[Code of Federal Regulations]
[Title 38, Volume 2]
[Revised as of July 1, 2003]
From the U.S. Government Printing Office via GPO Access
[CITE: 38CFR52.110]

[Page 854-855]
 
            TITLE 38--PENSIONS, BONUSES, AND VETERANS' RELIEF
 
          CHAPTER I--DEPARTMENT OF VETERANS AFFAIRS (CONTINUED)
 
PART 52--PER DIEM FOR ADULT DAY HEALTH CARE OF VETERANS IN STATE HOMES--
Table of Contents
 
                          Subpart D--Standards
 
Sec. 52.110  Participant assessment.

    The program management must conduct initially, semi-annually and as 
required by a change in the participant's condition a comprehensive, 
accurate, standardized, reproducible assessment of each participant's 
functional capacity.
    (a) Intake screening. An intake screening must be completed to 
determine the appropriateness of the adult day health care program for 
each participant.
    (b) Enrollment orders. The program management must have physician 
orders for the participant's immediate care and a medical assessment, 
including a medical history and physical examination, within a time 
frame appropriate to the participant's condition, not to exceed 72 hours 
after enrollment, except when an examination was performed within five 
days before enrollment and the findings were provided and placed in the 
clinical record on enrollment.
    (c) Comprehensive assessments--(1) The program management must make 
a comprehensive assessment of a participant's needs using (on and after 
January 1, 2002) the Minimum Data Set for Home Care (MSD-HC) Instrument 
Version 2.0, August 2, 2000.
    (2) Frequency. Participant assessments must be completed--
    (i) No later than 14 calendar days after the date of enrollment; and

[[Page 855]]

    (ii) Promptly after a significant change in the participant's 
physical, mental, or social condition.
    (3) Review of assessments. Program management must review each 
participant no less than once every six months and as appropriate and 
revise the participant's assessment to assure the continued accuracy of 
the assessment.
    (4) Use. The results of the assessment are used to develop, review, 
and revise the participant's individualized comprehensive plan of care, 
under paragraph (e) of this section.
    (d) Accuracy of assessments--(1) Coordination. (i) Each assessment 
must be conducted or coordinated with the appropriate participation of 
health professionals.
    (ii) Each assessment must be conducted or coordinated by a 
registered nurse who signs and certifies the completion of the 
assessment.
    (2) Certification. Each person who completes a portion of the 
assessment must sign and certify the accuracy of that portion of the 
assessment.
    (e) Comprehensive care plans--(1) The program management must 
develop an individualized comprehensive care plan for each participant 
that includes measurable objectives and timetables to meet a 
participant's physical, mental, and psychosocial needs that are 
identified in the comprehensive assessment. The care plan must describe 
the following--
    (i) The services that are to be provided by the program and by other 
sources to attain or maintain the participant's highest physical, 
mental, and psychosocial well-being as required under Sec. 52.120;
    (ii) Any services that would otherwise be required under Sec. 52.120 
but are not provided due to the participant's exercise of rights under 
Sec. 52.70, including the right to refuse treatment under 
Sec. 52.70(b)(4);
    (iii) Type and scope of interventions to be provided in order to 
reach desired, realistic outcomes;
    (iv) Roles of participant and family/caregiver; and
    (v) Discharge or transition plan, including specific criteria for 
discharge or transfer.
    (2) A comprehensive care plan must be--
    (i) Developed within 21 calendar days from the date of the adult day 
care enrollment and after completion of the comprehensive assessment;
    (ii) Assigned to one team member for the accountability of 
coordinating the completion of the interdisciplinary plan;
    (iii) Prepared by an interdisciplinary team that includes the 
primary physician, a registered nurse with responsibility for the 
participant, social worker, recreational therapist and other appropriate 
staff in disciplines as determined by the participant's needs, the 
participation of the participant, and the participant's family or the 
participant's legal representative; and
    (iv) Periodically reviewed and revised by a team of qualified 
persons after each assessment.
    (3) The services provided or arranged by the facility must--
    (i) Meet professional standards of quality; and
    (ii) Be provided by qualified persons in accordance with each 
participant's written plan of care.
    (f) Discharge summary. Prior to discharging a participant, the 
program management must prepare a discharge summary that includes--
    (1) A recapitulation of the participant's care;
    (2) A summary of the participant's status at the time of the 
discharge to include items in paragraph (c)(2) of this section; and
    (3) A discharge/transition plan related to changes in service needs 
and changes in functional status that prompted another level of care.

(Authority: 38 U.S.C. 101, 501, 1741-1743)

(The Office of Management and Budget has approved the information 
collection requirements in this paragraph under control number 2900-
0160.)