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Considerations for Weekend and Evening Returns from Hospitalizations in Assisted Living

As renters of a housing setting, a resident has the right to return to their home following an absence at any time. In some instances, the person has had a change of need that requires added home care services, supplies, or even an interim stay at somewhere like a rehabilitation or transitional care setting. Communication with a resident/representative and hospital staff is vital to assure a smooth transition and appropriate services and supplies being in place. 

A hospital social service referral can be requested, even upon day of admission, if it appears that a rehab stay may be required, to assist in planning and locating an appropriate option.

There may be situations where, upon return, family, friends, or private-duty home care may supplement the care being provided by the “arranged home care provider” associated with the assisted living setting. Coordination of care and clarity on who will provide each component of care is vital to assure needs are addressed.

The Minnesota Comprehensive Home Care Law, which regulates the large majority of arranged home care providers in Minnesota Assisted Living settings, requires in 144A.4791, Subd.8c:

(c) Ongoing client monitoring and reassessment must be conducted as needed based on changes in the needs of the client and cannot exceed 90 days from the last date of the assessment. The monitoring and reassessment may be conducted at the client's residence or through the utilization of telecommunication methods based on practice standards that meet the individual client's needs.

The related sample policies from the LeadingAge Minnesota Comprehensive Home Care Manual intend to be useful to provider’s in establishing required practices. Policy 03-003.17 states: The RN will review the nursing assessment and service plan and, if necessary, will update the assessment and service plan, whenever the client has returned from a hospital or nursing home stay, has a change in condition or experiences an incident such as a fall.

The related procedure covers suggested components of the assessment and the updating of the service plan, also covered in Policy 04-005.17 Development and Revisions to the Service Plan.

As stated in the Frequently Asked Questions of the MDH Home Care and Assisted Living webpage, the registered nurse (RN) may elect to assign to a licensed practical nurse (LPN) the nursing task of the ongoing client monitoring and reassessment that is required by Minnesota Statutes, section 144A.4791, subdivision 8 (c). This is because Minnesota Statutes, section 148.171, subdivision 14 states that it is within an LPN’s scope of practice to conduct focused assessments. However, this same statute requires an LPN to report any changes in the condition or needs of a client to an RN.

The RN scope of practice includes providing a comprehensive assessment and evaluating responses to interventions and the effectiveness of the plan of care. Therefore, an RN should conduct reassessments triggered by changes in a client’s condition. Since a hospitalization would indicate, at least the possibility of a change of condition, the law is clear that the RN will conduct the assessment and that the assessment may be done in person or through the use of telecommunication methods, which would not require the RN to be on site.

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