How Often Should I Update the Physician’s Report and Service Plan?

Last week we reviewed the California RCFE requirements for updating resident appraisals. This week we turn our attention to the Physician’s Report and Service Plan.

Physician’s Report
RCFE Regulation 87458 states that you must “obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year.” It goes on to say that you must “obtain an updated medical assessment when required by the department.” So for your typical RCFE resident, regulations do not require that you update the physician’s report on a regular basis.

However, if the resident has dementia, Regulation 87705 requires that the physician’s report (or medical assessment) be updated at least annually.

Of course you would also obtain an updated medical assessment if there is a change in condition, or if your LPA requests it.

Service Plan
The requirements to maintain a service plan type document (although the term “service plan” is not used) can be found in Regulation 87467. In the regulation it states that you must meet with the resident and appropriate individuals to review and revise the plan “when there is a significant change in the resident’s condition, or once every 12 months, whichever occurs first.” However, as we discussed last week regarding appraisals, many providers choose to review service plans more often, such as twice a year or quarterly.

13 Responses to “How Often Should I Update the Physician’s Report and Service Plan?”

  1. Does the POLST Form take the place of the DNR Form in the residents file or do you need both?
    Is there a comprensive list of forms required in a residents file? The list on pg 152 of the 2009 RCFE Adm. Certification Manual says that it is not a substitute for all the records required by regulation.

  2. These are 2 follow-up questions. Is the LIC 602 the format that should be used for this update? And, what about TB tests? Do they need to be repeated? This comes up often, especially when a resident is known to have positive reactions to the skin test.
    Thanks for additional clarification,

  3. Hello Linda. I addressed this in a recent blog article that you can see here:

  4. Sylvia… the POLST is an alternative to the DNR and can be used in its place. If a resident has both a POLST and a DNR, the most current document should be followed.

  5. Hi Josh,

    I was not able to find information in title 22 regarding first aid and cpr in an assisted living. I wanted to know if caregivers are to perform CPR in an event that a resident requires resuscitation. I was told that only first aid is required for caregivers to know in an assisted living.

  6. Hello Beverly. California RCFE Regulation 87411 states:

    “Staff providing care shall receive appropriate training in first aid…”

    RCFE caregivers are not required to be trained in nor perform CPR. There are some providers that choose to make it a policy to train staff in CPR, but it is not required.

  7. Hello – I’m trying to find documentation that states you are required to call 911 in a emergency situation, even though the resident has a DNR

  8. Hello “sjacobs”. What state are you working in?

  9. Hi Josh- I’m in San Diego county , a town named Borrego Springs.

  10. Sjacobs… You do not always have to call 911 when the resident has a DNR. It depends on whether the resident is on hospice and whether a licensed medical professional is available. California Health and Safety Section 1569.73 and 1569.74 provide further clarification.

  11. What type of initial training is required before an LVN begins working at an RCFE?

  12. what are the regulations for rcfe medication administration to dementia clients? Does a licensed nurse need to determine the needs for a PRN medication to a dementia client?

  13. Nurseqte1… RCFE regulations allow trained staff to “assist with self-administration” of medications. If the mess must be administered it has to be done by the resident or a licensed medical professional.

Discussion Area - Leave a Comment