An agency shall take reasonable measures to ensure that all individuals who are referred to provide services to clients do so in accordance with Maryland laws and regulations, including but not limited to the Health Occupations Article, Annotated Code of Maryland. Provision of Services. A registered nurse shall assess each new client who requires skilled services and assistance with the activities of daily living. The registered nurse shall also: Participate in developing the client’s plan of care and in assigning appropriate personnel; Determine whether the client requires the services of a certified nursing assistant, or whether services may be provided by an individual who is not certified; and Participate in training and retraining the individuals who will provide the care, when indicated. Plan of Care. A client’s plan of care shall be based on assessments of the client’s health, function, and psychosocial condition. An assessment of a client shall be completed: When the client is requesting or requiring services regulated by this chapter; Before the client receives services from the agency unless: The client does not request skilled care or skilled services; and There is no reason to believe that the client requires skilled care or skilled services, such as discharge instructions requiring skilled care; Within 48 hours of when the client begins services when the client requires, including but not limited to: Wound and catheter care; Treatment of stage three or stage four skin ulcers; Ventilator services; Skilled monitoring, testing, and aggressive adjustment of medications and treatments where there is the presence of, or risk for, a fluctuating acute condition; Monitoring of a chronic medical condition that is not readily controllable through available medications and treatments; Infusion therapy; Specialized intravenous therapies or nutrition support; Monitoring for being at high risk for health or safety complications which cannot be adequately managed; or A different level of care after notification of a significant change of condition; At the request of the client or the client representative; At least annually; and Except in the following circumstances: Weather-related emergencies; Natural disasters; or Federal, state, or local declaration of an emergency. When a registered nurse determines in the nurse’s clinical judgment that the client does not require an assessment within 48 hours of a significant change of condition as provided in §C(2)(c) of this regulation, the registered nurse shall: Document the determination in the client’s record; and Ensure that an assessment of the client is conducted within 7 calendar days. The agency shall ensure that the care plan developed for the client at a minimum addresses: The services to be provided to the client, which are based on the assessment of the client; When and how often the services are to be provided; How and by whom the services are to be provided; Long-range and short-range goals for the client; and Physical needs, including safety measures to protect against injury. Client care plans shall be reviewed by a registered nurse or another health care practitioner who is authorized to do so under Health Occupations Article, Annotated Code of Maryland, when appropriate. Informed Consent. An adult client who is competent to make decisions or a client representative with legal authority to make health care decisions may consent to make changes to the agency’s recommended plan of care. A cognitively capable adult client, but not a client representative with legal authority to make health care decisions, may waive the licensee’s recommendation of certified care services to be provided in the adult client’s home to assist with treatments of a routine nature, or with the self-administration of medications. A cognitively capable adult client may waive the licensee’s recommended skilled care. Consents. The consent given under §D(1)—(3) of this regulation may be granted only after a discussion of the risks and benefits with the client or, if appropriate, the client representative with legal authority to make health care decisions. This discussion shall be reflected in an informed consent form. The informed consent form shall be: Signed and dated by the client, or the client representative with legal authority over health care decisions; and Documented in the client’s records. A form confirming a waiver of skilled services shall be signed by a cognitively capable adult client and maintained in the client’s record. Client medications shall be administered in accordance with §F of this regulation. Nursing Supervision. For clients who require skilled services or assistance with the activities of daily living, an agency shall have a registered nurse to provide oversight for: Implementation of the care plan; Delegation; Supervision; and Training. The registered nurse shall provide periodic, on-site supervision of care: At least every 45 days if the staff administers medications to the client; At least every 3 months if the staff assists the client with self-administration of medications; At least every 4 months if the staff does not administer medications or assist the client with medication self-administration; or At a greater frequency established by the registered nurse due to the client's medical condition or clinical status. The agency shall maintain accurate documentation of the supervision that is provided by the registered nurse. Medication Administration. If agency employees, independent contractors, or contractual employees administer medications, the agency shall: Provide for administration of drugs and treatments by licensed or certified staff consistent with Maryland law and the client’s plan of care, unless the client has executed an informed consent form under §D of this regulation; Provide for drugs and treatments to be administered only as ordered by the physician; and Document in the client’s clinical record: Medications administered or taken; Medication errors; and Adverse drug reactions and corrective action. On-Call Services. The agency shall: Establish a procedure by which current clients or their representatives may contact a representative of the agency by communication device at any time, 24 hours a day and 7 days a week; Recognize and respond to emergency inquiries in a manner that is consistent with medical and nursing standards; Ensure that the inquiry is directed to an individual for response as required by medical and nursing standards; Ensure that the individual responds to an inquiry not later than 1 hour after the inquiry is received by the agency or sooner as necessitated by medical standards; Maintain a log of inquiries that includes the identity of the response personnel, content of the inquiry, and the time of each inquiry; and Provide clients or the client representatives with written procedures and the phone number for on-call service.