PSSL - Skilled nursing
Professional Support Services
All personnel providing professional support services shall assure that their efforts effectively complement other services provided to the consumer/service recipient, are functionally integrated into the individual daily routine and support the outcome outlined in the individual support plan. A written report of progress shall be provided to the consumer’s support coordinator/case manager monthly. A written summary report for each consumer shall be sent to the attending physician at least annually.
Plan of Care.
a. The written plan of care, developed in consultation with Burks Agency staff, shall cover all pertinent diagnoses, including mental status, types of services and equipment required, frequency of services, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items. If a physician refers a consumer/service recipient under a plan of care which cannot be completed until after an evaluation visit, the physician shall be consulted to approve additions or modifications to the original plan. Orders for professional support services shall include the specific treatment or modalities to be used and their amount, frequency and duration. The therapist and other agency personnel shall participate in developing the plan of care.
b. The plan(s) of care for acute or episodic illness shall be reviewed by the attending physician and agency personnel involved in the consumer’s care as often as the severity of the consumer’s condition requires, but at least annually. Plans of care resulting from Comprehensive Nursing Assessment will be reviewed in accordance with the physical status review schedule. Evidence of review by the physician must include the physician’s signature and date of the review on the plan of care. A facsimile of the physician’s signature is acceptable. Professional staff shall promptly alert the physician to any changes that suggest a need to alter the plan of care.
Drugs and treatments shall be administered by appropriately licensed or certified agency personnel, acting within the scope of their licenses or certification. Orders for drugs and treatments shall be signed and dated by the physician.
Skilled Nursing Services.
a. When skilled nursing is provided, the services shall be provided by or under the supervision of a registered nurse who has no current disciplinary action against his/her license, in accordance with the plan of care. This person shall be available at all times during operating hours and participate in all activities relevant to the professional support services provided, including the development of qualifications and assignment of personnel.
b. The registered nurse duties shall include but are not limited to the following:
A. make the initial evaluation visit, except in those circumstances where the physician has ordered therapy services as the only skilled service;
B. regularly evaluate the consumer’s nursing needs; initiate the plan of care and
necessary revisions;
C. provide those services requiring substantial specialized nursing skill;
D. initiate appropriate preventive and rehabilitative nursing procedures;
E. prepare clinical and progress notes;
F. coordinate services;
G. inform the physician and other personnel of changes in the consumer’s condition
and needs;
H. counsel the consumer and family in meeting nursing and related needs;
I. participate in in-service programs;
J. supervise and teach other nursing personnel.
K. The registered nurse or appropriate agency staff shall initially and periodically
evaluate drug interactions, duplicative drug therapy and non-compliance to drug
therapy.
c. The licensed practical nurse shall provide services in accordance with agency policies, which may include but are not limited to the following:
A. prepare clinical and progress notes;
B. assist the physician and/or registered nurse in performing specialized procedures;
C. prepare equipment and materials for treatments;
D. observe aseptic technique as required; and
E. assist the consumer in learning appropriate self-care techniques.