Iowa Administrative Code
Agency 481 - Inspections and Appeals Department
Inspections Division
Chapter 62 - Residential Care Facilities for Persons With Mental Illness (RCFs/PMI)
Rule 481-62.5 - Evaluation Services

Universal Citation: IA Admin Code 481-62.5

Current through Register Vol. 47, No. 6, September 18, 2024

(1) Evaluation services shall be provided to each resident. An annual evaluation of each resident shall be completed no later than 12 months from the date of the last available evaluation. For residents who are on leave from a state mental health institution, the institution shall be responsible for the completion of the evaluation. The facility shall ensure the completion of the evaluation of all other residents. The annual evaluation shall identify physical health and current level of functioning and need for services. (II, III)

(2) The portion of the evaluation to identify the resident's physical health shall:

a. Result in identification of current illness and disabilities and recommendations for physical and physiological treatment and services. (II, III)

b. Include an evaluation of the resident's ability for health maintenance. (Ill)

c. Be performed by a primary care provider. (II, III)

(3) Evaluation.

a. The portion of the evaluation to identify the resident's current level of functioning and need for services shall:
(1) Identify the resident's level of functioning and need for services in each of the following areas: self-care, community living skills, psychotherapeutic treatment, vocational skills, and academic skills. (II, III)

(2) Be of sufficient detail to determine the appropriateness of placement according to the skills and needs of the resident. (II, III)

(3) Be made without regard to the availability of services. (Ill)

(4) Be performed by a QMHP, in consultation with the interdisciplinary team. (II, III)

b. If an evaluation is available from the referral source, the evaluation shall be secured by the facility prior to the admission of the applicant. (Ill)

c. If an evaluation is not available or does not contain all the required information, the facility shall ensure an evaluation to the extent necessary to determine if the applicant meets the criteria for admission. For those admitted, the remainder of the evaluation shall be performed prior to the development of a service plan. (Ill)

d. Results of all evaluations shall be in writing and maintained in the resident's record. Evaluations subsequent to the initial evaluation shall be performed in sufficient detail to determine changes in the resident's physical health, skills and need for services. (II, III)

(4) A narrative social history shall be completed for each resident within 30 days of admission and approved by the qualified mental health professional prior to the development of the service plan. (Ill)

a. When the social history was secured from another provider, the information contained shall be reviewed within 30 days of admission. The date of the review, signature of the staff reviewing the history, and a summary of significant changes in the information shall be entered in the resident's record. (Ill)

b. An annual review of the information contained within the social history shall be incorporated into the service plan progress note. (Ill)

c. The social history shall minimally address the following areas:
(1) Referral source and reason for admission, (II, III)

(2) Legal status, (II, III)

(3) A description of previous living arrangements, (III)

(4) A description of previous services received and summary of current service involvements, (II, III)

(5) A summary of significant medical conditions including, but not limited to, illnesses, hospitalizations, past and current drug therapies, and special diets, (II, III)

(6) Substance abuse history, (II, III)

(7) Work history, (III)

(8) Educational history, (III)

(9) Relationship with family, significant others, and other support systems, (III)

(10) Cultural and ethnic background and religious affiliation, (II, III)

(11) Hobbies and leisure time activities, (III)

(12) Likes, dislikes, habits, and patterns of behavior, (II, III)

(13) Impressions and recommendations. (II, III)

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