to implement any order(s) as well as ensure that medications, supplies, and/or equipment are readily available to comply with the physician's orders. The nurse will orient the staff on the new orders and/or instructions for treatment and ensure that the staffs understand. It will be ensured that the staffs are aware of what signs and symptoms to monitor that may indicate a problem and that they know to notify the nurse immediately for any acute changes and problems. The Post Acute Medical Care Instruction Form will be completed and posted for staff to review. If any additional instructions, the nurse will also indicate them on this form.
- The Post Acute Care Follow-up Report will be completed by a staff member. This designated staff member may not be a staff person who provides direct support to those who receive residential habilitation services. These are the steps the designated staff member is to take to evaluate:
- See the person in his/her home.
- Determine if the person's condition has improved, worsened, or remained unchanged.
- Review the orders/instructions to determine if needed medications, supplies, and or equipment are available and in sufficient quantity to comply with orders.
- Determine if staff can competently perform the duties required to comply with the orders.
- Determine if staff can identify the signs and symptoms for worsening or lack of improvement of the person's condition.
- Determine if staff know what to do if condition changes for the worse; if they have questions; and if they need additional items to comply with the order(s).
- Report immediately (before leaving the residence) to the Executive Director or designee situations in which:
- Medications, supplies and/or equipment are not available.
- Staff on duty are not competent to fulfill orders nor have a clear and accurate instructions or materials to comply with orders.
- The person's condition has worsened or has not adequately improved and no action has been take to address this.
- Following the verbal report, staff must complete, date, and sign a report of the evaluation that provides a detailed description of the adverse finding(s) and action(s) taken.
- Provide the original report to the Executive Director/designee within 48 hours of the completion or the next business day, whichever is later.
- Any situation reported to the Executive Director/designee as outlined in #g (above) will be considered an unusual and unfavorable occurrence that has harmful or otherwise negative effects to the person and therefore, must be reported to the DDSN following the steps outlined in 100-09-DD, Reporting of Critical Incidents.
- Completed Post Acute Care Follow-up Reports along with copies of the physician's orders and the Post Acute Medical Care Instruction Form will be kept by the area Residential Administrator.