QUESTION OF THE WEEK:
What are the NIAHO (DNV) requirements for patient assessments and plans of care?


Question:
What are the NIAHO (DNV) requirements for patient assessments and plans of care?

Answer:
NIAHO updated their standards as of 12-29-11. Standard NS.3 use to address only the plan of care but it now addresses assessments and plans of care.

Standard NS.3 requirements are as follows:

  • Nursing develops and maintains a plan of care for each patient
  • The plan of care is developed with 24 hours of admission
  • The patient’s plan of care is review and revised as necessary and if the patient’s condition changes
  • Nursing completes a patient assessment within 24 hours of admission to an inpatient setting
  • The nursing assessment includes (not all inclusive):

     •  Allergies
     •  Admitting problem
     •  History of pain
     •  Current pain level
     •  Preexisting conditions
     •  Current medications to including time of last dose
     •  History of using illicit drugs
     •  ADL needs
     •  Dietary requirements
     •  Other requirements per hospital policy

  • Nursing performs patient assessments according to hospital policy in all other areas of the hospital i.e., surgery center, outpatient department, clinics
  • Nursing performs reassessments at defined intervals and when there is a change in a patient’s condition

Standard NS.3 is in line with the following CMS regulations:

§482.23(b) Standard: Staffing and Delivery of Care

  • Interpretive Guidelines §482.23(b) – The nursing service must ensure that patient needs are met by ongoing assessments of patients‘ needs and provides nursing staff to meet those needs. There must be sufficient numbers, types and qualifications of supervisory and staff nursing personnel to respond to the appropriate nursing needs and care of the patient population of each department or nursing unit.

§482.23(b)(4) – The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient.

  • Interpretive Guidelines §482.23(b)(4) – Nursing care planning starts upon admission. A nursing care plan is based on assessing the patient‘s nursing care needs (not solely those needs related to the admitting diagnosis) and developing appropriate nursing interventions in response to those needs.
  • The nursing care plan is kept current by ongoing assessments of the patient‘s needs and the patient‘s response to interventions, and updating or revising the patient‘s nursing care plan in response to assessments.
  • The nursing care plan is part of the patient‘s medical record and must comply with the requirements for patient records and other patient information.

References:
National Integrated Accreditation for Healthcare Organizations
Accreditation Requirements Interpretive Guidelines & Surveyor Guidance Version 9.0, Effective 01-15-2012

CMS State Operations Manual, Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, Rev. 81, 03-23-1

Related Products from MCN:
Provision of Care, Treatment and Services Manual

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