(b) Resident assessment and service plan.
Within 14 days of admission, a resident comprehensive assessment and an
individual service plan for providing care, which is based on the comprehensive
assessment, must be completed. The comprehensive assessment must be completed
by the appropriate staff and documented on a form developed by the facility.
When a facility is unable to obtain information required for the comprehensive
assessment, the facility should document its attempts to obtain the
information.
(1) The comprehensive assessment
must include the following items:
(A) the
location from which the resident was admitted;
(E) psychosocial issues (e.g., a psychosocial
functioning assessment that includes an assessment of mental or psychosocial
adjustment difficulty; a screening for signs of depression, such as withdrawal,
anger or sad mood; assessment of the resident's level of anxiety; and
determining if the resident has a history of psychiatric diagnosis that
required in-patient treatment);
(F)
Alzheimer's disease/dementia history;
(G) activities of daily living patterns
(e.g., wakened to toilet all or most nights, bathed in morning/night, shower or
bath);
(H) involvement patterns and
preferred activity pursuits (e.g., daily contact with relatives, friends,
usually attended religious services, involved in group activities, preferred
activity settings, general activity preferences);
(I) cognitive skills for daily
decision-making (e.g., independent, modified independence, moderately impaired,
severely impaired);
(J)
communication (e.g., ability to communicate with others, communication
devices);
(K) physical functioning
(e.g., transfer status; ambulation status; toilet use; personal hygiene;
ability to dress, feed and groom self);
(M) nutritional status (e.g., weight changes,
nutritional problems or approaches);
(P) medications (e.g., administered,
supervised, self-administers);
(Q)
health conditions and possible medication side effects;
(R) special treatments and
procedures;
(S) hospital admissions
within the past six months or since last assessment; and
(T) preventive health needs (e.g., blood
pressure monitoring, hearing-vision assessment).
(2) The service plan must be approved and
signed by the resident or a person responsible for the resident's health care
decisions. The facility must provide care according to the service plan. The
service plan must be updated annually and upon a significant change in
condition, based upon an assessment of the resident.
(3) For respite clients, the facility may
keep a service plan for six months from the date on which it is developed.
During that period, the facility may admit the individual as frequently as
needed.
(4) Emergency admissions
must be assessed and a service plan developed for them.