NAC449.541. Interdisciplinary teams; plans for care of patients.

     1. Each facility shall establish and comply with a policy which specifies that the services provided to each patient of the facility are coordinated using an interdisciplinary team. The interdisciplinary team must consist of:

     (a) The primary dialysis physician of the patient;

     (b) A registered nurse;

     (c) A social worker; and

     (d) A licensed dietitian.

     2. Each interdisciplinary team specified in subsection 1 shall develop a written, individualized and comprehensive plan to provide care to the patient for whom the plan is prepared. The plan must:

     (a) Specify the services that are required to address the medical, psychological, social and functional needs of the patient; and

     (b) Include a statement setting forth the objectives for providing treatment to the patient.

     3. Each plan for the care of a patient prepared pursuant to the provisions of subsection 2 must include:

     (a) If required to ensure the provision of safe care for the patient, evidence of coordination with any other provider of service for the patient, including a hospital, long-term care facility, an agency that provides residential or community support services, or a provider of transportation; and

     (b) Evidence indicating that:

          (1) The provisions of the plan were disclosed to the patient or his or her legal representative; and

          (2) The patient or his or her legal representative was provided an opportunity to participate in and discuss the preparation of the plan.

     4. Each plan for the care of a patient must be:

     (a) Prepared within 30 days after the patient is admitted to the facility; and

     (b) Revised at least once every 6 months or immediately after the occurrence of any change in the medical, nutritional or psychosocial condition of the patient.

     5. Each member of the interdisciplinary team shall periodically evaluate the progress of the patient toward achieving the objectives specified in the plan. Any action taken by a member of the interdisciplinary team, if the objectives are not achieved, must be documented and included in the clinical record of the patient.

     (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001; A by R090-12, 12-20-2012)