Introduction

A service plan/care plan is a very important tool. These plans help direct the caregiver to deliver the care, support, and services that meet each person's goals, strengths, and needs. The assessment is the foundation of the plan!

Rules and Regulations Related to Assessments

The Board of Nursing and state and federal regulations require an assessment. The state regulations for nursing assessments can be found here:

• Texas Occupations Code, Title 3, Subtitle E, Chapter 301 Nurses, Subchapter A General Provisions, Sec. 301.002 Definitions. http://www.statutes.legis.state.tx.us/Docs/OC/htm/OC.301.htm

The Texas Board of Nursing (BON), through the Nurse Practice Act (NPA), dictates all of a nurse's’ responsibilities, as mentioned in the role of the nurse in the assessments section. Here are the specific BON rule sections, position statements, and links for easier access to the information:

• Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule §217.11 Standards of Nursing Practice. http://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=11&ch=217&rl=11
• TX BON Differentiated Essential Competencies of Graduates of Texas Nursing Programs. http://www.bon.texas.gov/pdfs/publication_pdfs/delc-2010.pdf

Nurses should have a full understanding of their scope of practice, knowing what they are allowed to do, with regards to assessing care recipients. The NPA details that an LVN is not allowed to perform a comprehensive assessment as this is the responsibility of the RN.

Nurses, regardless of their licensure, should be aware of the federal rules and regulations related to nursing assessments. Federal regulations require the completion of an assessment, and requires that the assessment is used in the creation of the service, support and care plan but not all care settings have to follow Federal regulations but they do have to follow State regulations.

Below are the statute and regulations regarding the need for individualized service plans/care plans.

State Regulations

• Texas Health and Safety Code, Chapter 592, Subchapter C rule §592.33
• Texas Administrative Code (TAC) Title 40, Part 1, Chapter 92, Subchapter C rule §92.41
• Texas Administrative Code (TAC) Title 40, Part 1, Chapter 97, Subchapter C, Division 4 rule §97.281

For the facilities that have to follow Federal regulations, these regulations are listed below.

Federal Regulations

• 42 CFR Part 484, Subpart B §484.18
• 42 CFR Part 484, Subpart B §484.55

All these regulations require that the individual, if capable, or their legal guardian, be involved in the planning of the care to be provided. It is important that when developing an individualized service plan or care plan it should contain the following information:

• Customary routines
• Medical and physical information
• Mental status
• Current medications
• Living arrangements
• Nutritional requirements
• Safety measures

State regulations provide information that you need to follow when providing assessments. Care providers should familiarize themselves with the regulations and know where to look for these resources to make sure they are in compliance.