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Individual Health Policy and Procedure Policy Number six point thirteen This policy and procedure is applicable to all departments within Hope Enterprises, Inc. where employees provide services to individuals. Hope utilizes medical information to decide whether an individual’s needs can be met. Obtaining medical information assists in the development of accurate assessments and person-centered plans and ensures that the medical needs set forth therein are met. Policy Section One: Health Services Hope will ensure all individuals served receive medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed. Hope will contact the individual’s Licensed Health Care Professional if the individual refuses routine medical, dental treatment, or psychiatric treatment. Hope will ensure Staff/Providers do not make changes to any health care form after a Licensed Health Care Professional’s signature is obtained to protect the integrity of the document. Policy Section Two: Physical Examination Individuals who participate in licensed services provided by Hope will be required to have a completed Physical Examination within 12 months prior to admission and annually thereafter. For facilities licensed to operate under the Department of Aging regulations, individuals will be required to have a completed physical examination within 3 months prior to admission and annually thereafter. Policy Section Three: Dental Care Individuals who participate in licensed services provided by Hope will be required to have a dental examination, including teeth cleaning or checking gums and dentures, by a licensed dentist at least annually. Policy Section Four: Psychiatric Illness Individuals who participate in licensed services provided by Hope and receive a medication prescribed to treat a psychiatric illness will have a written protocol as part of the individual plan and a review by a licensed physician every 3 months. Policy Section Five: Individual Illness Individuals who participate in licensed services provided by Hope will receive medical treatment as needed. Procedure Section One: Health Services Staff/Provider who attend a medical appointment or contact a Licensed Health Care Professional will complete a Medical Contact Form. Staff/Provider will document pertinent information. Staff/Provider will notify the individual’s management staff. Staff/Provider will schedule any follow up appointments as recommended by the Licensed Health Care Professional. Staff/Provider will document if a scheduled appointment is changed or canceled on a Medical Contact Form/Dental Examination Form/Psychiatric Appointment Form. Staff/Provider will notify the Individual’s management staff. Procedure Section Two: Refusal of Treatments Program Specialists will develop a Refusal of Treatment Plan for individuals who refuse medications or treatments. Staff/Provider will follow the Individual’s Refusal of Treatment Plan. Staff/Provider will document any refusals of medication or treatments by the individual. Staff/Provider will notify the prescribing Licensed Health Care Professional of any refusals of medication or treatments by the individual. If an individual has a serious medical or dental condition, reasonable efforts will be made to obtain consent from the individual or substitute consent as permitted by applicable law. Program Specialists will review the Refusal of Treatment Plan monthly. Procedure Section Three: Physical Examination The Program Specialist will update the Annual Physical Examination form with current diagnoses, family medical history and immunizations. The Programs Specialist will complete the Physical Memorandum form. The Physical Memorandum form will be included in the Physical packet. Physical packet includes the Physical Memorandum form, Annual Physical Examination form, Standing Order for Non-prescription Medication, and Adaptive Equipment form. The Staff/Provider will ensure the individual’s Physical Examination is attended and completed within the required timeframe. The Program Specialist will review completed Annual Physical Examination forms and the requirements to ensure that all required information is documented. The Program Specialist will make updates to the Individual’s Plan to include revisions from the most recent Annual Physical Examination form. The Program Specialist will document and track the most recent exam dates for assigned individuals to ensure compliance. The Program Specialist will ensure the most recent copy of the Annual Physical Examination form is kept within the individual’s record. The Program Specialist will ensure changes made after the Physical Examination appointment, such as a change in diet recommendations, are received from the physician’s office and attached to the Annual Physical Examination form. Procedure Section Four: Dental Care The Residential Manager and/or Program Specialist will ensure the Individual’s dental examination is scheduled based on the recommendations of the licensed dentist. Staff/Provider will complete the Dental Examination Form at the time of the appointment with a licensed dentist. The Program Specialist will review the completed Dental Examination Form to ensure all required information is documented. The Program Specialist will update the Individual’s Dental Hygiene Plan annually and after each Dental Examination as necessary to include revisions from the most recent Dental Examination Form. The Program Specialist will ensure the most recent copies of the Dental Hygiene Plan and the Dental Examination Form are kept within the individual’s record. Procedure Section Five: Psychiatric Illness The Residential Manager and/or Program Specialist will ensure the individual’s Psychiatric Appointment is scheduled at least every three months. Staff/Provider will complete the Psychiatric Appointment Form at the time of the appointment with the licensed physician. The Program Specialist will ensure the most recent copy of the Psychiatric Appointment Form is kept within the individual’s record. Procedure Section Six: Lifetime Medical History A Lifetime Medical History record will be maintained within the individual’s record and updated at least on an annual basis, or sooner as revisions occur. The Program Specialist will ensure the most recent copy of the Lifetime Medical History is kept within the individual’s record. Procedure Section Seven: Non-Licensed Services Staff will document appointments for non-licensed services on the individual’s service note as part of the service delivery. Procedure Section Eight: Individual Illness This is a list of symptoms, (not all inclusive), when an individual will not attend the designated day program: Diarrhea Displaying cold and/or respiratory symptoms such as: frequent coughing and/or thick yellow or green colored nasal drainage Eyes are pink and crusty Fever 101° F or above The individual is diagnosed with a contagious illness (Hope Staff will follow the Infectious Control Manual for further education) The individual is diagnosed with Influenza The individual is ordered a specialty diet short term for an illness, such as a BRAT diet or clear liquids. Vomiting Hope Residential Service Only- Employees will reference the Standing Order for Non-Prescription Medications form attached to the most recent Annual Physical. These orders are over the counter medications or common treatments that are recommended in the event of a medical complaint. Hope Residential Service Only- The individual’s Licensed Health Care Professional will be contacted if the medication outlined by the Standing Order does not relieve the symptoms as directed. The medication administered needs to be documented on the individual’s corresponding Medication Administration record. If there are no instructions noted, contact the Licensed Health Care Professional for further clarification. Hope will require a written excuse from a Licensed Health Care Professional for any medically necessary restriction of activities prior to implementing. Hope will inform the individual’s Guardian, Family Designee, and/or Provider when an individual has been prescribed any medically necessary restriction of activities. Hope will require a written excuse from a Licensed Health Care Professional if an individual is absent from day program because of illness for 3 or more consecutive days prior to returning. Attachments to the policy include the following: Physical Memorandum Annual Physical Examination Standing Order for Non-Prescription Medications Adaptive Equipment Medical Contact Form Dental Contact Form Psychiatric Contact Form Lifetime Medical History